An International Consensus on Actions to Improve Lung Cancer Survival: A Modified Delphi Method Among Clinical Experts in the International Cancer Benchmarking Partnership

BACKGROUND

Research from the International Cancer Benchmarking Partnership (ICBP) demonstrates that international variation in lung cancer survival persists, particularly within early stage disease. There is a lack of international consensus on the critical contributing components to variation in lung cancer outcomes and the steps needed to optimise lung cancer services. These are needed to improve the quality of options for and equitable access to treatment, and ultimately improve survival.

METHODS

Semi-structured interviews were conducted with 9 key informants from ICBP countries. An international clinical network representing 6 ICBP countries (Australia, Canada, Denmark, England, Ireland, New Zealand, Northern Ireland, Scotland & Wales) was established to share local clinical insights and examples of best practice. Using a modified Delphi consensus model, network members suggested and rated recommendations to optimise the management of lung cancer. Calls to Action were developed via Delphi voting as the most crucial recommendations, with Good Practice Points included to support their implementation.

RESULTS

Five Calls to Action and thirteen Good Practice Points applicable to high income, comparable countries were developed and achieved 100% consensus. Calls to Action include (1) Implement cost-effective, clinically efficacious, and equitable lung cancer screening initiatives; (2) Ensure diagnosis of lung cancer within 30 days of referral; (3) Develop Thoracic Centres of Excellence; (4) Undertake an international audit of lung cancer care; and (5) Recognise improvements in lung cancer care and outcomes as a priority in cancer policy.

CONCLUSION

The recommendations presented are the voice of an expert international lung cancer clinical network, and signpost key considerations for policymakers in countries within the ICBP but also in other comparable high-income countries. These define a roadmap to help align and focus efforts in improving outcomes and management of lung cancer patients globally.

The Effect of Major and Minor Complications After Lung Surgery on Length of Stay and Readmission

The effect of post-operative adverse events (AEs) on patient outcomes such as length of stay (LOS) and readmissions to hospital is not completely understood. This study examined the severity of AEs from a high-volume thoracic surgery center and its effect on the patient postoperative LOS and readmissions to hospital. This study includes patients who underwent an elective lung resection between September 2018 and January 2020. The AEs were grouped as no AEs, 1 or more minor AEs, and 1 or more major AEs. The effects of the AEs on patient LOS and readmissions were examined using a survival analysis and logistic regression, respectively, while adjusting for the other demographic or clinical variables. Among 488 patients who underwent lung surgery, (Wedge resection [n = 100], Segmentectomy [n = 51], Lobectomy [n = 310], Bilobectomy [n = 10], or Pneumonectomy [n = 17]) for either primary (n = 440) or secondary (n = 48) lung cancers, 179 (36.7%) patients had no AEs, 264 (54.1%) patients had 1 or more minor AEs, and 45 (9.2%) patients had 1 or more major AEs. Overall, the median of LOS was 3 days which varied significantly between AE groups; 2, 4, and 8 days among the no, minor, and major AE groups, respectively. In addition, type of surgery, renal disease (urinary tract infection [UTI], urinary retention, or acute kidney injury), and ASA (American Society of Anesthesiology) score were significant predictors of LOS. Finally, 58 (11.9%) patients were readmitted. Readmission was significantly associated with AE group (P = 0.016). No other variable could significantly predict patient readmission. Overall, postoperative AEs significantly affect the postoperative LOS and readmission rates.

Contemporary trends in the level of evidence in general thoracic surgery clinical research

OBJECTIVES

The large volume of scientific publications and the increasing emphasis on high-quality evidence for clinical decision-making present daily challenges to all clinicians, including thoracic surgeons. The objective of this study was to evaluate the contemporary trend in the level of evidence (LOE) for thoracic surgery clinical research.

METHODS

All clinical research articles published between January 2010 and December 2017 in 3 major general thoracic surgery journals were reviewed. Five authors independently reviewed the abstracts of each publication and assigned a LOE to each of them using the 2011 Oxford Centre for Evidence-Based Medicine classification scheme. Data extracted from eligible abstracts included study type, study size, country of primary author and type of study designs. Three auditing processes were conducted to establish working definitions and the process was validated with a research methodologist and 2 senior thoracic surgeons. Intra-class correlation coefficient was calculated to assess inter-rater agreement. Chi-square test and Spearman correlation analysis were then used to compare the LOE between journals and by year of publication.

RESULTS

Of 2028 publications reviewed and scored, 29 (1.4%) were graded level I, 75 (3.7%) were graded level II, 471 (23.2%) were graded level III, 1420 (70.2%) were graded level IV and 33 (1.6%) were graded level V (lowest level). Most publications (94.9%) were of lower-level evidence (III-V). There was an overall increasing trend in the lower LOE (P < 0.001). Inter-rater reliability was substantial with 95.5% (95%, confidence interval: 0.95-0.96) level of agreement between reviewers.

CONCLUSIONS

General thoracic surgery literature consists mostly of lower LOE studies. The number of lower levels of evidence is dominating the recent publications, potentially indicating a need to increase the commitment to produce and disseminate higher-level evidence in general thoracic surgery.

Robotic vs. Thoracoscopic Anatomic Lung Resection in Obese Patients: A Propensity Adjusted Analysis

BACKGROUND

Minimally-invasive lung resections can be particularly challenging in obese patients. We hypothesized robotic surgery (RTS) is associated with less conversion to thoracotomy than thoracoscopic surgery (VATS) in obese populations.

METHODS

The STS GTSD, Epithor French National Database, and McMaster University Database were queried for obese (BMI≥30 kg/m²) patients who underwent VATS or RTS lobectomy or segmentectomy for clinical T1-2, N0-1 NSCLC between 2015-2019. Propensity score adjusted logistic regression analysis was used to compare the rate of conversion to thoracotomy between the VATS and RTS cohorts.

RESULTS

Overall, 8,108 patients (STS GTSD: n=7,473; Epithor: n=572; McMaster: n=63) met inclusion criteria with a mean age of 66.6 years (SD 9 years) and BMI of 34.7 kg/m² (SD 4.5 kg/m²). After propensity score adjusted multivariable analysis, patients who underwent VATS were over 5 times more likely to experience conversion to thoracotomy than those who underwent RTS (OR=5.33; 95% CI 4.14, 6.81, p<0.001). There was a linear association between degree of obesity and odds ratio of VATS conversion to thoracotomy compared to RTS. The VATS cohort had a longer mean length of stay (5.0 vs. 4.3 days, p<0.001), higher rate of respiratory failure (2.8% [168/5975] vs. 1.8% [39/2133], p=0.026), and were less likely to be discharged to their home (92.5% [5,525/5,975] vs. 94.3% [2,012/2,133]; p=0.013) compared to RTS patients.

CONCLUSIONS

In obese patients, RTS anatomic lung resection is associated with a lower rate of conversion to thoracotomy than VATS.

Endobronchial Ultrasound Staging of Operable Non-small Cell Lung Cancer: Do Triple-Normal Lymph Nodes Require Routine Biopsy?

BACKGROUND

Staging guidelines for lung cancer recommend endobronchial ultrasound (EBUS) and systematic biopsy of at least three mediastinal lymph node (LN) stations for accurate staging. A four-point ultrasonographic score (Canada Lymph Node Score [CLNS]) was developed to determine the probability of malignancy in each LN. A LN with a CLNS of < 2 is considered low probability for malignancy. We hypothesized that, in patients with cN0 non-small cell lung cancer, LNs with CLNS of < 2 may not require routine biopsy because they represent true node-negative disease.

RESEARCH QUESTION

Do LNs considered triple normal on CT scanning, PET scanning, and CLNS evaluation require routine biopsy?

STUDY DESIGN AND METHODS

LNs were evaluated for ultrasonographic features at the time of EBUS and the CLNS was applied. Triple-normal LNs were defined as cN0 on CT scanning (short axis, < 1 cm), PET scanning (no hypermetabolic activity), and EBUS (CLNS, < 2). Specificity and negative predictive value (NPV) were calculated against the gold standard pathologic diagnosis from surgically excised specimens.

RESULTS

In total, 143 LNs from 57 cN0 patients were assessed. Triple-normal LNs showed a specificity and NPV of 60% (95% CI, 51.2%-68.3%) and 93.1% (95% CI, 85.6%-97.4%), respectively. After pathologic assessment, only 5.6% (n = 8/143) of triple-normal nodes were proven to be malignant.

INTERPRETATION

At the time of staging for lung cancer, combining CT scanning, PET scanning, and CLNS criteria can identify triple-normal LNs that have a high NPV for malignancy. This raises the question of whether triple-normal LNs require routine sampling during EBUS and transbronchial needle aspiration. A prospective trial is required to confirm these findings.

The effect of colchicine administration on postoperative pleural effusion following lung resection: a randomized blinded placebo-controlled feasibility pilot study

OBJECTIVES

This substudy of the colchicine for prevention of perioperative atrial fibrillation (COP-AF) pilot trial seeks to assess the effect of colchicine administration on the volume of postoperative pleural drainage, duration of chest tube in situ and length of stay following lung resection.

METHODS

Between April 2014 and April 2015, 100 patients undergoing lung resection at 2 tertiary care centres participated in a pilot blinded randomized trial comparing perioperative twice daily 0.6 mg of colchicine orally (n = 49) or placebo (n = 51) twice daily for 10 days. The primary outcome was total pleural drainage volume, which was recorded in 8-h intervals for the first 2 postoperative days per standardized protocol.

RESULTS

Only 1 patient did not complete the trial. The mean volume of pleural drainage at 40-h mark postoperation was significantly less in the colchicine group (550.9 ml) compared with the placebo group (741.3 ml, P = 0.039). Compared with the placebo group, the colchicine group showed significantly less mean pleural drainage on postoperative Day 2 (583.8 vs 763.3 ml, P = 0.039) and beyond. There were no differences in mean time to chest tube removal (6.8 days for the colchicine group vs 5.9 days for the placebo group, P = 0.585) and mean hospital length of stay (7.4 vs 6.9 days, P = 0.641).

CONCLUSIONS

Oral colchicine is potentially effective in diminishing the amount of pleural drainage following lung resection and can be considered in patients at high risk of large postoperative pleural effusion. A full-scale, prospective placebo-controlled randomized trial is needed to assess the clinical significance of perioperative colchicine administration following oncological lung resection.

Incentive Spirometry After Lung Resection: A Randomized Controlled Trial

BACKGROUND

Incentive spirometry (IS) is thought to reduce the incidence of postoperative pulmonary complications (PPC) after lung resection. We sought to determine whether the addition of IS to routine physiotherapy following lung resection results in a lower rate of PPC, as compared with physiotherapy alone.

METHODS

A single-blind prospective randomized controlled trial was conducted in adults undergoing lung resection. Individuals with previous lung surgery or home oxygen were excluded. Participants randomized to the control arm (PHY) received routine physiotherapy alone (deep breathing, ambulation and shoulder exercises). Those randomized to the intervention arm (PHY/IS) received IS in addition to routine physiotherapy. The trial was powered to detect a 10% difference in the rate of PPC (β = 80%). Student's t test and chi-square were utilized for continuous and categorical variables, respectively, with a significance level of p = 0.05.

RESULTS

A total of 387 participants (n = 195 PHY/IS; n = 192 PHY) were randomized between 2014 and 2017. Baseline characteristics were comparable for both arms. The majority of patients underwent a pulmonary lobectomy (PHY/IS = 59.5%, PHY = 61.0%; p = 0.84), with no difference in the rates of minimally invasive and open procedures. There were no differences in the incidence of PPC at 30 days postoperatively (PHY/IS = 12.3%, PHY = 13.0%; p = 0.88). There were no differences in rates of pneumonia (PHY/IS = 4.6%, PHY = 7.8%; p = 0.21), mechanical ventilation (PHY/IS = 2.1%, PHY = 1.0%; p = 0.41), home oxygen (PHY/IS = 13.8%, PHY = 14.6%; p = 0.89), hospital length of stay (PHY/IS = 4 days, PHY = 4 days; p = 0.34), or rate of readmission to hospital (PHY/IS = 10.3%, PHY = 9.9%; p = 1.00).

CONCLUSIONS

The addition of IS to routine postoperative physiotherapy does not reduce the incidence of PPC after lung resection.

Does the usage of digital chest drainage systems reduce pleural inflammation and volume of pleural effusion following oncologic pulmonary resection?-A prospective randomized trial

BACKGROUND

Prolonged air leak and high-volume pleural drainage are the most common causes for delays in chest tube removal following lung resection. While digital pleural drainage systems have been successfully used in the management of post-operative air leak, their effect on pleural drainage and inflammation has not been studied before. We hypothesized that digital drainage systems (as compared to traditional analog continuous suction), using intermittent balanced suction, are associated with decreased pleural inflammation and postoperative drainage volumes, thus leading to earlier chest tube removal.

METHODS

One hundred and three [103] patients were enrolled and randomized to either analog (n=50) or digital (n=53) drainage systems following oncologic lung resection. Chest tubes were removed according to standardized, pre-defined protocol. Inflammatory mediators [interleukin-1B (IL-1B), 6, 8, tumour necrosis factor-alpha (TNF-α)] in pleural fluid and serum were measured and analysed. The primary outcome of interest was the difference in total volume of postoperative fluid drainage. Secondary outcome measures included duration of chest tube in-situ, prolonged air-leak incidence, length of hospital stay and the correlation between pleural effusion formation, degree of inflammation and type of drainage system used.

RESULTS

There was no significant difference in total amount of fluid drained or length of hospital stay between the two groups. A trend for shorter chest tube duration was found with the digital system when compared to the analog (P=0.055). Comparison of inflammatory mediator levels revealed no significant differences between digital and analog drainage systems. The incidence of prolonged post-operative air leak was significantly higher when using the analog system (9 versus 2 patients; P=0.025). Lobectomy was associated with longer chest tube duration (P=0.001) and increased fluid drainage when compared to sub-lobar resection (P<0.001), regardless of drainage system.

CONCLUSIONS

Use of post-lung resection digital drainage does not appear to decrease pleural fluid formation, but is associated with decreased prolonged air leaks. Total pleural effusion volumes did not differ with the type of drainage system used. These findings support previously established benefits of the digital system in decreasing prolonged air leaks, but the advantages do not appear to extend to decreased pleural fluid formation.

Practice patterns in venous thromboembolism (VTE) prophylaxis in thoracic surgery: a comprehensive Canadian Delphi survey

BACKGROUND

The incidence of venous thromboembolic events (VTE) after resection of thoracic malignancies can reach 15%, but prophylaxis guidelines are yet to be established. We aimed to survey Canadian practitioners regarding perioperative risk factors for VTE, impact of those factors on extended prophylaxis selection, type of preferred prophylaxis, and timing of initiation and duration of thromboprophylaxis.

METHODS

A modified Delphi survey was undertaken over three rounds with thoracic surgeons, thoracic anesthesiologists and thrombosis experts across Canada. Participants were asked to rate each parameter on a ten-point scale. Agreement was determined a priori as an item reaching a coefficient of variation of ≤30% (0.3), with the item then discontinued from later rounds.

RESULTS

In total, 72, 57 and 50 respondents participated in three consecutive rounds, respectively. Consensus was reached on previous VTE, age, cancer diagnosis, thrombophilia, poor mobilization, extended resections, and pre-operative chemotherapy as risk factors. Consensus on risk factors impacting extended prophylaxis decisions was achieved on cancer diagnosis, obesity, previous VTE and poor mobilization. With respect to perioperative prophylaxis, once daily low-molecular-weight heparin (LMWH) was the only parameter that demonstrated agreement as a common practice pattern. No agreement was achieved regarding the role of mechanical prophylaxis, unfractionated heparin (UFH) or timing of initiation of peri-operative treatment. VTE prophylaxis until discharge reached agreement but there was substantial variability regarding the role of extended prophylaxis.

CONCLUSIONS

There is agreement between Canadian clinicians treating patients with thoracic malignancies regarding most risk factors for VTE, but there is no agreement on timing of initiation of prophylaxis, the agents used or factors mandating usage of extended prophylaxis.

The effect of regionalization on outcome in pulmonary lobectomy: a Canadian national study

Objective

To examine the effect of regionalization of thoracic surgery services in Canada by evaluating change over time in hospital volumes of pulmonary lobectomy and its impact on length of stay and in-hospital mortality.

Methods

Data on pulmonary lobectomy between 1999 and 2007 were abstracted from the Canadian Institute for Health Information Discharge Abstract Database. In-hospital mortality was analyzed by logistic regression, and log-transformed length of stay was analyzed by linear regression. Cross-sectional analysis of hospital volume, in-hospital mortality, and length of stay was performed, controlling for clustering. Within-hospital changes in annual volume on outcome was analyzed using multivariable logistic regression, controlling for Charlson comorbidity index and other confounders.

Results

Of 19,732 patients, 10, 281 (52%) were male, with an average age of 63.3 years. There was a 45% (95% confidence interval, 21–61; P = .001) relative risk reduction in in-hospital mortality with a 19% reduction in length of stay (95% confidence interval, 12–25; P < .0001). On comparison of volume between hospitals, an increase of 20 cases was associated with a 15% relative risk reduction (95% confidence interval, 9–19; P < .0001) in in-hospital mortality and a 5% relative decrease (95% confidence interval, 3–7; P < .001) in length of stay. Within hospitals there was a nonsignificant relationship between volume and in-hospital mortality.

Conclusions

In-hospital mortality and length of stay for lobectomies have decreased in Canada. In multivariate analysis, volume was associated with improved in-hospital mortality, but there was no reduction in mortality when volume was increased within a given hospital. However, the proportion of patients treated in high-volume centers has increased over time, inferring the importance of high-volume centers in improved outcomes. This supports regionalization policies for pulmonary lobectomy.

Factors associated with postoperative symptoms after laparoscopic Heller myotomy

BACKGROUND

Our objective is to ascertain if preoperative and perioperative treatments affect the short- and long-term symptom frequency or symptom scores for dysphagia, regurgitation, and heartburn in patients with laparoscopic Heller myotomy for achalasia.

METHODS

From 1994 to 2008, 261 patients undergoing laparoscopic esophageal myotomy were enrolled prospectively. The diagnosis of classic achalasia was made on clinical history, barium swallow, endoscopy, and manometry. A validated symptom questionnaire and history was taken for each patient at the preoperative visit and at each postoperative visit.

RESULTS

In all, 261 patients had laparoscopic Heller myotomy during the study period. Preoperatively, 137 patients (62.3%) tried medications, 101 (38.7%) were treated with pneumatic dilation, and 29 (11.1%) were treated initially with at least one injection of botulinum toxin into the lower esophageal sphincter. In all, 134 patients (51.3%) received a Dor anterior fundoplication. On multivariate regression controlling for age and sex, preoperative dilation (p = 0.031), injection of botulinum toxin (p = 0.044), and a fundoplication (p = 0.005) were associated with significantly worse early postoperative dysphagia, with odds ratios of 2.11, 2.56, and 2.80, respectively; previous botulinum toxin injection was associated with worse late postoperative dysphagia (p = 0.001), regurgitation (p = 0.031), and heartburn (p = 0.049), with odds ratios of 5.24, 2.87, and 2.52, respectively. There was a trend for no fundoplication to be associated with late postoperative heartburn (p = 0.077) with an odds ratio of 1.80.

CONCLUSIONS

Many patients presenting for Heller myotomy have previously undergone a different form of treatment. Early postoperative dysphagia was affected by dilation, botulinum toxin injection, and fundoplication. Only botulinum toxin injection was associated with late symptoms.

The demographics of significant firearm injury in Canadian trauma centres and the associated predictors of inhospital mortality

OBJECTIVE

Our primary objective was to evaluate demographic and causal factors of inhospital mortality for significant firearm-related injuries (i.e., those with an Injury Severity Score [ISS] > 12) in Canadian trauma centres.

METHODS

We analyzed data submitted to the Canadian Institute for Health Information (CIHI) in the National Trauma Registry for all firearm-injured patients for fiscal years 1999-2003. Univariate and bivariate adjusting for ISS and multivariate logistic regression were performed.

RESULTS

Men accounted for 94% of the 784 injured. In all patients, the percentages of self-inflicted, intentional, unintentional and unknown injuries were 27.8%, 60.3%, 6.1% and 5.7%, respectively. The inhospital fatality rate was 39.8%, with 83% of fatalities occurring on the first day. Two-thirds of patients were discharged home. Univariate and adjusted analysis found that ISS, first systolic blood pressure (BP), first systolic BP under 100, first Glasgow Coma Scale (GCS) score, age over 45 years, self-inflicted injury, intentional injury and injury at home significantly worsened the odds ratio of death in hospital and that police shooting was relatively beneficial. BP under 100, age over 45 years and a low GCS score had an adjusted odds ratio of death of 4.12, 1.99 and 0.64 per point increase, respectively. The multivariate model showed that ISS, BP under 100, first GCS score, sex and self-inflicted injury were significant in predicting inhospital death.

CONCLUSION

A predominance of young men are injured intentionally with handguns in Canada, whereas older patients suffer self-inflicted injuries with long guns. The significant number of firearm deaths, largely in the first day, highlights the importance of preventative strategies and the need for rapid transport of patients to trauma centres for urgent care.

Practical Approaches to the Surgical Management of Achalasia

Achalasia is a primary motor disorder of the esophagus characterized by an abnormal hypertensive, nonrelaxing lower esophageal sphincter (LES) and nonfunctioning, aperistaltic esophageal body resulting in significant regurgitation and dysphagia. The primary goal of treatment is palliation of symptoms. At present, all treatment techniques are directed at relieving the functional obstruction at the level of the LES by disruption or paralysis of the esophageal muscle constituting the LES. Destruction of the LES function also places the patient at risk for pathologic gastroesophageal reflux disease. Therefore, the treatment of patients with achalasia must strike a balance between the relief of dysphagia and potential creation of pathologic gastroesophageal reflux. The advent of laparoscopic esophageal myotomy for the treatment of achalasia over the past decade has resulted in most patients with the disease being referred to surgeons for definitive treatment. At the time of consultation the patient may present with a myriad of symptoms, investigative results, and previous treatments. Based on our experience of over 300 patients treated with surgery at our institution between 1990 and 2007, this review will address the practical problems encountered in the surgical management of achalasia.

Practical approaches to the surgical management of achalasia

Achalasia is a primary motor disorder of the esophagus characterized by an abnormal hypertensive, nonrelaxing lower esophageal sphincter (LES) and nonfunctioning, aperistaltic esophageal body resulting in significant regurgitation and dysphagia. The primary goal of treatment is palliation of symptoms. At present, all treatment techniques are directed at relieving the functional obstruction at the level of the LES by disruption or paralysis of the esophageal muscle constituting the LES. Destruction of the LES function also places the patient at risk for pathologic gastroesophageal reflux disease. Therefore, the treatment of patients with achalasia must strike a balance between the relief of dysphagia and potential creation of pathologic gastroesophageal reflux. The advent of laparoscopic esophageal myotomy for the treatment of achalasia over the past decade has resulted in most patients with the disease being referred to surgeons for definitive treatment. At the time of consultation the patient may present with a myriad of symptoms, investigative results, and previous treatments. Based on our experience of over 300 patients treated with surgery at our institution between 1990 and 2007, this review will address the practical problems encountered in the surgical management of achalasia.

Judicial outcome for the intoxicated driver admitted to a regional trauma center

OBJECTIVE

To examine the judicial outcomes for intoxicated drivers who were admitted to regional trauma centers as a result of motor vehicle collisions (MVCs).

METHODS

A retrospective review of the trauma registry of a Level I trauma center was conducted for the period from January 1, 1989, through December 31, 1990. Inclusion criteria for entry into the study were 1) identification of the patient as the driver involved in an MVC, 2) a blood alcohol content (BAC) above 0.10 g/dL, and 3) survival until discharge from the hospital. A total 245 patients from the trauma registry met the inclusion criteria. The number of persons from the submitted list who were later convicted of driving under the influence of alcohol (DUI) was obtained from the Department of Motor Vehicles (DMV) of the Common- wealth of Virginia.

RESULTS

Of the list submitted to the DMV, only nine individuals (3.7%; 95% confidence interval = 1.3--6.0%) were convicted of DUI during the MVCs that led to hospitalization during the study period. During the same time period, the statewide conviction rate for DUI-cited drivers was 85%.

CONCLUSION

Admission to the trauma service at a Level I trauma center may provide a refuge from legal consequences for intoxicated drivers involved in MVCs.

Angiotensin-converting enzyme inhibitor-induced angioedema: still unrecognized

Angiotensin-converting enzyme inhibitors are a widely used antihypertensive modality. While they have a favorable side effect profile, there is a .1% to .2% incidence of potentially life threatening angioedema. The edema usually presents in the head and neck, especially the face, lips, tongue, and glottis. Patients may initially be treated with standard anti-allergic therapy; however, the situation may dictate a more aggressive therapeutic approach. The authors present the case of a patient who presented with angioedema 18 times over a 3-year period to qualified emergency physicians before the correct diagnosis of angiotensin-converting enzyme inhibitor-induced angioedema was made. Despite recent literature on the subject, there appears to be a lack of familiarization among emergency department physicians regarding this relatively common adverse effect.

Metal fume fever

Metal fume fever is an ancient occupational disease still encountered among metal workers. The delay between exposure and onset of non-specific symptoms makes this an elusive diagnosis. We present the case of a patient who developed symptoms several hours after welding. The historical background, pathogenesis, clinical presentation, and self-limited course of this common, yet frequently unrecognized illness are discussed.