A prospective, open-label, randomized clinical trial to evaluate the efficacy and safety of remimazolam in patients undergoing EBUS-TBNA: REST trial design

BACKGROUND

Remimazolam is safe and effective for moderate sedation during flexible bronchoscopy, but its safety and efficacy during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) remains undetermined. The REST trial (NCT06275594) will be a prospective randomized study of remimazolam in patients undergoing EBUS-TBNA with conscious sedation. The primary aim is to evaluate whether remimazolam is safe and effective for moderate sedation during EBUS-TBNA compared to real-world midazolam and on-label midazolam.

METHODS

The REST trial will recruit 330 patients from four university hospitals with mediastinal lesions suspected of being lung cancer who are eligible for EBUS-TBNA under moderate sedation. The participants will be randomized into groups using remimazolam, real-world midazolam, and on-label midazolam (US prescribing information dosage) to perform EBUS-TBNA for procedural sedation. The primary endpoint will be procedural success using composite measures.

DISCUSSION

The REST trial will prospectively evaluate the efficacy and safety of remimazolam during EBUS-TBNA under moderate sedation. It will provide information for optimizing sedation modalities and contribute to practical benefits in patients undergoing EBUS-TBNA.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT06275594). Prospectively registered on 15 February 2024.

Stressors, emotions, and social support systems among respiratory nurses during the Omicron outbreak in China: a qualitative study

BACKGROUND

Respiratory nurses faced tremendous challenges when the Omicron variant spread rapidly in China from late 2022 to early 2023. An in-depth understanding of respiratory nurses' experiences during challenging times can help to develop better management and support strategies. The present study was conducted to explore and describe the work experiences of nurses working in the Department of Pulmonary and Critical Care Medicine (PCCM) during the Omicron outbreak in China.

METHODS

This study utilized a descriptive phenomenological method. Between January 9 and 22, 2023, semistructured and individual in-depth interviews were conducted with 11 respiratory nurses at a tertiary hospital in Wuhan, Hubei Province. A purposive sampling method was used to select the participants, and the sample size was determined based on data saturation. The data analysis was carried out using Colaizzi's method.

RESULTS

Three themes with ten subthemes emerged: (a) multiple stressors (intense workload due to high variability in COVID patients; worry about not having enough ability and energy to care for critically ill patients; fighting for anxious clients, colleagues, and selves); (b) mixed emotions (feelings of loss and responsibility; feelings of frustration and achievement; feelings of nervousness and security); and (c) a perceived social support system (team cohesion; family support; head nurse leadership; and the impact of social media).

CONCLUSION

Nursing managers should be attentive to frontline nurses' needs and occupational stress during novel coronavirus disease 2019 (COVID-19) outbreaks. Management should strengthen psychological and social support systems, optimize nursing leadership styles, and proactively consider the application of artificial intelligence (AI) technologies and products in clinical care to improve the ability of nurses to effectively respond to future public health crises.

Gender equity of authorship in pulmonary medicine over the past decade

BACKGROUND

Gender disparity in authorship broadly persists in medical literature, little is known about female authorship within pulmonary medicine.

METHODS

A bibliometric analysis of publications from 2012 to 2021 in 12 journals with the highest impact in pulmonary medicine was conducted. Only original research and review articles were included. Names of the first and last authors were extracted and their genders were identified using the Gender-API web. Female authorship was described by overall distribution and distribution by country/region/continent and journal. We compared the article citations by gender combinations, evaluated the trend in female authorship, and forecasted when parity for first and last authorship would be reached. We also conducted a systematic review of female authorship in clinical medicine.

RESULTS

14,875 articles were included, and the overall percentage of female first authors was higher than last authors (37.0% vs 22.2%, p<0.001). Asia had the lowest percentage of female first (27.6%) and last (15.2%) authors. The percentages of female first and last authors increased slightly over time, except for a rapid increase in the COVID-19 pandemic periods. Parity was predicted in 2046 for the first authors and 2059 for the last authors. Articles with male authors were cited more than articles with female authors. However, male-male collaborations significantly decreased, whereas female-female collaborations significantly increased.

CONCLUSIONS

Despite the slow improvement in female authorship over the past decade, there is still a substantial gender disparity in female first and last authorship in high-impact medical journals in pulmonary medicine.

ABO blood group and rhesus factor association with inpatient COVID-19 mortality and severity: a two-year retrospective review

Background

Early reports have indicated a relationship between ABO and rhesus blood group types and infection with SARS-CoV-2. We aim to examine blood group type associations with COVID-19 mortality and disease severity.

Methods

This is a retrospective chart review of patients ages 18 years or older admitted to the hospital with COVID-19 between January 2020 and December 2021. The primary outcome was COVID-19 mortality with respect to ABO blood group type. The secondary outcomes were 1. Severity of COVID-19 with respect to ABO blood group type, and 2. Rhesus factor association with COVID-19 mortality and disease severity. Disease severity was defined by degree of supplemental oxygen requirements (ambient air, low-flow, high-flow, non-invasive mechanical ventilation, and invasive mechanical ventilation).

Results

The blood type was collected on 596 patients with more than half (54%, N=322) being O+. The ABO blood type alone was not statistically associated with mortality (P=0.405), while the RH blood type was statistically associated with mortality (P<0.001). There was statistically significant association between combined ABO and RH blood type and mortality (P=0.014). Out of the mortality group, the O+ group had the highest mortality (52.3%), followed by A+ (22.8%). The combined ABO and RH blood type was statistically significantly associated with degree of supplemental oxygen requirements (P=0.005). The Kaplan-Meier curve demonstrated that Rh- patients had increased mortality.

Conclusion

ABO blood type is not associated with COVID-19 severity and mortality. Rhesus factor status is associated with COVID-19 severity and mortality. Rhesus negative patients were associated with increased mortality risk.

Extra-long treatment of MDR-TB osteomyelitis of humerus due to neurotoxicity from the 2nd-line drugs: a case report

Infection with tuberculosis (TB) still considered a leading infectious cause of death, osteomyelitis TB rare entity, and being extraspinal MDR-TB make it very rare case; most of experience in treating osteomyelitis TB was derived from pulmonary TB experience, and we present a case of humerus MDR-TB that was treated for 5 years, with several interruption due to side effect and other causes.

Crossover Patient Outcomes for Targeted Lung Denervation in Moderate to Severe Chronic Obstructive Pulmonary Disease: AIRFLOW-2

BACKGROUND

Targeted Lung Denervation (TLD) is a potential new therapy for COPD. Radiofrequency energy is bronchoscopically delivered to the airways to disrupt pulmonary parasympathetic nerves, to reduce bronchoconstriction, mucus hypersecretion, and bronchial hyperreactivity.

OBJECTIVES

This work assesses the effect of TLD on COPD exacerbations (AECOPD) in crossover subjects in the AIRFLOW-2 trial.

METHOD

The AIRFLOW-2 trial is a multicentre, randomized, double-blind, sham-controlled crossover trial of TLD in COPD. Patients with symptomatic COPD on optimal medical therapy with an FEV1 of 30-60% predicted received either TLD or sham bronchoscopy in a 1:1 randomization. Those in the sham arm had the opportunity to cross into the treatment arm after 12 months. The primary end point was rate of respiratory adverse events. Secondary end points included adverse events, changes in lung function and health-related quality of life and symptom scores.

RESULTS

Twenty patients were treated with TLD in the crossover phase and were subsequently followed up for 12 months (50% female, mean age 64.1 ± 6.9 years). After TLD, there was a trend towards a reduction in time to first AECOPD (hazard ratio 0.65, p = 0.28, not statistically significant) in comparison to sham follow-up period. There was also a reduction in time to first severe AECOPD in the crossover period (hazard ratio 0.38, p = 0.227, not statistically significant). Symptom scores and lung function showed stability.

CONCLUSIONS

AIRFLOW-2 crossover data support that of the randomization phase, showing trends towards reduction in COPD exacerbations with TLD.

Prolonged mechanical ventilation after cardiac surgery: substudy of the Transfusion Requirements in Cardiac Surgery III trial

PURPOSE

Prolonged mechanical ventilation (MV) is a major complication following cardiac surgery. We conducted a secondary analysis of the Transfusion Requirements in Cardiac Surgery (TRICTS) III trial to describe MV duration, identify factors associated with prolonged MV, and examine associations of prolonged MV with mortality and complications.

METHODS

Four thousand, eight hundred and nine participants undergoing cardiac surgery at 71 hospitals worldwide were included. Prolonged MV was defined based on the Society of Thoracic Surgeons definition as MV lasting 24 hr or longer. Adjusted associations of patient and surgical factors with prolonged MV were examined using multivariable logistic regression. Associations of prolonged MV with complications were assessed using odds ratios, and adjusted associations between prolonged MV and mortality were evaluated using multinomial regression. Associations of shorter durations of MV with survival and complications were explored.

RESULTS

Prolonged MV occurred in 15% (725/4,809) of participants. Prolonged MV was associated with surgical factors indicative of complexity, such as previous cardiac surgery, cardiopulmonary bypass duration, and separation attempts; and patient factors such as critical preoperative state, left ventricular impairment, renal failure, and pulmonary hypertension. Prolonged MV was associated with perioperative but not long-term complications. After risk adjustment, prolonged MV was associated with perioperative mortality; its association with long-term mortality among survivors was weaker. Shorter durations of MV were not associated with increased risk of mortality or complications.

CONCLUSION

In this substudy of the TRICS III trial, prolonged MV was common after cardiac surgery and was associated with patient and surgical risk factors. Although prolonged MV showed strong associations with perioperative complications and mortality, it was not associated with long-term complications and had weaker association with long-term mortality among survivors.

STUDY REGISTRATION

www.

CLINICALTRIALS

gov (NCT02042898); registered 23 January 2014. This is a substudy of the Transfusion Requirements in Cardiac Surgery (TRICS) III trial.

Endobronchial blastomycoses: A rare pathogen in a unique location

A middle-aged woman from Southwest Virginia presented to pulmonary clinic with 4 months of dry cough. Further imaging with Computed Tomography (CT) of the chest showed an infiltrative lung mass. The patient underwent bronchoscopy that showed an endobronchial lesion on right and left main stem bronchi. Endobronchial biopsy of the lesion showed acute and chronic granulomatous inflammation and tissue cultures grew Blastomycoses dermatitides. We hereby present a rare case of endobronchial blastomycoses with pulmonary infiltrates presenting as chronic cough.

Airway microbial diversity is decreased in young children with cystic fibrosis compared to healthy controls but improved with CFTR modulation

BACKGROUND

Culture-independent next generation sequencing has identified diverse microbial communities within the cystic fibrosis (CF) airway. The study objective was to test for differences in the upper airway microbiome of children with CF and healthy controls and age-related differences in children with CF.

METHODS

Oropharyngeal swabs and clinical data were obtained from 25 children with CF and 50 healthy controls aged ≤6 years. Bacterial DNA was amplified and sequenced for the V4 region of 16S rRNA marker-gene. Alpha diversity was measured using operational taxonomic units (OTUs), Shannon diversity, and the inverse Simpson's index. Beta diversity was measured using Morisita-Horn and Bray-Curtis and Jaccard distances. General linear models were used for comparison of alpha diversity measures between groups to account for differences in demographics and exposures. Mixed effects general linear models were used for longitudinal comparisons 1) between children with CF of different ages and 2) between children with CF receiving CF transmembrane conductance regulator (CFTR) modulators, children with CF not receiving CFTR modulators, and healthy controls to adjust for repeated measures per subject.

RESULTS

Children with CF were more likely to have received antibiotics in the prior year than healthy controls (92% vs 24%, p < 0.001). Controlling age, race, ethnicity, length of breastfeeding, and having siblings, children with CF had a lower richness than healthy controls: OTUs 62.1 vs 83, p = 0.022; and trended toward lower diversity: Shannon 2.09 vs 2.35, p = 0.057; inverse Simpson 5.7 vs 6.92, p = 0.118. Staphylococcus, three Rothia OTUs, and two Streptococcus OTUs were more abundant in CF children versus healthy controls (all p < 0.05). Bray-Curtis and Jaccard distances, which reflect overall microbial community composition, were also significantly different (both p = 0.001). In longitudinally collected samples from children with CF, Morisita-Horn trended toward more similarity in those aged 0-2 years compared to those aged 3-6 years (p = 0.070). In children >2 years of age, there was a significant trend in increasing alpha diversity measures between children with CF not receiving CFTR modulators, children with CF receiving CFTR modulators, and healthy controls: OTUs 63.7 vs 74.7 vs 97.6, p < 0.001; Shannon 2.11 vs 2.34 vs 2.56, p < 0.001; inverse Simpson 5.78 vs 7.23 vs 7.96, p < 0.001.

CONCLUSIONS

Children with CF have lower bacterial diversity and different composition of organisms compared with healthy controls. This appears to start in early childhood, is possibly related to the use of antibiotics, and may be partially corrected with the use of CFTR modulators.

Joint Statement on the Role of Respiratory Rehabilitation in the COVID-19 Crisis: The Italian Position Paper

Due to the exponential growth of the number of subjects affected by coronavirus disease 2019 (COVID-19), the entire Italian health care system had to respond promptly and in a very short time with the need of semi-intensive and intensive care units. Moreover, trained dedicated COVID-19 teams consisting of physicians were coming from different specialties (intensivists or pneumologists and infectiologists), while respiratory therapists and nurses have been recruited to work on and on without rest. However, due to still limited and evolving knowledge of COVID-19, there are few recommendations concerning the need in respiratory rehabilitation and physiotherapy interventions. The presentation of this paper is the result of a consensus promoted by the Italian societies of respiratory health care professionals who contacted pulmonologists directly involved in the treatment and rehabilitation of COVID-19. The aim was to formulate the more proper and common suggestions to be applied in different hospital settings in offering rehabilitative programs and physiotherapy workforce planning for COVID-19 patients. Two main areas of intervention were identified: organization and treatment, which are described in this paper to face the emergency.

Use of PET/CT to aid clinical decision-making in cases of solitary pulmonary nodule: a probabilistic approach

Objective

To determine the frequency with which ¹⁸F-FDG-PET/CT findings change the probability of malignancy classification of solitary pulmonary nodules.

Materials and Methods

This was a retrospective analysis of all ¹⁸F-FDG-PET/CT examinations performed for the investigation of a solitary pulmonary nodule between May 2016 and May 2017. We reviewed medical records and PET/CT images to collect the data necessary to calculate the pre-test probability of malignancy using the Swensen model and the Herder model. The probability of malignancy was classified as low if < 5%, intermediate if 5-65%, and high if > 65%. Cases classified as intermediate in the Swensen model were reclassified by the Herder model.

Results

We reviewed the records for 33 patients, of whom 17 (51.5%) were male. The mean age was 68.63 ± 12.20 years. According to the Swensen model, the probability of malignancy was intermediate in 23 cases (69.7%). Among those, the application of the Herder model resulted in the probability of malignancy being reclassified as low in 6 (26.1%) and as high in 8 (34.8%).

Conclusion

¹⁸F-FDG-PET/CT was able to modify the probability of malignancy classification of a solitary pulmonary nodule in more than 50% of the cases evaluated.

Pulmonary Therapy 2020 Update and Podcast: Meet the Journal's Editors-in-Chief

The Editors-in-Chief of Pulmonary Therapy have prepared podcasts summarizing their current research, recent highlights from the field, and future predictions. Audio-only versions and the transcripts can be downloaded here: https://doi.org/10.6084/m9.figshare.11938863. Following this is a written summary of the journal’s recent developments and the transcripts from the podcasts.

Sleep-disordered breathing and effectiveness of cardiac resynchronization therapy in heart failure patients: gender differences?

OBJECTIVES

This study evaluated heart failure (HF) patients who underwent cardiac resynchronization therapy (CRT) and who had device-documented sleep-disordered breathing (SDB). We found gender differences in acute changes in SDB due to CRT impact.

BACKGROUND

SDB typically occurs in HF patients. However, the role of SDB and its response to CRT in HF patients, as well as the relation with gender are currently not fully researched.

METHODS

Among 63 consecutive patients who received CRT with an SDB algorithm, 23 patients documented SDB at one-month cardiac device interrogation and represented our population. We defined a Sleep apnoea Severity SCore(SSSC), and consequently, patients were categorized to have mild, moderate, and severe sleep apnoea syndrome divided into two groups: Group-1: 18 males (78%); Group-2: 5 females (22%). We evaluated the variation of apnoea burden and CRT response based on gender differences.

RESULTS

A significantly higher proportion of patients in the male group were non-responders to CRT at 12-months follow-up (p = 0.076) while in the female population 5/5 patients (100%) were responders to CRT at the same follow-up time (p = 0.021). Among Group-2 subjects, we documented a significant linear decrease in SSSC(p > 0,01) while in Group-1 the CRT effect on SSSC was variable. At 12-months follow-up, the difference in SSSC between the two groups was statistically significant (p < 0.001).

CONCLUSIONS

Our study reports a correlation between CRT response and sleep apnoea burden considering gender differences. In particular, HF-women responders to CRT demonstrate a significant linear decrease in sleep apnoea burden determined through a device algorithm, when compared to a similar male population. Further research is needed to confirm these findings.

[Apps in General Medicine : A topic for medical education?​]

BACKGROUND

Health-related apps can provide helpful resources for both doctors and patients. The selection of potentially useful apps and the appraisal of their quality are particularly important in the context of medicine as false or confusing app content may put patients at risk.

AIM

In this article a brief overview of the topic is provided and the results of a pilot study, in which medical students tested and evaluated the quality of 143 health-related apps on the topics of cardiology and pulmonology are presented.

MATERIAL AND METHODS

Using the semiautomated retrospective app store analysis (SARASA) method, a group of apps concerned with cardiology and pulmonology were identified from a pool of over 2,000,000 apps available in the Apple Store. As part of a practical exercise, 138 4th year medical students tested a total of 143 of these apps, subsequently evaluating them using a specially devised questionnaire.

RESULTS

The most frequent target population among the tested apps was identified as patients and their carers and the primary purpose in the majority of cases was the provision of information. Despite this, at least one quarter of all apps tested required users to enter sensitive health-related information. The evaluations by the students portrayed a large range in terms of the quality of the apps tested.

DISCUSSION

Health-related apps play a growing role in the management of illnesses in the field of internal medicine. Doctors must be aware of the benefits and limitations of using such apps and should be prepared during their medical studies for the challenge of advising patients on this topic.

Metastatic SMARCB1 (INI-1)-Deficient Sinonasal Carcinoma Diagnosed by Endobronchial Ultrasound-Guided Fine-Needle Aspiration (EBUS-FNA): A Potential Diagnostic Pitfall and Review of the Literature

SMARCB1 (INI-1)-deficient sinonasal carcinoma is a rare entity within the subgroup of poorly differentiated sinonasal tract carcinomas. As there are only two papers describing the cytologic features of this entity, herein we describe the unique cytomorphologic features of a pulmonary metastasis of this tumor and include the differential diagnosis based on tumor location. The patient was a 53-year-old male who initially presented with sinus congestion and vision changes including left-eye proptosis and diplopia. The initial biopsy of the ethmoid-centered sinonasal mass was non-keratinizing squamous cell carcinoma based on strong immunoreactivity with p40 and absence of immunoreactivity for chromogranin, synaptophysin, p16, and EBER. However, the final diagnosis of the surgical resection was amended to SMARCB1 (INI-1)-deficient sinonasal carcinoma after additional immunohistochemical stains were performed. Post-primary resection, follow-up computed tomography imaging revealed significant interval progression of a solitary, initially indeterminate 1-cm lung nodule in the left upper lobe. Endobronchial ultrasound-guided fine-needle aspiration with concomitant core-needle biopsy was performed. Rapid on site evaluation of cytologic smears revealed a hypercellular specimen consisting of sheets of epithelioid cells with very scant to absent cytoplasm, ill-defined cell borders, enlarged fragile nuclei, and areas of nuclear molding. Mitotic figures were present. Other areas showed tumor cells with spindled to elongated nuclei and scant to ill-defined wispy cytoplasm. Both cytology cell block and core-needle biopsy histopathologic material showed the tumor cells to be negative for INI-1 nuclear staining as well as CK5/6, CAM5.2, p40, p63, CK7, AE1/3, and TTF-1. SMARCB1 (INI-1)-deficient sinonasal carcinoma can have a spectrum of morphologies and may mimic "small-round-blue-cell" and spindle-cell tumors on cytology preparations. Given the pulmonary location of the aspirate, familiarity with the cytomorphologic spectrum of SMARCB1 (INI-1)-deficient sinonasal carcinoma, inclusion of this entity within the differential diagnosis, and performance of immunohistochemistry will aid in arriving at the correct diagnosis.

Inhaler use and education characteristics among English and non-English speaking patients: A pilot needs assessment survey

OBJECTIVE

Identify inhaler use characteristics among English (ESP) and non-English speaking patients (NSP) to develop quality improvement efforts.

METHODS

Outpatients were surveyed for technique confidence, education, preferences and disease control. We compared characteristics between ESP and NSP.

RESULTS

Of 197 respondents, 75% were ESP, 25% were NSP. Compared to NSP, ESP responders were more likely female (57% vs 31%, p = 0.001), used inhalers for a longer time (10 vs 6 years, p = 0.008) and had higher rates of metered dose inhaler use (85% vs. 60%, p < 0.001). Both language groups had similar confidence in inhaler use, after adjustment for age, gender and duration of use. Similar rates of inhaler technique education were reported by ESP and NSP at the initial visit. More NSP reported receiving education at subsequent visits (54% vs. 72%, p = 0.03). Education for both groups was mostly performed by a clinician. Both language groups reported low internet use for learning proper technique, low interest in a separate education session, preferred an active learning method.

CONCLUSIONS

These findings will be used to further develop quality inhaler education efforts at our institution.

PRACTICAL IMPLICATIONS

Local patient preferences should be considered when designing inhaler education programs.

Impact of a digital health intervention on asthma resource utilization

Digital health interventions have been associated with reduced rescue inhaler use and improved controller medication adherence. This quality improvement project assessed the benefit of these interventions on asthma-related healthcare utilizations, including hospitalizations, emergency department (ED) utilization and outpatient visits. The intervention consisted of electronic medication monitors (EMMs) that tracked rescue and controller inhaler medication use, and a digital health platform that presented medication use information and asthma control status to patients and providers. In 224 study patients, the number of asthma-related ED visits and combined ED and hospitalization events 365 days pre- to 365 days post-enrollment to the intervention significantly decreased from 11.6 to 5.4 visits (p < 0.05) and 13.4 to 5.8 events (p < 0.05) per 100 patient-years, respectively. This digital health intervention was successfully incorporated into routine clinical practice and was associated with lower rates of asthma-related hospitalizations and ED visits.

Pictorial review of the pulmonary vasculature: from arteries to veins

Pathology of the pulmonary vasculature involves an impressive array of both congenital and acquired conditions. While some of these disorders are benign, disruption of the pulmonary vasculature is often incompatible with life, making these conditions critical to identify on imaging. Many reviews of pulmonary vascular pathology approach the pulmonary arteries, pulmonary veins and bronchial arteries as individual topics. The goal of this review is to provide an integrated overview of the high-yield features of all major disorders of the pulmonary vasculature. This approach provides a more cohesive and comprehensive conceptualisation of respiratory pathology. In this review, we present both the salient clinical and imaging features of congenital and acquired disorders of the pulmonary vasculature, to assist the radiologist in identifying pathology and forming a robust differential diagnosis tailored to the presenting patient. TEACHING POINTS: • Abnormalities of the pulmonary vasculature are both congenital and acquired. • Pathology of a single pulmonary vascular territory often affects the entire pulmonary vasculature. • Anomalous pulmonary venous flow is named as a function of its location and severity. • Bronchial arteries often undergo dilatation secondary to cardio-respiratory pathology.

Who treats lung cancer? Results from a global survey

BACKGROUND

In most Western nations, the medical oncologist plays a significant role in the administration of systemic therapy for lung cancer. In Japan however, treatment for lung cancer has historically been provided by pulmonologists and thoracic surgeons. A comparison of the management of advanced disease between Japan and other nations has not been described.

METHODS

An online, self-administered, international survey was sent to 3907 active members of the American Society of Clinical Oncology. Eligible participants were degreed physicians who prescribed systemic agents for adult cancer treatment within the past five years.

RESULTS

In total, 281 respondents answered the questions regarding management of lung cancer. Thorough analysis demonstrated that pulmonologists play a significant role in Japan and the Netherlands, where the role of oncologic specialists is not well established. Of note, all the respondents from the Netherlands reported that pulmonary medicine primarily manages systemic chemotherapy in stage IV, adjuvant chemotherapy, and targeted therapy.

CONCLUSION

We found there are several nations where non-oncologic specialists play a critical role in the systemic treatment of lung cancer. We expect this practice pattern to continue until the global adoption of the oncologic specialty role.

Implementing flexible bronchoscopy in least developed countries according to international guidelines is feasible and sustainable: example from Phnom-Penh, Cambodia

BACKGROUND

Flexible bronchoscopy is pivotal for the diagnosis of most respiratory diseases. A flexible bronchoscopy unit (FBU) was created in 2008 in the Preah Kossamak university hospital (Phnom Penh, Cambodia) through a cooperation program between a French and a Cambodian team. In 2009 we conducted an assessment of the compliance of the FBU to international standards and found that most of French and British guidelines were fully applied or adapted to local practice. The aim of the current work was to assess FBU again 6 years later, in order to determine if compliance to international guidelines was sustainable.

METHODS

The 2015 evaluation was conducted identically to 2009. All recommendation items from the French and the British Thoracic Societies guidelines were assessed individually. Each recommendation was assigned a status expressing the level at which it was respected in Cambodia: applied, adapted, not applied and not evaluable. An endoscope microbial sampling was performed as recommended by the French Ministry of Health.

RESULTS

Between 2009 and 2015, the pattern of international recommendations in the Cambodian FBU did not change. Notably the rates of applied French evaluable recommendations remained stable: respectively 58% vs 57%. Main changes in French guidelines occurred in adapted items that became applied (n = 5/15) while 4 previously adapted/applied items became not applied. Furthermore, all microbial analyses showed sterile results.

CONCLUSIONS

Our results show that implementation of a high quality FBU in a least-developed country is feasible. In addition, the performance is maintained in the long-term.

Life expextancy of parents with Hereditary Haemorrhagic Telangiectasia

Background

Hereditary Haemorrhagic Telangiectasia (HHT) is an autosomal dominant disease associated with epistaxis, arteriovenous malformations and telangiectasias. Disease complications may result in premature death.

Method

We investigated life-expectancies of parents of HHT patients compared with their non-HHT partners using self- or telephone-administered questionnaires sent to their children. Patients were extracted from the databases of 2 participating HHT Centres: the Toronto HHT Database (Toronto, Canada) and the St. Antonius Hospital HHT Database (Nieuwegein, The Netherlands).

Results

Two hundred twenty five/407 (55 %) of respondents were included creating HHT- (n = 225) and control groups (n = 225) of equal size. Two hundred thirteen/225 (95 %) of the HHT group had not been screened for organ involvement of the disease prior to death. The life expectancy in parents with HHT was slightly lower compared to parents without (median age at death 73.3 years in patients versus 76.6 years in controls, p0.018). Parents with ACVRL 1 mutations had normal life expectancies, whereas parents with Endoglin mutations died 7.1 years earlier than controls (p = 0.024). Women with Endoglin mutations lived a median of 9.3 years shorter than those without (p = 0.04). Seven/123 (5 %) of deaths were HHT related with a median age at death of 61.5 years (IQ range 54.4–67.7 years).

Conclusion

Our study showed that the life expectancy of largely unscreened HHT patients was lower than people without HHT. Female patients with Endoglin mutations were most strikingly at risk of premature death from complications. These results emphasize the importance of referring patients with HHT for screening of organ involvement and timely intervention to prevent complications.

[Residents in respiratory medicine: Assessment of the course and wishes regarding their career]

INTRODUCTION

The aim of this study was to assess the feelings of residents in respiratory medicine regarding the quality and organization of their training and towards their career prospects.

METHODS

A prospective survey conducted over the Internet among all the members of the French Young Pulmonologists Association (AJPO2).

RESULTS

One hundred and thirty-two (71.5%) members responded. The rating given to theoretical training was 6 [5-7] whereas the practical training was rated at 7 [6-8] out of 10. The majority of the residents considered that the length of their course should be adapted (80.3%). Of them, 74.2% wanted to add a mandatory semester. The proposed mandatory semester was in bronchoscopy (40.3%). Seventy-two percent of the resident wanted to acquire a specialisation, the most common of which was in oncology (36.6%). Among the residents, 96.2% wanted to conduct a fellowship. The main reason for this was their feeling of inability to correctly handle patients at the end of their residency. Of the residents, 55.3% were considering working in a public hospital.

CONCLUSION

There are opportunities to improve the French respiratory residency training both in its theory and practical aspects. The modalities of this training could also be adapted. Access to a fellowship is a major concern for the residents.

Systems medicine: a new approach to clinical practice

Most respiratory diseases are considered complex diseases as their susceptibility and outcomes are determined by the interaction between host-dependent factors (genetic factors, comorbidities, etc.) and environmental factors (exposure to microorganisms or allergens, treatments received, etc.) The reductionist approach in the study of diseases has been of fundamental importance for the understanding of the different components of a system. Systems biology or systems medicine is a complementary approach aimed at analyzing the interactions between the different components within one organizational level (genome, transcriptome, proteome), and then between the different levels. Systems medicine is currently used for the interpretation and understanding of the pathogenesis and pathophysiology of different diseases, biomarker discovery, design of innovative therapeutic targets, and the drawing up of computational models for different biological processes. In this review we discuss the most relevant concepts of the theory underlying systems medicine, as well as its applications in the various biological processes in humans.

Telepulmonology: effect on quality and efficiency of care

BACKGROUND

Interpreting spirometry results has proven challenging in primary care practice, among others potentially leading to under- and misdiagnosis of COPD. In telepulmonology a general practitioner (GP) digitally consults a pulmonologist to support the interpretation of spirometry results. This study assessed the effect of telepulmonology on quality and efficiency of care.

METHODS

Quality of care was measured by five indicators, among others the percentage of TelePulmonology Consultations (TPCs) sent by GPs for advice, percentage of those TPCs resulting in a physical referral, and educational effect of telepulmonology as experienced by GPs. Efficiency was defined as the percentage of prevented unnecessary physical referrals of patients to the pulmonologist.

RESULTS

Between April 2009 and November 2012 1.958 TPCs were sent by 158 GPs to 32 pulmonologists. Sixty-nine percent of the TPCs were sent for advice. Based on the advice of the pulmonologist 18% of these TPCs led to a physical referral of patients who would not have been referred without telepulmonology. Thirty-one percent of the TPCs were intended to prevent a physical referral, 68% of these actually prevented a physical referral to a pulmonologist.

CONCLUSION

The results show telepulmonology can contribute to quality of care by supporting GPs and can additionally prevent unnecessary physical referrals.