[Evaluation of the use of a simulation software in the learning of cardiopulmonary auscultation in undergraduate medical students]

INTRODUCTION

Medsounds™ software allows to create an auscultation learning platform, by providing real pre-recorded cardiopulmonary sounds on virtual chests. The study aimed at comparing the skills in cardiopulmonary auscultation between students who benefited from this platform and students who did not have access to it.

METHODS

A controlled trial was conducted with 2nd year medical students randomised into three groups. Groups A, B and C received 10 h of cardiopulmonary clinical training. In addition, group B benefited from an online access to the educative platform, and group C had a demonstration of the platform during their clinical training, then an online access. The main outcome was a 3-point multiple-choice questionnaire based on 2 original case vignettes about the description of cardiopulmonary sounds. The secondary outcome was the faculty exam on high-fidelity cardiopulmonary simulator.

RESULTS

Groups A and B included 127 students, and group C 117. Students in group C had a significantly higher score than those in group A (1.72/3 versus 1.48/3; p = 0.02), without difference between the groups B and C. Students who actually had a demonstration of the platform and used it at home had a higher score than those who did not use it (1.87 versus 1.51; p = 0.01). Students who had a demonstration of the platform before using it performed a better pulmonary examination on high-fidelity simulators.

CONCLUSION

The supervised use of an online auscultation simulation software in addition to the traditional clinical training seems to improve the auscultation performances of undergraduated medical students.

Diagnostic accuracy of screening tests for COPD: a systematic review and meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is widely underdiagnosed. A number of studies have evaluated the accuracy of screening tests for COPD, but their findings have not been formally summarised. We therefore sought to determine and compare the diagnostic accuracy of such screening tests in primary care.

METHODS

Systematic review and meta-analysis of the diagnostic accuracy of screening tests for COPD confirmed by spirometry in primary care. We searched MEDLINE, EMBASE and other bibliographic databases from 1997 to 2013 for diagnostic accuracy studies that evaluated 1 or more index tests in primary care among individuals aged ≥35 years with no prior diagnosis of COPD. Bivariate meta-analysis of sensitivity and specificity was performed where appropriate. Methodological quality was assessed independently by 2 reviewers using the QUADAS-2 tool.

RESULTS

10 studies were included. 8 assessed screening questionnaires (the COPD Diagnostic Questionnaire (CDQ) was the most evaluated, n=4), 4 assessed handheld flow meters (eg, COPD-6) and 1 assessed their combination. Among ever smokers, the CDQ (score threshold ≥19.5; n=4) had a pooled sensitivity of 64.5% (95% CI 59.9% to 68.8%) and specificity of 65.2% (52.9% to 75.8%), and handheld flow meters (n=3) had a sensitivity of 79.9% (95% CI 74.2% to 84.7%) and specificity of 84.4% (68.9% to 93.0%). Inadequate blinding between index tests and spirometry was the main risk of bias.

CONCLUSIONS

Handheld flow meters demonstrated higher test accuracy than the CDQ for COPD screening in primary care. The choice of alternative screening tests within whole screening programmes should now be fully evaluated.

PROSPERO REGISTRATION NUMBER

CRD42012002074.

[Age-adjusted D-dimers and pulmonary embolism]

Plasma D-dimer measurement is the first diagnostic test performed in patients with a non-high or an unlikely clinical probability of pulmonary embolism (PE) but its clinical usefulness is limited in elderly patients due to a low specificity in this subgroup. PE can be excluded based on D-dimers and clinical probability only in about 5% of patients over 80 years when using the conventional cut-off. Age-adjusted D-dimer cut-off (adjusted cut-off value = age x 10 in patients over 50) increases the specificity of the test without significantly reducing its sensitivity. Using the age-adjusted D-dimer cut-off markedly reduces the need for further diagnostic studies such as computed tomography pulmonary angiography (CTPA). The age-adjusted cut-off has been widely validated in retrospective cohorts, and more recently in a prospective management study.

"I can't find anything wrong: it must be a pulmonary embolism": Diagnosing suspected pulmonary embolism in primary care, a qualitative study

BACKGROUND

Before using any prediction rule oriented towards pulmonary embolism (PE), family physicians (FPs) should have some suspicion of this diagnosis. The diagnostic reasoning process leading to the suspicion of PE is not well described in primary care.

OBJECTIVE

to explore the diagnostic reasoning of FPs when pulmonary embolism is suspected.

METHOD

Semi-structured qualitative interviews with 28 FPs. The regional hospital supplied data of all their cases of pulmonary embolism from June to November 2011. The patient's FP was identified where he/she had been the physician who had sent the patient to the emergency unit. The first consecutive 14 FPs who agreed to participate made up the first group. A second group was chosen using a purposeful sampling method. The topic guide focused on the circumstances leading to the suspicion of PE. A thematic analysis was performed, by three researchers, using a grounded theory coding paradigm.

RESULTS

In the FPs' experience, the suspicion of pulmonary embolism arose out of four considerations: the absence of indicative clinical signs for diagnoses other than PE, a sudden change in the condition of the patient, a gut feeling that something was seriously wrong and an earlier failure to diagnose PE. The FPs interviewed did not use rules in their diagnostic process.

CONCLUSION

This study illustrated the diagnostic role of gut feelings in the specific context of suspected pulmonary embolism in primary care. The FPs used the sense of alarm as a tool to prevent the diagnostic error of missing a PE. The diagnostic accuracy of gut feelings has yet to be evaluated.

The diagnosis and treatment of acute cough in adults

BACKGROUND

Cough is the most common complaint for which patients visit their primary care physician, being present in about 8% of consultations. A profusion of new evidence has made it necessary to produce a comprehensively updated version of the guideline on cough of the German College of General Practitioners and Family Physicians (Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin, DEGAM), which was last issued in 2008.

METHOD

The interdisciplinary evidence and consensus based S3 guideline on cough of the DEGAM was updated on the basis of a systematic review of the relevant literature published from 2003 to July 2012 (MEDLINE, Cochrane Library, EMBASE, Web of Science). Evidence levels were assessed and consensus procedures were followed as prescribed by AWMF standards, with the participation of 7 medical societies.

RESULTS

182 publications were used to update the guideline, including 45 systematic reviews (26 of which included a meta-analysis) and 17 randomized controlled trials (RCTs). 11 recommendations for acute cough were approved by consensus in a nominal group process. The history and physical examination are the basis of diagnostic evaluation. When the clinical diagnosis is that of an acute, uncomplicated bronchitis, no laboratory tests, sputum evaluation, or chest x-rays should be performed, and antibiotics should not be given. There is inadequate evidence for the efficacy of antitussive or expectorant drugs against acute cough. The state of the evidence for phytotherapeutic agents is heterogeneous. Persons with community-acquired pneumonia should receive empirical antibiotic treatment for 5 to 7 days; specific risk factors can influence the choice of drug to be used. It is recommended that laboratory tests should not be performed and neuraminidase inhibitors should not be given in the routine management of influenza.

CONCLUSION

A specifically intended effect of these recommendations is to reduce the use of antibiotics to treat colds and acute bronchitis, for which they are not indicated. Further clinical trials of treatments for cough should be performed in order to extend the evidence base, which is now fragmentary.

An official American Thoracic Society clinical practice guideline: classification, evaluation, and management of childhood interstitial lung disease in infancy

BACKGROUND

There is growing recognition and understanding of the entities that cause interstitial lung disease (ILD) in infants. These entities are distinct from those that cause ILD in older children and adults.

METHODS

A multidisciplinary panel was convened to develop evidence-based guidelines on the classification, diagnosis, and management of ILD in children, focusing on neonates and infants under 2 years of age. Recommendations were formulated using a systematic approach. Outcomes considered important included the accuracy of the diagnostic evaluation, complications of delayed or incorrect diagnosis, psychosocial complications affecting the patient's or family's quality of life, and death.

RESULTS

No controlled clinical trials were identified. Therefore, observational evidence and clinical experience informed judgments. These guidelines: (1) describe the clinical characteristics of neonates and infants (<2 yr of age) with diffuse lung disease (DLD); (2) list the common causes of DLD that should be eliminated during the evaluation of neonates and infants with DLD; (3) recommend methods for further clinical investigation of the remaining infants, who are regarded as having "childhood ILD syndrome"; (4) describe a new pathologic classification scheme of DLD in infants; (5) outline supportive and continuing care; and (6) suggest areas for future research.

CONCLUSIONS

After common causes of DLD are excluded, neonates and infants with childhood ILD syndrome should be evaluated by a knowledgeable subspecialist. The evaluation may include echocardiography, controlled ventilation high-resolution computed tomography, infant pulmonary function testing, bronchoscopy with bronchoalveolar lavage, genetic testing, and/or lung biopsy. Preventive care, family education, and support are essential.

Near point-of-care administration by the attending physician of the rapid influenza antigen detection immunochromatography test and the fully automated respiratory virus nucleic acid test: contribution to patient management

Rapid influenza antigen detection tests (RIADTs) using immunochromatography are the most readily available tools for the diagnosis and management of influenza. This study was designed to assess whether near point-of-care administration by primary care physicians of the RIADT and a fully automated respiratory virus nucleic acid test (Verigene Respiratory Virus Plus®; RV+) would contribute to improved patient management. When viral culture and RT-PCR/bi-directional sequencing were used as the gold standard, sensitivities and specificities for RIADT and RV+ were 58.3% and 90.9%, and 97.2% and 100%, respectively. Within 12 hours from onset of fever, sensitivities were 44.4% and 94.4%, respectively, for RIADT and RV+. In clinical situations where a higher-sensitivity test is needed, such as during pre-admission evaluations, for testing of hospital employees during the prodromal phase of infection, during the therapeutic decision-making process, and during outbreaks, we suggest that patients testing negative by the RIADT can be reassessed with the RV+ test to achieve maximal diagnostic accuracy.

Scoring system for the diagnosis of tuberculosis in indigenous children and adolescents under 15 years of age in the state of Mato Grosso do Sul, Brazil

OBJECTIVE

To evaluate the process of diagnosing pulmonary tuberculosis in smear-negative indigenous children and adolescents under 15 years of age with the modified Brazilian National Ministry of Health Scoring System (mBNMH-SS).

METHODS

This was a retrospective descriptive study involving 49 indigenous patients under 15 years of age with tuberculosis, treated between 2007 and 2010 in the state of Mato Grosso do Sul, Brazil.

RESULTS

Of the 49 patients, 27 (56%) were under 5 years of age, 33 (67%) had symptoms suggestive of tuberculosis, 24 (49%) were underweight, and 36 (73.5%) had been BCG vaccinated. The tuberculin skin test was positive in 28 patients (57%), 18 (64%) of whom had an induration > 10 mm. Chest X-rays were performed in 37 (76%) of the patients, 31 (84%) of whom had only one chest X-ray taken. Among those 37 patients, the radiological findings were suggestive of tuberculosis in 16 (43%), infiltration/condensation in 10 (27%), and normal in 4 (11%). The Indigenous Health Care Teams made the diagnosis in 31 (63%) of the cases, using the original BNMH-SS in only 14 (45%). We calculated the mBNMH-SS scores for 30 (61%) of the 49 patients. Among the 30 cases scored, a diagnosis of tuberculosis was found to be highly likely, possible, and unlikely in 16 (53%), 11 (37%), and 3 (10%), respectively.

CONCLUSIONS

The proportion of highly likely and possible diagnoses was consistent with the standard proportion of cases diagnosed by the teams (90%), demonstrating the epidemiological applicability of the mBNMH-SS for the diagnosis of pulmonary tuberculosis in the indigenous population, within the scenario of the health care provided.

Performance of frontloading for smear microscopy in the diagnosis of pulmonary tuberculosis: a cross-sectional study at a referral hospital in Uganda

Objective

To compare the performance of frontloading and the standard WHO method for diagnosis of pulmonary TB at Mulago Hospital in order to validate the technique in this setting.

Methods

This was a cross-sectional study in which 229 adult (≥18 years) TB suspects were consecutively enrolled. Suspects submitted three sputum samples as follows: at initial presentation, one hour after the first sample, and the next morning. The first and next morning samples formed the standard WHO method, while the first and the one hour later samples formed the frontloading method. Sample processing was by the standard N-acetyl L-cystein (NALC)-NaOH method, and fluorescent microscopy was done for both methods, while cultures of the first sample on Lowenstein-Jensen slants acted as a gold standard. The sensitivity, specificity and predictive values for the WHO standard and frontloading methods were compared.

Results

The sensitivity of both the frontloading and standard schemes was 91.1% while their specificities were 86.2% and 91.7% respectively. There was excellent agreement between the diagnostic capacity of the two methods (kappa statistic = 0.87, P<0.0001). The positive predictive value for the frontloading scheme was 87.2% and that for the standard approach was 91.9%, while the negative predictive values were 90.4% and 90.9%, respectively. Among the HIV positive patients, frontloading identified 59/79 (74.7%) culture positive samples while the standard approach identified 55/79 (69.6%). In the HIV sero-negative category, on the other hand, front-loading identified 48/110 (43.6%) culture positive samples compared to 45/110 (40.9%) by the standard approach.

Conclusion

Frontloading based on smear examination of two same-day sputum samples has a similar performance to the current standard method and would not be associated with any significant missed diagnosis. It may therefore be advocated for use in our setting so as to reduce time to completion of diagnosis and patient loss to follow-up.

[Periodicity and quality of clinical diagnostics of protracted pneumonia in a tuberculosis clinic]

Analysis of the quality and modes of clinical diagnostics of protracted pneumonia in a tuberculosis clinic revealed the most frequent causes of this condition responsible for hyperdiagnostics of tuberculosis. These are concomitant diseases, pneumosclerosis, chronic bronchitis, fibrous transformation of the bronchial tree, complicated clinical course of pneumonia, age above 60 years, history of tuberculosis, inadequate or short-term antibiotic therapy at the initial stages of diagnostics. Motivational prerequisites for high-quality diagnostic work include compliance with standards and guidelines for the examination and management of patients suspected of having pneumonia with a view to detecting tuberculosis. Such approach would decrease the frequency of ungrounded hospitalization of patients at tuberculosis clinics.

[The expertise of quality of diagnostics of bronchial asthma in ambulatory polyclinic institutions]

The article deals with the comprehensive expertise of quality of diagnostics of bronchial asthma in ambulatory polyclinic institutions of pediatric profile. The following techniques were applied: the retrospective analysis of all cases of bronchial asthma among children of City of Yugorsk of Hanti-Mansiisky autonomous okrug (n = 92), expertise of the causes of late diagnostics and possible ways of optimization of earlier diagnostics of bronchial asthma in ambulatory polyclinic institution (20 experts), testing the pediatricians working in children polyclinics (n = 95) on the knowledge of dealing with bronchial asthma. The late diagnostics is ascertained in 95% of cases and average period of diagnostics delay consisted 3 days. The leading role of inadequate theoretical background of pediatricians as a "triggering device" in progressive development of disease is established. The necessity to develop various forms of ongoing training of physicians of primary care for optimizing modern diagnostics of bronchial asthma in polyclinic conditions is justified.

[Analysis of reasons for late recognition of tuberculosis and cancer of the lung and the ways of enhancing the efficiency of their differential diagnosis]

Difficulties in the differential diagnosis of tuberculosis and cancer of the lung were analyzed in 272 patients from a regional tuberculosis dispensary. The efficiency of using the real-time polymerase chain reaction (PCR) to detect Mycobacterium tuberculosis DNA molecule fragments in the sputum specimens from 111 patients of this category was studied to improve the differential diagnosis of these diseases. The real-time PCR was ascertained to be a rather highly sensitive (78.3%) and highly specific (96.1%) technique for tuberculosis diagnosis, which considerably improves the etiological recognition of the pathological process. Examinations of patients with peripheral lung cancer and benign round shadow formations in the lung yielded encouraging results. The specificity of the technique in this pathology is as high as 100%.

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary

Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

Diagnostic strategies for nosocomial pneumonia

PURPOSE OF REVIEW

This review describes advances in clinical and microbiological modalities for diagnosis of nosocomial pneumonia and the role of biological markers.

RECENT FINDINGS

Serial assessments with the clinical pulmonary infection score identifies nonsurvivors and allows discontinuation of antibiotics when there is low suspicion of pneumonia. Studies evaluating its clinical utility show mixed results. A meta-analysis revealed that an invasive approach does not affect mortality but reduces costs, antibiotic exposure, and multidrug resistance. In contrast to these findings, a recent trial comparing nonquantitative endotracheal aspirate and quantitative bronchoalveolar lavage cultures showed similar clinical outcomes and antibiotic utilization. The role of quantitative endotracheal aspirate for diagnosis of pneumonia not related to mechanical ventilation was recently evaluated. Procalcitonin and soluble triggering receptor expressed on myeloid cells-1 aid in diagnosis, identify sepsis related to ventilator-associated pneumonia and patients with worst outcomes.

SUMMARY

The diagnostic modality chosen depends on availability, personnel experience, and the patient's clinical status. Recent guidelines support the use of quantitative cultures in an integrated clinical and microbiological algorithm. The decision to adjust antibiotics involves clinical reassessment and interpretation of culture results. Biological markers have a potential role as screening and prognostic tools.

Agreement between clinical scoring systems used for the diagnosis of pediatric tuberculosis in the HIV era

BACKGROUND

Diagnosis of childhood tuberculosis (TB) remains a challenge, especially in high human immunodeficiency virus (HIV) prevalence areas.

METHODS

Retrospective study of TB cases registered at a pediatric hospital over a 1-year period in Kinshasa, Democratic Republic of Congo. Data were used to calculate scores for eight diagnostic scoring systems. Correlations between scores, agreement among scoring systems on which children are in need of treatment, and clinical presentation by HIV infection status were assessed using Spearman rank correlations, kappa statistics and bivariate analysis.

RESULTS

The 42 HIV-infected children were more likely to be older, exposed to TB, have a history of TB, and present with lymphadenopathy and malnutrition, compared to the 45 non-HIV-infected children. Correlations of scores between scales unrelated in their development and agreement among scales on decision to treat were moderate to poor. One in seven children would not have received treatment according to at least one scale.

CONCLUSION

The clinical presentation of TB in HIV-infected and non-infected children was quite similar, but HIV-infected children were more likely to have a prior history of TB. Correlation between clinical scoring systems was poor, with some disagreement on the decision of whom to treat, underscoring the need for improved childhood TB diagnostics.

Validez de los criterios diagnósticos del síndrome de distrés respiratorio agudo

Acute respiratory distress syndrome (ARDS) is defined according to the criteria of the 1994 consensus conference. These criteria aim to <<bring clarity and uniformity to the definition of this clinical entity>>. However, the histological criteria that correspond to ARDS are the criteria of diffuse alveolar damage described in 1976 by Katzenstein et al., which are still valid at present. In the last decade, different studies have been published that have tried to correlate the clinical syndrome with the histological findings. These studies have been basically done in experimental animals, but also by the description of the pulmonary biopsy findings and post-mortem study findings. The present article aims to show discrepancy between clinical and histological diagnosis of the acute pulmonary lesion, basically having an effect on the difficulty of the ARDS diagnosis when its origin is pulmonary and the implications of this discrepancy in the clinical practice and research.

Evaluation of a proposed diagnostic scoring system for pulmonary tuberculosis in Brazilian children

In a case-control study to evaluate a systematic scoring system for diagnosing pulmonary tuberculosis (PTB) in children, cases had gastric lavage cultures positive for Mycobacterium tuberculosis and recovered after anti-tuberculosis treatment, while controls had negative cultures and recovered with non-anti-tuberculosis treatment. Radiological aspect (OR = 25.39), contact with a tuberculous adult (OR = 10.67) and tuberculin skin test > or = 10 mm (OR = 8.23) were associated with PTB diagnosis. The sensitivity of the score ranged from 58% to 89% and the specificity from 98% to 86%, with cut-offs of respectively > or = 40 or > or = 30. The scoring system may be a useful diagnostic method in areas with a high prevalence of TB.

A critical appraisal of methods used in early clinical development of novel drugs for the treatment of asthma

Asthma is a heterogeneous disorder characterized by chronic airway inflammation, hyperresponsiveness and remodeling. Being the hallmark of asthma, airway inflammation has become the most important target for therapeutic agents. Consequently, during the past decade various semi-and non-invasive methods have been explored to sample the airway inflammation in asthma. In this review, we provide a practical overview of the current status of various sampling techniques including sputum induction, exhaled breath analysis, and bronchoprovocation tests (BPTs). We focus on their applicability for monitoring in clinical practice and in intervention trials in asthma.

Validation of a rapid diagnostic strategy for determination of significant bacterial counts in bronchoalveolar lavage samples

CONTEXT

Bacterial cultures of bronchoscopic samples require 1 to 2 days for results to be available for use in clinical decisions. We developed a rapid diagnostic testing strategy that is highly sensitive for screening bacteria in bronchoalveolar lavage (BAL) samples, with results available within hours of collection.

OBJECTIVE

To validate the ability of a bacterial adenosine triphosphate (ATP) assay and routine Gram stain microscopy to detect significant bacterial counts in BAL samples.

DESIGN

Four hundred seventy-seven BAL samples from 319 patients suspected of having pneumonia were tested using a rapid diagnostic strategy, consisting of Gram stain and a bacterial ATP assay. Rapid results were compared with quantitative cultures with a positive cutoff of 10(4) CFU/mL or higher.

RESULTS

Significant bacterial counts were identified in 107 samples (22%). The most common etiologic agents were Staphylococcus aureus (25%), Haemophilus influenzae (17%), and Streptococcus pneumoniae (12%). The rapid test results were false negative in 5 cases (S aureus in 2, both Klebsiella pneumoniae and S aureus in 1, and Stenotrophomonas maltophilia and S pneumoniae in 1 case each). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the rapid diagnostic strategy were 95.3%, 54.9%, 37.9%, 97.6%, and 63.9%, respectively.

CONCLUSION

A negative result with this rapid diagnostic testing strategy rules out significant bacterial counts in BAL samples with a high degree of certainty and may allow use of narrow-spectrum antimicrobial agents or withholding of empiric antimicrobial therapy in patients suspected of having ventilator-associated pneumonia.

Validity of the HEDIS criteria to identify children with persistent asthma and sustained high utilization

BACKGROUND

The most widely used performance measure for asthma, the Health Plan Employer Data and Information Set (HEDIS), has been criticized because the delay between classification (year 1) and assessment of medication dispensing (year 2) may produce a "misalignment" and weaken the validity of the measure.

OBJECTIVE

To examine whether a previously observed association between the HEDIS performance measure and asthma-related emergency department visits is robust when the period between the classification and outcome assessment is evaluated during a 2-year period as defined.

METHODS

Children (N = 2766) aged 3 to 15 years enrolled in 1 of 3 managed care organizations with at least 1 asthma diagnosis listed for a hospitalization, an emergency department visit, or an ambulatory encounter and at least 2 consecutive years of data for analysis from July 1996 through June 1999 were identified.

RESULTS

Children did not consistently meet the HEDIS criteria for persistent asthma, and 24% to 28% of children did not requalify in year 2 of observation. Multivariate regression models showed that a protective relationship between controller medication dispensing and asthma-related emergency department visits was no longer seen among children meeting the HEDIS criteria for persistent asthma when the total period of observation is extended to 2 years (odds ratio, 0.7; 95% confidence interval, 0.4-1.2).

CONCLUSIONS

Our results suggest that the variable nature of asthma may affect how the HEDIS performance measure should be used for assessing quality of care. The period between identification of the target population and performance assessment should be closely related in time.

Minimum dataset for the recording of findings of flexible nasopharyngolaryngoscopy

A dataset for assessing and recording findings of flexible nasopharyngolaryngoscopy is proposed.

Potential Limitations of Clinical Criteria for the Diagnosis of Idiopathic Pulmonary Fibrosis/Cryptogenic Fibrosing Alveolitis

BACKGROUND

The need to perform surgical lung biopsy (SLB) in all cases of suspected idiopathic pulmonary fibrosis/cryptogenic fibrosing alveolitis (IPF/CFA) is controversial. The American Thoracic Society (ATS) and the European Respiratory Society (ERS) recently endorsed explicit clinical criteria for the diagnosis of IPF/CFA in the absence of SLB. Prior studies evaluating clinical criteria for the diagnosis of IPF/CFA have been limited in that either they were performed by clinicians with expertise in the diagnosis of IPF/CFA or they did not utilize explicit diagnostic criteria. We investigated the accuracy of the ATS/ERS criteria when applied in a general pulmonary medicine setting.

OBJECTIVES

To determine the interobserver variability of clinical criteria for the diagnosis of IPF/CFA.

METHODS

This was a retrospective, blinded evaluation by three board certified pulmonary physicians without extensive experience in the evaluation of IPF/CFA performed at a United States Army tertiary care academic medical center. Patients referred for surgical lung biopsy as part of a diagnostic evaluation of interstitial lung disease (ILD) were evaluated. The physicians reviewed high-resolution computed tomography scans of the chest (HRCT) and clinical data for each patient. The physicians were blinded to all other data and to the opinions of other study participants. Employing the histologic presence of usual interstitial pneumonia (UIP) coupled with appropriate clinical findings as the gold standard for a diagnosis of IPF/CFA we determined the accuracy and interobserver variability for a diagnosis of IPF/CFA based on HRCT alone and based on the ATS/ERS clinical criteria.

RESULTS

The sensitivity and positive predictive value for a HRCT diagnosis of IPF/CFA were 71% each while specificity and negative predictive value were 67% each. For the ATS/ERS criteria sensitivity, specificity, positive predictive value and negative predictive value were 71, 75, 77 and 69%, respectively. The interobserver variability, expressed as a kappa coefficient, for HRCT and the ATS/ERS criteria were 0.59 and 0.53, respectively.

CONCLUSIONS

Both HRCT and the ATS/ERS clinical criteria may lead to misdiagnosis of patients with ILD. Further studies are needed to fully characterize the accuracy of these tests when applied in a routine pulmonary medicine practice setting.

The "frequently" normal chest x-ray

An organized approach to CXR interpretation will take you most of the way toward your goal, which is to lead you to a well grounded differential diagnosis or, in the case of a normal CXR, to rule out a variety of possibilities. Working in collaboration with your radiologist, your own interpretations will allow you to institute treatment in a timely fashion, and the subsequent radiological review will serve to confirm, or correct, initial impressions. Over time this process will improve your skill, and your patients will reap the benefits.

Retrospective analysis of evidence base for tests used in diagnosis and monitoring of disease in respiratory medicine

OBJECTIVES

To determine how many common clinical tests used in a respiratory medicine outpatient clinic are based on high quality evidence.

DESIGN

Retrospective review of case notes. Record of first three tests for each patient. Diagnostic tests, tests used to assess existing condition, explicit trials of therapy were included. Literature search for supporting evidence and grading of best evidence for each test.

SETTING

Inner city university teaching hospital in the United Kingdom.

PARTICIPANTS

All new outpatients referred to a single respiratory medicine team over a period of three months.

MAIN OUTCOME MEASURES

Proportion of tests supported by level 1a-1c evidence (scale developed by Centre for Evidence Based Medicine).

RESULTS

Only half the tests that were used to make or exclude a diagnosis and a fifth of the tests used to assess a known condition were supported by level 1a-1c evidence. There was no evidence to support trials of therapy.

CONCLUSIONS

A large proportion of clinical tests in respiratory medicine are not supported by level 1a-1c evidence. None of the therapeutic trials that were used were supported by evidence.

Heterogeneous case definitions used for the surveillance of influenza in Europe

We reviewed the case definitions used by 21 influenza sentinel-based surveillance networks in Western Europe. Two clinical syndromes were used with a wide range of case definitions that nevertheless shared common criteria. Although there is currently no international consensus, efforts are being undertaken to standardise influenza case definitions in Europe.

Evaluation of a portable device for diagnosing the sleep apnoea/hypopnoea syndrome

Waiting times for hospital-based monitoring of the obstructive sleep apnoea/hypopnoea syndrome (OSAHS) are rising. This study tested whether Embletta, a new portable device, may accurately diagnose OSAHS at home. A synchronous comparison to polysomnography was performed in 40 patients and a comparison of home Embletta studies with in-laboratory polysomnography was performed in 61 patients. In the synchronous study, the mean difference (polysomnography-Embletta) in apnoeas+hypopnoeas (A+H) x h(-1) in bed was 2 h(-1). In comparison to the apnoea/ hypopnoea index (AHI) x h(-1) slept, the Embletta (A+H) x h(-1) in bed differed by 8 x h(-1). These data were used to construct diagnostic categories in symptomatic patients from their Embletta results: "OSAHS" (> or = 20 (A+H) x h(-1) in bed), "possible OSAHS" (10-20 (A+H) x h(-1) in bed) or "not OSAHS" (<10 (A+H) x h(-1) in bed). In the home study, the mean difference in (A+H) x h(-1) in bed was 3 x h(-1). In comparison to the polysomnographic AHI x h(-1) slept, the Embletta (A+H) x h(-1) in bed differed by 6 +/- 14 x h(-1). Using the above classification, all nine patients categorised as not OSAHS had AHI < 15 x h(-1) slept on polysomnography and all 23 with OSAHS on Embletta had an AHI > or = 15 on polysomnography, but 18 patients fell into the possible OSAHS category potentially requiring further investigation and 11 home studies failed. Most patients were satisfactorily classified by home Embletta studies but 29 out of 61 required further investigation. The study suggested a 42% saving in diagnostic costs over polysomnography if this approach were adopted.

Performance characteristics of different modalities for diagnosis of suspected lung cancer: summary of published evidence

STUDY OBJECTIVES

To determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

DESIGN, SETTING, AND PARTICIPANTS

A systematic search of MEDLINE, HealthStar, and Cochrane Library databases to July 2001 and print bibliographies was performed to identify studies comparing the results of sputum cytology, bronchoscopy, transthoracic needle aspirate (TTNA), or biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer.

MEASUREMENT AND RESULTS

For sputum cytology, the pooled specificity was 0.99 and the pooled sensitivity was 0.66, but sensitivity was higher for central lesions than for peripheral lesions (0.71 vs 0.49, respectively). Studies on bronchoscopic procedures provided data only on diagnostic yield (sensitivity). The diagnosis of endobronchial disease by bronchoscopy in 30 studies showed the highest sensitivity for endobronchial biopsy (0.74), followed by cytobrushing (0.59) and washing (0.48). The sensitivity for all modalities combined was 0.88. Thirty studies reported on peripheral lesions. Cytobrushing demonstrated the highest sensitivity (0.52), followed by transbronchial biopsy (0.46) and BAL/washing (0.43). The overall sensitivity for all modalities was 0.69. Peripheral lesions < 2 cm or > 2 cm in diameter showed sensitivities of 0.33 and 0.62, respectively. Updating a previous meta-analysis with 19 studies revealed a pooled sensitivity of 0.90 for TTNA. A trend toward lower sensitivity was noted for lesions that were < 2 cm in diameter. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 0.98, with individual studies ranging from 0.94 to 1.0. The average false-positive and false-negative rates were 0.09 and 0.02, respectively.

CONCLUSIONS

The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions that are < 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease. The distinction between small cell lung cancer and non-small cell lung cancer by cytology appears to be accurate.

Diagnosis of lung cancer: the guidelines

Lung cancer is usually suspected in individuals who have abnormal chest radiograph findings or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of suspected lung cancer depends on the type of lung cancer (ie, small cell lung cancer or non-small cell lung cancer), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient. Achieving a diagnosis and staging are usually done in concert because the most efficient way to make a diagnosis often is dictated by the stage of the cancer. The best sequence of studies and interventions in a particular patient involves careful judgment of the probable reliability of a number of presumptive diagnostic issues, so as to maximize the sensitivity and to avoid performing multiple or unnecessary invasive procedures. In this article, we consider all manner of clinical presentations of lung cancer in light of currently available diagnostic procedures. Published data supporting a particular diagnostic approach is weighed based on the quality of the benefit as well as the estimated net benefit. Recommendations are graded in terms of strength to provide clinicians with guidance as to the most efficient and approach to the diagnosis of lung cancer in individual patients.

A new method of evaluation of upper airway in patients with obstructive sleep apnoea--computer-assisted quantitative videoendoscopic analysis

INTRODUCTION

Prospective study to quantitatively examine the static and dynamic changes of upper airways in patients with obstructive sleep apnoea (OSA) by engaging a new inexpensive clinical method which accurately evaluates the morphology of obstructive sites of upper airway. The aim was to minimise the subjective visual estimations and eliminate individual variations of the traditional method of nasopharyngoscopic assessment of upper airway.

METHOD

Videoendoscopic (video-nasopharyngoscopic) examinations of upper airways of 15 patients were carried out with a calibrator inserted through the scope and placed at the levels of interest. Images of upper airways during quiet respiration, muller manoeuvre at erect and supine positions were obtained, digitalised and analysed by computers to generate the actual dimensions, surface areas and hence collapsibility of obstructive sites of upper airways. These measurements were validated by comparing videoendoscopic measurements (supine, quiet respiration) with upper airway magnetic resonance imaging (MRI) scans. We compared the area measurements of 30 videoendoscopic images with MRI scans of 15 patients at two levels (points above uvula and epiglottis) and calculated the accuracy percentage by examining the differences of surface areas of these two methods of measurement. The MRI scan measurements were used as standard, and the differences were presented as an accuracy percentage.

RESULTS

The accuracy for the first level was 89.50% and the second level was 88.15%; the mean accuracy was 88.82%. The mean area of MRI was 1.50 cm2 (SD = 0.69) and the mean area of videoendoscopic images was 1.45 cm2 (SD = 0.64), with a correlation of 0.93 and a P value of less than 0.001.

CONCLUSION

This new cost-effective and convenient clinical method of upper airway evaluation enables us to quantitatively and accurately examine the morphology of obstructive sites of upper airway, so that we could further research the pathophysiology of upper airway obstruction, engage the most appropriate treatment and provide accurate pre and postoperative assessments for patients with obstructive sleep apnoea.

Detection of the nasal cycle

The nasal cycle is a fluctuation of nasal patency due to the stages of congestion and decongestion of the nasal mucosa on both the right and left nasal conchae. We compared the effectiveness of the rhinostereometer in detecting the presence of a nasal cycle with the acoustic rhinometer whose effectiveness we have demonstrated in previous studies. The rhinostereometer measures the horizontal range of the most anterior portion of the inferior turbinate. The acoustic rhinometer measures the volume and various cross-sectional areas of the nostril using a pulse emitted from a sound tube. Among some of the subjects tested, it was found that rhinostereometer and acoustic rhinometer measurements of nasal patency correlated reasonably well with r values up to 0.78. The overall correlation between rhinostereometry and acoustic rhinometry was not as strong at r = 0.36. Observed variations between rhinostereometry and acoustic rhinometry could be a result of certain confounding variables that may have altered the nasal cycle between measurements.

Intra and inter technologist variability in the quality assessment of respiratory tract specimens

The majority of microbiology laboratories have implemented quality improvement procedures such as a Q scoring system to assess the nature of clinical specimens. Our study reviewed the sources and the amount of variation when Q scoring of lower respiratory secretions was performed. In total, 450 slides representing lower respiratory tract secretions were Q scored by three experienced technologists. Total agreement regarding the number of neutrophils, squamous epithelial cells and Q scores was 76%, 57% and 57% respectively. The major factor influencing Q score values was the enumeration of epithelial cells. From our findings, we expect that there is greater variability in Q scoring then is generally acknowledged and there is a substantial degree of subjectivity on part of individual technologists reading gram stains.

Computed tomographic scan of the chest, latex agglutination test and plasma (1AE3)-beta-D-glucan assay in early diagnosis of invasive pulmonary aspergillosis: a prospective study of 215 patients

BACKGROUND AND OBJECTIVES

Blood and radiologic tests are frequently used for diagnosis of invasive pulmonary aspergillosis, but it remains unknown which is more useful for its early diagnosis. Aim of the study was to compare usefulness of computed tomographic (CT) scan of chest, latex agglutination (LA) test and determination of plasma (1-->3)-beta-D-glucan (BDG) levels for early diagnosis of invasive pulmonary aspergillosis (IPA).

DESIGN AND METHODS

We treated 215 consecutive patients who underwent cytotoxic chemotherapy. From initiation of chemotherapy until death or discharge, blood samples were taken weekly and subjected to LA and BDG tests. We performed chest CT scans when patients had any signs of pulmonary infection or an antibiotic-resistant fever.

RESULTS

Of the 215 patients, 30 (14. 0%) were diagnosed as having IPA. In sixteen cases the diagnosis was definite and in 14 it was suspected. In patient-based analysis, sensitivities of LA and BDG were 44% and 63%, respectively. Sensitivity tended to be lower in patients with IPA localized to the lung than those with disseminated invasive aspergillosis. Specificities were 93% and 74%, respectively. Either a halo or an air-crescent was observed in 7 of the 16 patients with IPA, and all of the IPA patients showed some abnormal signs on chest CT scans. On average, CT scan signs preceded a positive LA test by 7.1 days and a positive BDG assay by 11.5 days. In 6 of the 11 patients who became positive for either LA or BDG assay, CT scan signs preceded the positive results by more than seven days.

INTERPRETATION AND CONCLUSIONS

Chest CT scan is more beneficial than the blood tests and X-ray for early diagnosis of IPA.

[Bronchoalveolar lavage in the diagnosis of diffuse interstitial lung disease]

Since the introduction of bronchoalveolar lavage (BAL), this technique is used both clinically and for research. Use of BAL as a diagnostic aid was introduced fairly recently. For the different steps of the procedure a standardized approach has been proposed. Analysis of BAL fluid includes determination of the total number of cells, of the differentiation and of non-cellular components, as well as various staining and culturing methods. The analysis may be useful in the diagnosis of interstitial pulmonary diseases and opportunistic infections. Smoking and pharmacotherapy affect the results of the analysis. BAL is a safe procedure with hardly any side effects. This method may in some diseases replace more invasive diagnostic procedures such as biopsy by demonstrating characteristic cells or micro-organisms.