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Highlights from this issue

2018-01-15T08:35:38-08:00

The ‘Carry On’ films consisted of 31 British comedies that were produced between 1958 and 1992. In this edition of Airwaves, we consider if ‘Carry on Thorax’ would have made the Director’s cut...

Carry on Columbus

Although it has been over 500 years since Christopher Columbus discovered the Americas in 1492, it took Kamdar et al from the US 5 years to investigate the occupational outcome of patients after acute respiratory distress syndrome (ARDS) (see page 125). In a 5-year multisite prospective longitudinal cohort study, 138 ARDS survivors were followed up with 31% never returning to work over 5 years of follow-up. Predictors of delayed return to work included baseline comorbidity, mechanical ventilation duration and discharge location. The loss of earnings ranged from £28,662 to £32,515 per person per year.

Carry on Spying

A top-secret formula stolen by STENCH (the Society for the Total Extinction of...




Primary ciliary dyskinesia: keep it on your radar

2018-01-15T08:35:38-08:00

Primary ciliary dyskinesia (PCD) is a rare disorder of mucociliary clearance resulting in chronic oto-sinopulmonary disease. While the prevalence worldwide is estimated to be 1:10 000–1:15 000, it may be much higher in certain communities, especially where consanguinity is more prevalent. In the British South Asian community, for example, the prevalence has been estimated at 1:2450, similar to that of cystic fibrosis among caucasians.1

In Thorax, Shoemark and colleagues2 describe PCD in a highly consanguineous UK South Asian community, due to homozygous missense variants in CCDC103, usually resulting in the loss of both outer and inner dynein arms. The investigators identified 86 patients of South Asian (primarily Pakistani) descent with clinical signs and symptoms of PCD from the UK National PCD Diagnostic and Management Services. These individuals had a compatible clinical phenotype, but diagnosis was complicated by the fact that many of the standard diagnostic tests for...




Air pollution exposure and IPF: prevention when there is no cure

2018-01-15T08:35:38-08:00

The clinical management of idiopathic pulmonary fibrosis (IPF) is challenging. For patients with a progressive disease with no known cure, realistic goals include slowing the rate of disease progression, optimising comorbidities and functional status, managing symptoms, and preventing what is preventable. The latter is short however, mainly including smoking cessation and infection prevention measures. Despite adherence to recommended management, most patients deteriorate over time, with some experiencing acute exacerbation (AE), and the majority dying due to their IPF.1 Identifying modifiable risk factors that limit disease progression or death could change clinical practice, offering preventative tools with which to achieve the goal of improving patient quality and quantity of life.

Air pollution exposure is ubiquitous and a well-established risk factor for a wide range of adverse health outcomes including cardiovascular disease and all-cause mortality.2–4 Arguably the most common target is the respiratory...




Lower respiratory infections in early life are linked to later asthma

2018-01-15T08:35:38-08:00

Asthma is the most prevalent chronic respiratory disease worldwide.1 While much progress has been made to understand the determinants of asthma, why a specific individual develops asthma is not entirely clear. Within this discussion, it should be noted that asthma is not a homogenous disease; that is to say, there are many (endo)types of asthma.2 In children, the most common pattern is a T2 exaggerated immune response with eosinophils, interleukin (IL)-4, IL-5 and IL-13 playing important roles. While clearly asthma is a complex disease, some of the noise in the literature surrounding the determinants of asthma is a result of disease definition. The presence of wheezing or reduced FEV1 may represent a number of endotypes of asthma or indeed non-asthma phenotypes.

With this caveat in mind, it is clear that viral infections and allergic sensitisation are key factors associated with a diagnosis of asthma.3...




Functional phenotypes determined by fluctuation-based clustering of lung function measurements in healthy and asthmatic cohort participants

2018-01-15T08:35:38-08:00

Rationale

Asthma is characterised by inflammation and reversible airway obstruction. However, these features are not always closely related. Fluctuations of daily lung function contain information on asthma phenotypes, exacerbation risk and response to long-acting β-agonists.

Objectives

In search of subgroups of asthmatic participants with specific lung functional features, we developed and validated a novel clustering approach to asthma phenotyping, which exploits the information contained within the fluctuating behaviour of twice-daily lung function measurements.

Methods

Forced expiratory volume during the first second (FEV1) and peak expiratory flow (PEF) were prospectively measured over 4 weeks in 696 healthy and asthmatic school children (Protection Against Allergy – Study in Rural Environments (PASTURE)/EFRAIM cohort), and over 1 year in 138 asthmatic adults with mild-to-moderate or severe asthma (Pan-European Longitudinal Assessment of Clinical Course and BIOmarkers in Severe Chronic AIRway Disease (BIOAIR) cohort). Using enrichment analysis, we explored whether the method identifies clinically meaningful, distinct clusters of participants with different lung functional fluctuation patterns.

Measurements and main results

In the PASTURE/EFRAIM dataset, we found four distinct clusters. Two clusters were enriched in children with well-known clinical characteristics of asthma. In cluster 3, children from a farming environment predominated, whereas cluster 4 mainly consisted of healthy controls. About 79% of cluster 3 carried the asthma-risk allele rs7216389 of the 17q21 locus. In the BIOAIR dataset, we found two distinct clusters clearly discriminating between individuals with mild-to-moderate and severe asthma.

Conclusions

Our method identified dynamic functional asthma and healthy phenotypes, partly independent of atopy and inflammation but related to genetic markers on the 17q21 locus. The method can be used for disease phenotyping and possibly endotyping. It may identify participants with specific functional abnormalities, potentially needing a different therapeutic approach.




Healthcare resource use and costs of severe, uncontrolled eosinophilic asthma in the UK general population

2018-01-15T08:35:38-08:00

Background

Little is known about the prevalence of severe, uncontrolled eosinophilic asthma (SUEA) and associated costs.

Aims

We sought to determine the prevalence of SUEA and compare asthma-related healthcare resource use (HCRU) and associated costs with overall means for a general asthma population.

Methods

This cohort study evaluated anonymised medical record data (December 1989 through June 2015) from the Clinical Practice Research Datalink and the Optimum Patient Care Research Database to study UK patients with active asthma (diagnostic code and one or more drug prescriptions in the baseline year), aged 5 years and older, without concomitant COPD, and with recorded eosinophil count. SUEA was defined as two or more asthma attacks during 1 baseline year preceding a high blood eosinophil count (≥0.3x109/L) for patients prescribed long-acting β2-agonist (LABA) and high-dosage inhaled corticosteroids (ICS) during baseline plus 1 follow-up year. We compared asthma-related HCRU and associated direct costs (2015 pounds sterling, £) during the follow-up year for SUEA versus the general asthma population.

Results

Of 363 558 patients with active asthma and recorded eosinophil count, 64% were women, mean (SD) age was 49 (21) years; 43% had high eosinophil counts, 7% had two or more attacks in the baseline year and 10% were prescribed high-dosage ICS/LABA for 2 study years. Overall, 2940 (0.81%; 95% CI 0.78% to 0.84%) patients had SUEA. Total mean per-patient HCRU and associated costs were four times greater for SUEA versus all patients (HCRU and cost ratios 3.9; 95% CI 3.7 to 4.1).

Conclusions

Less than 1% of patients in a general asthma population had SUEA. These patients accounted for substantially greater asthma-related HCRU and costs than average patients with asthma.




Return to work and lost earnings after acute respiratory distress syndrome: a 5-year prospective, longitudinal study of long-term survivors

2018-01-15T08:35:38-08:00

Background

Delayed return to work is common after acute respiratory distress syndrome (ARDS), but has undergone little detailed evaluation. We examined factors associated with the timing of return to work after ARDS, along with lost earnings and shifts in healthcare coverage.

Methods

Five-year, multisite prospective, longitudinal cohort study of 138 2-year ARDS survivors hospitalised between 2004 and 2007. Employment and healthcare coverage were collected via structured interview. Predictors of time to return to work were evaluated using Fine and Grey regression analysis. Lost earnings were estimated using Bureau of Labor Statistics data.

Results

Sixty-seven (49%) of the 138 2-year survivors were employed prior to ARDS. Among 64 5-year survivors, 20 (31%) never returned to work across 5-year follow-up. Predictors of delayed return to work (HR (95% CI)) included baseline Charlson Comorbidity Index (0.77 (0.59 to 0.99) per point; p=0.04), mechanical ventilation duration (0.67 (0.55 to 0.82) per day up to 5 days; p<0.001) and discharge to a healthcare facility (0.49 (0.26 to 0.93); p=0.03). Forty-nine of 64 (77%) 5-year survivors incurred lost earnings, with average (SD) losses ranging from US$38 354 (21,533) to US$43 510 (25,753) per person per year. Jobless, non-retired survivors experienced a 33% decrease in private health insurance and concomitant 37% rise in government-funded coverage.

Conclusions

Across 5-year follow-up, nearly one-third of previously employed ARDS survivors never returned to work. Delayed return to work was associated with patient-related and intensive care unit/hospital-related factors, substantial lost earnings and a marked rise in government-funded healthcare coverage. These important consequences emphasise the need to design and evaluate vocation-based interventions to assist ARDS survivors return to work.




Delayed neutrophil apoptosis enhances NET formation in cystic fibrosis

2018-01-15T08:35:38-08:00

Background

Cystic fibrosis (CF) lung disease is defined by large numbers of neutrophils and associated damaging products in the airway. Delayed neutrophil apoptosis is described in CF although it is unclear whether this is a primary neutrophil defect or a response to chronic inflammation. Increased levels of neutrophil extracellular traps (NETs) have been measured in CF and we aimed to investigate the causal relationship between these phenomena and their potential to serve as a driver of inflammation. We hypothesised that the delay in apoptosis in CF is a primary defect and preferentially allows CF neutrophils to form NETs, contributing to inflammation.

Methods

Blood neutrophils were isolated from patients with CF, CF pigs and appropriate controls. Neutrophils were also obtained from patients with CF before and after commencing ivacaftor. Apoptosis was assessed by morphology and flow cytometry. NET formation was determined by fluorescent microscopy and DNA release assays. NET interaction with macrophages was examined by measuring cytokine generation with ELISA and qRT-PCR.

Results

CF neutrophils live longer due to decreased apoptosis. This was observed in both cystic fibrosis transmembrane conductance regulator (CFTR) null piglets and patients with CF, and furthermore was reversed by ivacaftor (CFTR potentiator) in patients with gating (G551D) mutations. CF neutrophils formed more NETs and this was reversed by cyclin-dependent kinase inhibitor exposure. NETs provided a proinflammatory stimulus to macrophages, which was enhanced in CF.

Conclusions

CF neutrophils have a prosurvival phenotype that is associated with an absence of CFTR function and allows increased NET production, which can in turn induce inflammation. Augmenting neutrophil apoptosis in CF may allow more appropriate neutrophil disposal, decreasing NET formation and thus inflammation.




Role of atmospheric pollution on the natural history of idiopathic pulmonary fibrosis

2018-01-15T08:35:38-08:00

Introduction

Idiopathic pulmonary fibrosis (IPF) has an unpredictable course corresponding to various profiles: stability, physiological disease progression and rapid decline. A minority of patients experience acute exacerbations (AEs). A recent study suggested that ozone and nitrogen dioxide might contribute to the occurrence of AE. We hypothesised that outdoor air pollution might influence the natural history of IPF.

Methods

Patients were selected from the French cohort COhorte FIbrose (COFI), a national multicentre longitudinal prospective cohort of IPF (n=192). Air pollutant levels were assigned to each patient from the air quality monitoring station closest to the patient’s geocoded residence. Cox proportional hazards model was used to evaluate the impact of air pollution on AE, disease progression and death.

Results

Onset of AEs was significantly associated with an increased mean level of ozone in the six preceding weeks, with an HR of 1.47 (95% CI 1.13 to 1.92) per 10 µg/m3 (p=0.005). Cumulative levels of exposure to particulate matter PM10 and PM2.5 were above WHO recommendations in 34% and 100% of patients, respectively. Mortality was significantly associated with increased levels of exposure to PM10 (HR=2.01, 95% CI 1.07 to 3.77) per 10 µg/m3 (p=0.03), and PM2.5 (HR=7.93, 95% CI 2.93 to 21.33) per 10 µg/m3 (p<0.001).

Conclusion

This study suggests that air pollution has a negative impact on IPF outcomes, corroborating the role of ozone on AEs and establishing, for the first time, the potential role of long-term exposure to PM10 and PM2.5 on overall mortality.




Metal workers lung: spatial association with Mycobacterium avium

2018-01-15T08:35:38-08:00

Background

Outbreaks of hypersensitivity pneumonitis (HP) are not uncommon in workplaces where metal working fluid (MWF) is used to facilitate metal turning. Inhalation of microbe-contaminated MWF has been assumed to be the cause, but previous investigations have failed to establish a spatial relationship between a contaminated source and an outbreak.

Objectives

After an outbreak of five cases of HP in a UK factory, we carried out blinded, molecular-based microbiological investigation of MWF samples in order to identify potential links between specific microbial taxa and machines in the outbreak zone.

Methods

Custom-quantitative PCR assays, microscopy and phylogenetic analyses were performed on blinded MWF samples to quantify microbial burden and identify potential aetiological agents of HP in metal workers.

Measurements and main results

MWF from machines fed by a central sump, but not those with an isolated supply, was contaminated by mycobacteria. The factory sump and a single linked machine at the centre of the outbreak zone, known to be the workstation of the index cases, had very high levels of detectable organisms. Phylogenetic placement of mycobacterial taxonomic marker genes generated from these samples indicated that the contaminating organisms were closely related to Mycobacterium avium.

Conclusions

We describe, for the first time, a close spatial relationship between the abundance of a mycobacterium-like organism, most probably M. avium, and a localised outbreak of MWF-associated HP. The further development of sequence-based analytic techniques should assist in the prevention of this important occupational disease.




High prevalence of CCDC103 p.His154Pro mutation causing primary ciliary dyskinesia disrupts protein oligomerisation and is associated with normal diagnostic investigations

2018-01-15T08:35:38-08:00

Rationale

Primary ciliary dyskinesia is a genetically heterogeneous inherited condition characterised by progressive lung disease arising from abnormal cilia function. Approximately half of patients have situs inversus. The estimated prevalence of primary ciliary dyskinesia in the UK South Asian population is 1:2265. Early, accurate diagnosis is key to implementing appropriate management but clinical diagnostic tests can be equivocal.

Objectives

To determine the importance of genetic screening for primary ciliary dyskinesia in a UK South Asian population with a typical clinical phenotype, where standard testing is inconclusive.

Methods

Next-generation sequencing was used to screen 86 South Asian patients who had a clinical history consistent with primary ciliary dyskinesia. The effect of a CCDC103 p.His154Pro missense variant compared with other dynein arm-associated gene mutations on diagnostic/phenotypic variability was tested. CCDC103 p.His154Pro variant pathogenicity was assessed by oligomerisation assay.

Results

Sixteen of 86 (19%) patients carried a homozygous CCDC103 p.His154Pro mutation which was found to disrupt protein oligomerisation. Variable diagnostic test results were obtained including normal nasal nitric oxide levels, normal ciliary beat pattern and frequency and a spectrum of partial and normal dynein arm retention. Fifteen (94%) patients or their sibling(s) had situs inversus suggesting CCDC103 p.His154Pro patients without situs inversus are missed.

Conclusions

The CCDC103 p.His154Pro mutation is more prevalent than previously thought in the South Asian community and causes primary ciliary dyskinesia that can be difficult to diagnose using pathology-based clinical tests. Genetic testing is critical when there is a strong clinical phenotype with inconclusive standard diagnostic tests.




A population-based prospective cohort study examining the influence of early-life respiratory tract infections on school-age lung function and asthma

2018-01-15T08:35:38-08:00

Background

Early-life respiratory tract infections could affect airway obstruction and increase asthma risk in later life. However, results from previous studies are inconsistent.

Objective

We examined the associations of early-life respiratory tract infections with lung function and asthma in school-aged children.

Methods

This study among 5197 children born between April 2002 and January 2006 was embedded in a population-based prospective cohort study. Information on physician-attended upper and lower respiratory tract infections until age 6 years (categorised into ≤ 3 and >3–6 years) was obtained by annual questionnaires. Spirometry measures and physician-diagnosed asthma were assessed at age 10 years.

Results

Upper respiratory tract infections were not associated with adverse respiratory outcomes. Compared with children without lower respiratory tract infections ≤3 years, children with lower respiratory tract infections ≤3 years had a lower FEV1, FVC, FEV1:FVC and forced expiratory flow at 75% of FVC (FEF75) (Z-score (95% CI): ranging from –0.22 (–0.31 to –0.12) to –0.12 (–0.21 to –0.03)) and an increased risk of asthma (OR (95% CI): 1.79 (1.19 to 2.59)). Children with lower respiratory tract infections >3–6 years had an increased risk of asthma (3.53 (2.37 to 5.17)) only. Results were not mediated by antibiotic or paracetamol use and not modified by inhalant allergic sensitisation. Cross-lagged modelling showed that results were not bidirectional and independent of preschool wheezing patterns.

Conclusion

Early-life lower respiratory tract infections ≤3 years are most consistently associated with lower lung function and increased risk of asthma in school-aged children.




Autoadjusted versus fixed CPAP for obstructive sleep apnoea: a multicentre, randomised equivalence trial

2018-01-15T08:35:38-08:00

Background

The obstructive sleep apnoea syndrome (OSAS) is conventionally treated by continuous positive airway pressure set at a fixed level (fCPAP). Automatic mask pressure adjustment (autoCPAP) is increasingly used during home therapy. We investigated whether autoCPAP is equivalent to fCPAP in improving sleepiness in patients with OSAS in the long-term.

Methods

In this multicentre equivalence trial, 208 patients with OSAS, with median Epworth sleepiness score (ESS) 13, apnoea/hypopnoea index 48.4/hour, were randomised to treatment with autoCPAP (5–15 mbar) or fCPAP (pressure set at the 90th percentile applied by autoCPAP during 2–4 weeks adaptation). Coprimary outcomes were changes in subjective and objective sleepiness from baseline to 2 years after treatment. Equivalence ranges were ±2 points in ESS and ±3 min sleep resistance time evaluated by recording responses to light signals.

Results

At 2 years, in the intention to treat analysis, the reduction in sleepiness versus pretreatment baseline was similar in patients using autoCPAP (n=113, mean ESS-change –6.3, 95% CI –7.1 to –5.5; sleep resistance time +8.3 min, +6.9 to +9.7) and fCPAP (n=95, mean ESS-change –6.2, 95% CI –7.0 to –5.3; sleep resistance time +6.3 min, +4.7 to +7.8). The 95% CI of difference in ESS-reduction between autoCPAP and fCPAP was –0.9 to +1.4 and the 95% CI of difference in increase in sleep resistance time was –2.6 to +1.0 min. Blood pressure reduction and OSAS-related costs were similar between groups.

Conclusions

AutoCPAP and fCPAP are equivalent within prespecified ranges in improving subjective and objective sleepiness in patients with OSAS over the course of 2 years. Costs of these treatments are similar.

Trial registration number

ClinicalTrials.gov NCT00280800.




Trends in paediatric asthma hospitalisations - differences between neighbouring countries

2018-01-15T08:35:38-08:00

Paediatric asthma hospitalisation trends in Finland and Sweden over the past 10 years are unclear. We investigated the incidence of paediatric asthma hospitalisations in both countries from 2005 to 2014, using Finland's National Hospital Discharge Register and Sweden's National Patient Register which cover all hospitalisations in the respective countries. During the study period, the incidence of paediatric asthma hospitalisations decreased by 51% in Finland, but remained stable in Sweden. In both countries, asthma hospitalisations decreased over time among children aged 0–4 years, with unclear trends for older ages. The reasons for these intercountry differences are unclear, thus warranting future research.




Endoscopic advanced imaging of the respiratory tract: exploring probe-based confocal laser endomicroscopy in emphysema

2018-01-15T08:35:38-08:00

Probe-based confocal laser endomicroscopy (pCLE) was performed in 15 patients with emphysema and 15 healthy subjects to visualise small airways in a direct and dynamic way. Morphometry shows that the median cross-sectional area of the alveolar openings at the level of the alveolar ducts is significantly larger in emphysema (7.2x104 µm2) as compared with healthy subjects (5.2x104 µm2) (p=0.0002). Normalised autofluorescence intensity histograms show a decrease in median autofluorescence intensity (mAFI) in emphysema (p=0.001). mAFI correlates well with Tiffeneau index (r=0.66, p=0.007, 95% CI 0.21 to 0.88). Autofluorescence intensity in emphysema correlates with corresponding data of CT-based quantification. pCLE-based morphometry and autofluorescence intensity analysis in emphysema is able to detect regional changes inside the ‘quiet zone’.

Trial registration number

Results, NCT01204970.




Gait speed and pedestrian crossings in COPD

2018-01-15T08:35:38-08:00

The assumed minimum walking speed at pedestrian crossings is 1.2 m/s. In this prospective cohort study, usual walking speed was measured over a 4 m course in 926 community-dwelling, ambulatory patients with stable COPD. Mean (SD) walking speed was 0.91 (0.24) m/s with only 10.7% walking at a speed equal or greater than 1.2 m/s. In order for 95% of this cohort to safely negotiate a pedestrian cross, traffic lights would have to assume a minimum walking speed of 0.50 m/s (2.4 times longer than current times). The current assumed normal walking speed for pedestrian crossings is inappropriate for patients with COPD.

The studies were registered on clinicaltrials.gov and these data relate to the pre-results stage: NCT01649193, NCT01515709 and NCT01507415.




Acute pulmonary embolism and multiple pulmonary nodules mimicking metastatic disease

2018-01-15T08:35:38-08:00

Case presentation

A 62-year-old patient with a history of traumatic splenectomy after a paragliding accident and chronic hepatitis C presented to the emergency department with worsening dyspnoea and unintended weight loss of 8 kg in 2 months. He was a lifelong non-smoker and consumes alcohol on rare occasions. He also reported recent travels to Asia and South America for business affairs. On clinical examination, the patient was normotensive with a respiratory rate of 25/min. Lung auscultation and the remainder of the physical examination were uneventful. Laboratory parameters showed increased inflammatory parameters (leucocyte count 14.7 g/L, C reactive protein 87 mg/L), absolute eosinophilia (4.73 g/L) and elevated IgE levels (5170 kU/L). A CT scan revealed acute segmental pulmonary embolism and multiple irregular pulmonary nodules (figure 1A). A bronchoscopy showed no airway abnormalities such as inflammation or tumour protrusion; however, bronchoalveolar lavage revealed eosinophilia.

Assessment of the junior doctors

The radiological appearance mimicked...




Pneumomediastinum and pneumorrhachis from recreational nitrous oxide inhalation: no laughing matter

2018-01-15T08:35:38-08:00

A 16-year-old girl with no medical history presented to our emergency department with rapid onset and progressive facial and neck swelling, dyspnoea and dysphonia. The previous night she had attended a nightclub, had sniffed ketamine and inhaled nitrous oxide. On examination she had swelling of her face, neck and upper torso with palpable crepitus. Scattered bilateral expiratory wheeze was present on auscultation. She was mildly tachycardic and tachypnoeic but other observations were normal. Neurological examination was normal. A chest radiograph demonstrated extensive subcutaneous emphysema. CT scan of the neck, chest and abdomen without intravenous contrast confirmed the presence of extensive subcutaneous gas within the face, neck and thorax, including pneumomediastinum, pneumopericardium and small bilateral pneumothoraces (figure 1). Air was also seen tracking within the spinal canal in the cervical and thoracic regions, a phenomenon known as pneumorrhachis (figure 1, arrow).

She later reported that she...




Double whammy: the disappearing right atrium

2018-01-15T08:35:38-08:00

A 66-year-old man with hepatitis C virus (HCV) infection complicated by liver cirrhosis presented with about 6 months of severe right shoulder pain as well as more recent progressive dyspnoea on exertion and lower extremity oedema. On outpatient evaluation at the onset of shoulder symptoms, they had been ascribed to an orthopaedic aetiology. He had recently completed treatment for HCV with ledipasvir/sofosbuvir after failure to respond to a regimen of interferon/ribavirin. Approximately 2 years earlier, he had been diagnosed with unresectable multifocal stage III hepatocellular carcinoma (HCC) and treated with transarterial chemoembolisation (TACE), radiofrequency ablation and ethanol ablation as a bridge to possible liver transplantation. On presentation, he was hemodynamically stable with no reported pulsus paradoxus. Physical examination revealed an elevated jugular venous pulse, anasarca and decreased breath sounds over the right lower chest. There was no clinically overt ascites. His plain chest radiograph showed a right pleural effusion...




Lack of a pulmonary vein causing unilateral interlobular septal thickening

2018-01-15T08:35:38-08:00

Description

A 24-year-old woman presented with an 8-year history of chest tightness and shortness of breath during intense exercise. Physical examination showed decreased expansion of the right rib cage and respiratory sounds in the right lung were quiet. A routine examination was unremarkable. There were no systemic symptoms, including fever, skin rash and arthralgia. The erythrocyte sedimentation rate and high sensitivity C-reactive protein levels were normal. Autoantibodies, including antinuclear antibodies, antiextractable nuclear antigen antibodies and antineutrophil cytoplasmic antibodies, were negative.

Chest high-resolution CT showed a low right lung volume, markedly thickened interlobular septae (mainly in the right lower lung) and some ground-glass opacity, showing a wedge-shaped area of consolidation (figure 1A). Bronchoscopy showed submucosal varices of the right bronchial tree, with markedly increased surface secretions and mucosal hypertrophy (figure 2). Echocardiography showed normal inner atrial and ventricular diameters. Additionally, ostia of the right superior...




Whats hot that the other lot got

2018-01-15T08:35:38-08:00

The use of ROSE does not improve diagnostic yield in TBNA

Having rapid onsite cytological evaluation (ROSE) present on endobronchial ultrasound (EBUS) or conventional transbronchial needle aspiration (TBNA) should, in theory, reduce the number of needle passes required for diagnosis, procedure time and complication rates. In some smaller studies, ROSE has been shown to increase diagnostic yield. However, the cost of ROSE has limited its clinical use.

The systematic review by Sehgal et al (Chest. doi:10.1016/j.chest.2017.11.004) looked at five good-quality but heterogeneous randomised control trials examining ROSE in EBUS-TBNA and conventional TBNA to ascertain the effect of ROSE on procedure time and quality. The studies were looking at TBNA in suspected cancer, sarcoidosis and lymphadenopathy of unknown cause. While overall diagnostic yield, complication rate and procedure time were unaffected, there was a reduction in the need for additional procedures when ROSE was added to TBNA. However, this only translated to a reduction in...