Surgical lung biopsy is often required for a confident multidisciplinary diagnosis of idiopathic pulmonary fibrosis (IPF). Alternative, less-invasive biopsy methods, such as bronchoscopic lung ...cryobiopsy (BLC), are highly desirable.
To address the impact of BLC on diagnostic confidence in the multidisciplinary diagnosis of IPF.
In this cross-sectional study we selected 117 patients with fibrotic interstitial lung disease without a typical usual interstitial pneumonia pattern on high-resolution computed tomography. All cases underwent lung biopsies: 58 were BLC, and 59 were surgical lung biopsy (SLB). Two clinicians, two radiologists, and two pathologists sequentially reviewed clinical-radiologic findings and biopsy results, recording at each step in the process their diagnostic impressions and confidence levels.
We observed a major increase in diagnostic confidence after the addition of BLC, similar to SLB (from 29 to 63%, P = 0.0003 and from 30 to 65%, P = 0.0016 of high confidence IPF diagnosis, in the BLC group and SLB group, respectively). The overall interobserver agreement in IPF diagnosis was similar for both approaches (BLC overall kappa, 0.96; SLB overall kappa, 0.93). IPF was the most frequent diagnosis (50 and 39% in the BLC and SLB group, respectively; P = 0.23). After the addition of histopathologic information, 17% of cases in the BLC group and 19% of cases in the SLB group, mostly idiopathic nonspecific interstitial pneumonia and hypersensitivity pneumonitis, were reclassified as IPF.
BLC is a new biopsy method that has a meaningful impact on diagnostic confidence in the multidisciplinary diagnosis of interstitial lung disease and may prove useful in the diagnosis of IPF. This study provides a robust rationale for future studies investigating the diagnostic accuracy of BLC compared with SLB.
Usual interstitial pneumonia (UIP), is a necessary feature pathologically or radiologically for the diagnosis of idiopathic pulmonary fibrosis (IPF). The predictive value of transbronchial biopsy ...(TBB) in identifying UIP is currently unknown. The objective of this study is to assess the accuracy with which histopathologic criteria of usual interstitial pneumonia (UIP) can be identified in transbronchial biopsy (TBB) and to assess the usefulness of TBBx in predicting a the diagnosis of UIP pattern. We conducted a retrospective blinded and controlled analysis of TBB specimens from 40 established cases of UIP and 24 non-UIP interstitial lung diseases.
Adequate TBB specimens were available in 34 UIP cases (85% of all UIP cases). TBB contained histopathologic criteria to suggest a UIP pattern (ie. at least one of three pathologic features of UIP present; patchy interstitial fibrosis, fibroblast foci, honeycomb changes) in 12 cases (30% of all UIP cases). Sensitivity, specificity, positive and negative predictive values for the two pathologists were 30% (12/40), 100% (24/24), 100% (12/12), 46% (24/52) and 30% (12/40), 92% (22/24), 86% (12/14), 55% (22/40) respectively. Kappa coefficient of agreement between pathologists was good (0.61, 95% CI 0.31-0.91). The likelihood of identifying UIP on TBB increased with the number and size of the TBB specimens.
Although sensitivity is low our data suggest that even modest amount of patchy interstitial fibrosis, fibroblast foci, honeycomb changes detected on TBB can be highly predictive of a UIP pattern. Conversely, the absence of UIP histopathologic criteria on TBB does not rule out UIP.
Idiopathic pulmonary fibrosis (IPF) is the most common type of idiopathic interstitial pneumonia and has a dismal prognosis. Median age at IPF onset is 60-70 years and it is mainly related to ...cigarette smoke exposure. Its clinical profile is heterogeneous and different clinical phenotypes are now better defined: familial IPF, slow and rapid progressors, combined pulmonary fibrosis and emphysema, anti-neutrophil cytoplasmic antibodies/microscopic polyangiitis and IPF, and IPF associated with lung cancer. Acute exacerbation associated with rapid functional decline is an event that does not happen infrequently and affects survival. Diagnosis requires a typical usual interstitial pneumonia (UIP) pattern on computed tomography in the appropriate clinical setting or morphological confirmation of the UIP pattern when imaging findings are not characteristic enough. Surgical lung biopsy is the gold standard to obtain valuable information for histological analysis. However, less invasive procedures (transbronchial lung biopsy or even improved transbronchial lung biopsy by cryoprobes) are now under consideration. Prognostic indicators are mainly derived by pulmonary function tests. Recently, staging systems have been proposed.
Control tower to surgical theater Buccioli, Matteo; Traldi, Leo
Current directions in biomedical engineering,
9/2016, Letnik:
2, Številka:
1
Journal Article
Recenzirano
Odprti dostop
The main social priority is to reduce public debt and to streamline national health service (NHS) costs. Consequently, health managers need to acquire operating methods within their managerial ...structures so that all available resources are better planned in terms of effectiveness and efficiency, without compromising patient safety. In order to identify the information categories needed to know the whole surgical process is necessary to divide these in two main categories,
.
(DIG) contains the information that identify patients and its needs in terms of care. Instead
(SIG) contains information about hospital resources in order to cover the supply. The surgical process analyzed in terms such as industrial production process has the goal of produce the “
” and its central part is performed in the operating room by a surgical team. This does not mean that the precedent and subsequent phases of the operating room have minor importance, in fact to obtain a high quality “
” and reduce to a minimum the clinical risks related to the patient it is necessary that each phase of the process is carried out in the right way. The implementation of a Control Tower Approach allows for the management of productive process, able to guide hospital managers to identify the best strategies and to improve the risk management of patient safety in response to the guidelines of the World Health Organization.
Difficult airway (DA) occurs frequently (5–15%) in clinical practice. The El-Ganzouri Risk Index (EGRI) has a high sensitivity for predicting a difficult intubation (DI). However difficult mask ...ventilation (DMV) was never included in the EGRI. Since DMV was not included in the EGRI assessment, and obstructive sleep apnea (OSA) is also correlated with DMV, a study correlating the prediction of DA and OSA (identified by STOP-Bang questionnaire, SB) seemed important.
We accessed a database previously collected for a post analysis simulation of the airway difficulty predictivity of the EGRI, associated with normal and difficult airway, particularly DMV. As secondary aim, we measured the correlation between the SB prediction system and DA, compared to the EGRI.
A total of 2747 patients were included in the study. The proportion of patients with DI was 14.7% (95% CI 13.4–16) and the proportion of patients with DMV was 3.42% (95% CI 2.7–4.1). The incidence of DMV combined with DI was (2.3%). The optimal cutoff value of EGRI was 3. EGRI registered also an higher ability to predict DMV (AUC=0.76 (95% CI 0.71–0.81)). Adding the SB variables in the logistic model, the AUC increases with the inclusion of “observed apnea” variable (0.83 vs. 0.81, p=0.03). The area under the ROC curve for the patients with DI and DMV was 0.77 (95% CI 0.72–0.83).
This study confirms that the incidence of DA is not negligible and suggests the use of the EGRI as simple bedside predictive score to improve patient safety.
A via aérea difícil (VAD) ocorre com frequência (5-15%) na prática clínica. O Índice de Risco de El-Ganzouri (EGRI) tem uma alta sensibilidade para prever intubação difícil (ID). No entanto, a ventilação difícil via máscara (VDM) nunca foi incluída no EGRI. Como a VDM não foi incluída na avaliação EGRI e a apneia obstrutiva do sono (AOS) também está correlacionada com a VDM, um estudo correlacionando a previsão da VAD e AOS (identificada pelo questionário STOP-Bang, SB) pareceu importante.
Nós acessamos um banco de dados previamente coletados para simular uma análise posterior da previsibilidade do EGRI para via aérea difícil, associado à via aérea normal e difícil, particularmente VDM. Como objetivo secundário, avaliamos a correlação entre o sistema de previsão do SB e da VAD, em comparação com o EGRI.
No total, 2.747 pacientes foram incluídos no estudo. A proporção de pacientes com ID foi de 14,7% (IC de 95%; 13,4-16) e a proporção de pacientes com VDM foi de 3,42% (IC de 95% 2,7-4,1). A incidência da VDM combinada com a de ID foi de 2,3%. O valor de corte ideal de do EGRI foi 3. EGRI também registrou uma capacidade maior de prever VDM (ASC=0,76 (IC de 95%; 0,71-0,81)). Ao somar as variáveis do SB no modelo logístico, a ASC aumenta com a inclusão da variável “apneia observada” (0,83 vs. 0,81, p=0,03). A área sob a curva ROC para os pacientes com ID e VDM foi de 0,77 (IC de 95%; 0,72-0,83).
Este estudo confirma que a incidência de VAD não é desprezível e sugere o uso do EGRI como um escore de cabeceira preditivo simples para melhorar a segurança do paciente.
Idiopathic pulmonary fibrosis (IPF) is a progressive fibrotic lung disease with an overall poor prognosis. A simple-to-use staging system for IPF may improve prognostication, help guide management, ...and facilitate research.
To develop a multidimensional prognostic staging system for IPF by using commonly measured clinical and physiologic variables.
A clinical prediction model was developed and validated by using retrospective data from 3 large, geographically distinct cohorts.
Interstitial lung disease referral centers in California, Minnesota, and Italy.
228 patients with IPF at the University of California, San Francisco (derivation cohort), and 330 patients at the Mayo Clinic and Morgagni-Pierantoni Hospital (validation cohort).
The primary outcome was mortality, treating transplantation as a competing risk. Model discrimination was assessed by the c-index, and calibration was assessed by comparing predicted and observed cumulative mortality at 1, 2, and 3 years.
Four variables were included in the final model: gender (G), age (A), and 2 lung physiology variables (P) (FVC and Dlco). A model using continuous predictors (GAP calculator) and a simple point-scoring system (GAP index) performed similarly in derivation (c-index of 70.8 and 69.3, respectively) and validation (c-index of 69.1 and 68.7, respectively). Three stages (stages I, II, and III) were identified based on the GAP index with 1-year mortality of 6%, 16%, and 39%, respectively. The GAP models performed similarly in pooled follow-up visits (c-index ≥71.9).
Patients were drawn from academic centers and analyzed retrospectively.
The GAP models use commonly measured clinical and physiologic variables to predict mortality in patients with IPF.
Control tower to surgical theater Buccioli, Matteo; Traldi, Leo
Current directions in biomedical engineering,
9/2016, Letnik:
2, Številka:
1
Journal Article
Recenzirano
Abstract
The main social priority is to reduce public debt and to streamline national health service (NHS) costs. Consequently, health managers need to acquire operating methods within their ...managerial structures so that all available resources are better planned in terms of effectiveness and efficiency, without compromising patient safety. In order to identify the information categories needed to know the whole surgical process is necessary to divide these in two main categories,
supply and demand
.
Demand Information Group
(DIG) contains the information that identify patients and its needs in terms of care. Instead
Supply Information Group
(SIG) contains information about hospital resources in order to cover the supply. The surgical process analyzed in terms such as industrial production process has the goal of produce the “
health product for the patient
” and its central part is performed in the operating room by a surgical team. This does not mean that the precedent and subsequent phases of the operating room have minor importance, in fact to obtain a high quality “
health product
” and reduce to a minimum the clinical risks related to the patient it is necessary that each phase of the process is carried out in the right way. The implementation of a Control Tower Approach allows for the management of productive process, able to guide hospital managers to identify the best strategies and to improve the risk management of patient safety in response to the guidelines of the World Health Organization.
The 2008 financial crisis has changed administration methods of various activities and productive services, including health services. In fact in Italy it was necessary a deep reorganization of ...the healthcare system due to a strong reduction in the funds allocated to the health sector. Consequently the management of the hospital operative theaters like operating rooms (OR) has become a priority aspect in the health administration. In this context we performed a literary review about experiences or projects of operating room management (ORM) carried out in Italy between 2007 and nowadays. We searched Medline database and we found 12 articles meeting the inclusion criteria. Only one paper was submitted in 2007, the remain were drafted in the following years. The italian regions represented are mostly of the north center area. The topics discussed are heterogeneous: ORM reorganizations in clinical hospitals, simulations of models aimed to resolve OR slots assignment, surgical waiting lists management, OR process analysis and ORM literary review. Overall the results show that interest and competence for the ORM are quickly increasing in Italy. In fact, because OR are the most expansive and the most productive areas of every hospitals, it’s of paramount relief to implement strategies in order to optimize OR quality and minimize the non-productive and unnecessary costs, especially in the current period of austerity measures and continuous cuts to public funds.
Keywords: hospitals, management, crisis, resources, surgery, healthcare, ORM
Objective: As the care of Obstructive Sleep Apnoea (OSA) patients remains heterogeneous, we hypothesized that it may reflect insufficient OSA knowledge/awareness among clinicians. Methods: OSA ...Knowledge/Attitude Questionnaire (OSAKA) was translated into Italian and distributed to anaesthetists attending SIAARTI National Congress and Airways courses and Handson Workshops from October 2012 to June 2013. Results: In total, 370 anaesthetists returned the questionnaires (response rate, 62%); the median (interquartile range IQR) knowledge score was 12 (10-14), and the range was 1–17 with no difference by gender, age, professional title or years of practice. The knowledge items achieved a mean rate of corrected response of 66%}0.14%. With regard to attitude items, median (IQR) score was 15 (13-17) and range was 0–20. Females and anaesthetists with >15 years of practice reached higher scores, while anaesthesia residents showed a lower attitude score. Gender and Professional title were statistically associated with the attitude score (gender: F=14.6, p=0.0002; professional title: F=4.72, p=0.0099), whereas a weak association was observed within years in practice and attitude score (F=2.6, p=0.0519). Knowledge score correlated positively with attitude score (r=0.4, p<0.0001). For knowledge domains, there was a positive correlation between pathophysiology (mid-grade: r=0.3, p<0.0001), symptoms (low grade: r=0.2, p<0.0001), diagnosis (mid grade: r=0.3, p<0.0001) and the attitude score. Correlation close to zero was observed for epidemiology and treatment domains (r=0.09, p=0.06; r=−0.01, p=0.78,respectively). Conclusion: The results of our survey demonstrate lack of knowledge about OSA and its treatment, revealing the need to update the syllabus of teaching in medical practice and in national health care policies to improve perioperative care.
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