Artificial intelligence (AI) is transforming healthcare delivery. The digital revolution in medicine and healthcare information is prompting a staggering growth of data intertwined with elements from ...many digital sources such as genomics, medical imaging and electronic health records. Such massive growth has sparked the development of an increasing number of AI-based applications that can be deployed in clinical practice. Pulmonary specialists who are familiar with the principles of AI and its applications will be empowered and prepared to seize future practice and research opportunities. The goal of this review is to provide pulmonary specialists and other readers with information pertinent to the use of AI in pulmonary medicine. First, we describe the concept of AI and some of the requisites of machine learning and deep learning. Next, we review some of the literature relevant to the use of computer vision in medical imaging, predictive modelling with machine learning, and the use of AI for battling the novel severe acute respiratory syndrome-coronavirus-2 pandemic. We close our review with a discussion of limitations and challenges pertaining to the further incorporation of AI into clinical pulmonary practice.
These guidelines are an update of the evidence-based recommendations for follow-up and surveillance of patients after curative-intent therapy for lung cancer. Particular updates pertain to whether ...imaging studies, health-related quality-of-life (HRQOL) measures, tumor markers, and bronchoscopy improve outcomes after curative-intent therapy.
Meta-analysis of Observational Studies in Epidemiology guidelines were followed for this systematic review, including published studies on posttreatment outcomes in patients who received curative-intent therapy since the previous American College of Chest Physicians subject review. Four population, intervention, comparison, and outcome questions were formulated to guide the review. The MEDLINE and CINAHL databases were searched from June 1, 2005, to July 8, 2011, to ensure overlap with the search strategies used previously.
A total of 3,412 citations from MEDLINE and 431 from CINAHL were identified. Only 303 were relevant. Seventy-six of the 303 articles were deemed eligible on the basis of predefined inclusion criteria after full-text review, but only 34 provided data pertaining directly to the subject of the questions formulated to guide this review. In patients undergoing curative-intent surgical resection of non-small cell lung cancer, chest CT imaging performed at designated time intervals after resection is suggested for detecting recurrence. It is recommended that treating physicians who are able to incorporate the patient's clinical findings into decision-making processes be included in follow-up and surveillance strategies. The use of validated HRQOL instruments at baseline and during follow-up is recommended. Biomarker testing during surveillance outside clinical trials is not suggested. Surveillance bronchoscopy is suggested for patients with early central airway squamous cell carcinoma treated by curative-intent photodynamic therapy and for patients with intraluminal bronchial carcinoid tumor who have undergone curative-intent bronchoscopic treatment with Nd:YAG laser or electrocautery.
There is a paucity of well-designed prospective studies specifically targeting follow-up and surveillance modalities aimed at improving survival or QOL after curative-intent therapy. Additional research is warranted to clarify which curative-intent treatment modalities affect HRQOL the most and to identify patients who are at the most risk for recurrence or impaired QOL after treatment. Further evidence is needed to determine how the frequency and duration of surveillance programs that include imaging studies, QOL measurements, tumor markers, or bronchoscopy affect patient morbidity, survival, HRQOL, and health-care costs.
ABSTRACT
IP encompasses a complex list of procedures requiring knowledge, technical skills and competence. Modern, learner‐centric educational philosophies and an explosion of multidimensional ...educational tools including manikins, simulators, online resources, social media and formal programs can foster learning in IP, promoting professionalism and a culture of lifelong learning. This paper provides background and guidance to a structured, multidimensional and learner‐centric strategy for medical procedural education. Focusing on our experience in IP, we describe how competency‐based measures, simulation technology and various teaching modalities contribute to a more uniform learning environment in which patients do not suffer the burdens of procedure‐related training.
: Tracheobronchomalacia and excessive dynamic airway collapse are two separate forms of dynamic central airway obstruction that may or may not coexist. These entities are increasingly recognized as ...asthma and COPD imitators. The understanding of these disease processes, however, has been compromised over the years because of uncertainties regarding their definitions, pathogenesis and aetiology. To date, there is no standardized classification, diagnosis or management algorithm. In this article we comprehensively review the aetiology, morphopathology, physiology, diagnosis and treatment of these entities.
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is becoming standard of care for the sampling of mediastinal adenopathy. The need for a safe, effective, accurate ...procedure makes EBUS-TBNA ideal for mastery training and testing.
The Endobronchial Ultrasound Skills and Tasks Assessment Tool (EBUS-STAT) was created as an objective competency-oriented assessment tool of EBUS-TBNA skills and knowledge. This study demonstrates the reliability and validity evidence of this tool.
The EBUS-STAT objectively scores the EBUS-TBNA operator's skills, including atraumatic airway introduction and navigation, ultrasound image acquisition and optimization, identification of mediastinal nodal and vascular structures, EBUS-TBNA sampling, and recognition of EBUS/computed tomography images of mediastinal structures. It can be administered at the bedside or using combination of low- and high-fidelity simulation platforms. Two independent testers administered the EBUS-STAT to 24 operators at three levels of EBUS-TBNA experience (8 beginners, 8 intermediates, and 8 experienced) at three institutions; operators were also asked to self-assess their skills. Scores were analyzed for intertester reliability, correlation with prior EBUS-TBNA experience, and association with self-assessments.
Intertester reliability between testers was very high (r = 0.9991, P < 0.00005). Mean EBUS-STAT scores for beginner, intermediate, and experienced groups, respectively, were 31.1, 74.9, and 93.6 out of 100 (F(2,21) = 118.6, P < 0.0001). Groups were nonoverlapping: post hoc tests showed each group differed significantly from the others (P < 0.001). Self-assessments corresponded closely to actual EBUS-STAT scores (r(2) = 0.81, P < 0.001).
The EBUS-STAT can be used to reliably and objectively score and classify EBUS-TBNA operators from novice to expert. Its use to assess and document the acquisition of knowledge and skill is a step toward the goal of mastery training in EBUS-TBNA.
Sending retirees to the frontlines? Sabath, Bruce F.; Colt, Henri G.
Journal of community hospital internal medicine perspectives,
09/2020, Volume:
10, Issue:
5
Journal Article
Peer reviewed
Open access
Facing an unprecedented surge of patient volumes and acuity, institutions around the globe called for volunteer healthcare workers to aid in the effort against COVID-19. Specifically being sought out ...are retirees. But retired healthcare workers are taking on significant risk to themselves in answering these calls. Aside from the risks that come from being on the frontlines of the epidemic, they are also at risk due to their age and the comorbidities that often accompany age. If, for current or future COVID efforts, we as a society will be so bold as to exhort a vulnerable population to take on further risk, we must use much care and attention in how we involve them in this effort. Herein we describe the multifaceted nature of the risks that retired healthcare workers are taking by entering the COVID-19 workforce as well as suggest ways in which we might take advantage of their medical skills and altruism yet while optimizing caution and safety.
Silicone stent insertion is an alternative treatment for expiratory central airway collapse. This study evaluates the complications (mucus plugging, migration, and granulation tissue) associated with ...stenting in patients who failed medical therapy and were not surgical candidates.
Chart review from 15 consecutive patients treated by silicone stent insertion was done over a 2-year period. Outcomes included (1) changes in functional class, extent and severity of airway collapse (graded from 1 to 4 by using a multidimensional system), procedure- and stent-related complications at 48 hours after stent insertion; (2) frequency of stent-related complications; and (3) frequency of emergent flexible and rigid bronchoscopy (scheduled or emergent) over the follow-up period.
Mean functional class and severity and extent of airway collapse significantly improved within 48 hours after treatment (p < 0.05). There were no perioperative deaths. Stent-related complications within 48 hours after stent insertion occurred in 3 patients (1 granulation, 1 migration, and 1 mucus plugging). The mean duration of follow-up for the 12 patients who underwent clinical and bronchoscopic follow-up was 188 days. Twenty-six stent-related complications (12 mucus plugs, 8 migrations, and 6 granulation tissues) were seen in 10 of the 12 patients. Five emergent flexible bronchoscopies and 14 rigid bronchoscopies (6 of which were emergent) were performed during the follow-up period.
Silicone stent insertion improves functional status immediately after intervention in patients with expiratory central airway collapse, but is associated with a high rate of stent-related complications and need for repeat bronchoscopic interventions.
Background
Rigorous assessment of medical knowledge and technical skill inspires learning, reinforces confidence, and reassures the public. Identifying curricular effectiveness using objective ...measures of learning is therefore crucial for competency-oriented program development in a learner-centric educational environment. The aim of this study was to determine whether various measures of learning, including
class-average
normalized gain
, can be used to assess the effectiveness of a one-day introductory bronchoscopy course curriculum.
Methods
We conducted a quasi-experimental one-group pre-test/post-test study at the University of California, Irvine. The group comprised 24 first-year pulmonary and critical care trainees from eight training institutions in southern California. Class-average normalized gain, single-student normalized gain, absolute gain, and relative gain were used as objective measures of cognitive knowledge and bronchoscopy technical skill learning. A class-average normalized gain of 30% was used to determine curricular effectiveness. Perceived educational value using Likert-scale surveys and post-course questionnaires was determined during and 3 months after course participation.
Results
Mean test scores of cognitive knowledge improved significantly from 48 to 66% (
p
= 0.043). Absolute gain for the class was 18%, relative gain was 37%,
class
average normalized gain
〈g〉 was 34%, and the
average of the
single-student normalized gains
g(ave) was 29%. Mean test scores of technical skill improved significantly from 43 to 77% (
p
= 0.017). Absolute gain was 34%, relative gain was 78%,
class
average normalized gain
〈g〉 was 60%, and the
average of the
single-student normalized gains
g(ave) was 59%. Statistically significant improvements in absolute gain were noted in all five elements of technical skill (
p
< 0.05). Likert-scale surveys, questionnaires, and surveys demonstrated strong perceived educational value.
Conclusion
The effectiveness of a one-day introductory bronchoscopy curriculum was demonstrated using a pre-test/post-test model with calculation of normalized gain and related metrics.
In an era of increased emphasis on patient safety and competency-based education, demonstration of significant variability in the teaching of flexible bronchoscopy has led to initiatives for new ...standardized curricula and assessment tools.
To evaluate the efficacy of such curricula and to assess bronchoscopic skill, 2 measuring instruments have been developed: the Bronchoscopy Skills and Tasks Assessment Tool (BSTAT) and the Bronchoscopy Step-by-Step Evaluation Tool (BSET). We studied the validity and reliability of these 2 instruments.
Two independent testers simultaneously scored 22 volunteer participants at 3 levels novice (n = 7), fellow (n = 8) and attending (n = 7) on a virtual reality bronchoscopy simulator using the 2 instruments; each participant was tested twice, in 2 separate sessions. Intertester and test-retest reliability were analyzed with intraclass correlations (ICC); ANOVA was used to assess concurrent validity based on the subjects' expected skill level.
The ICCs between the testers were 0.98 for both the BSTAT and BSET. Comparison of the scores between the sessions showed high test-retest reliability by ICC (0.86 and 0.85 for BSTAT and BSET respectively), with a small yet statistically significant learning effect. The novice group's scores were lower than the fellows' and attendings' (p < 0.001) for both the BSTAT and BSET; the fellows' scores were consistently lower than the attendings' on both tests, yet the differences were not statistically significant.
This validation study of 2 objective tests of bronchoscopic skill demonstrated high reliability and concurrent validity. These instruments can now be used to evaluate the effectiveness of new competency-based bronchoscopy curricula.
Objective: This study aimed to assess prospectively the accuracy, safety and outcome of flex‐rigid pleuroscopy in the diagnosis of patients with indeterminate pleural effusions.
Methods: Included ...in the study were all patients with unilateral exudative pleural effusions of unknown aetiology who underwent diagnostic flex‐rigid pleuroscopy from July 2003 to June 2005, and were followed until December 2005. The procedure was conducted in the endoscopy suite under local anaesthesia and, where indicated, talc poudrage was carried out at the same time. Clinical data, length of hospitalization, chest tube drainage, outcome, diagnostic accuracy of pleuroscopy and procedure‐related adverse events were recorded prospectively.
Results: Fifty‐one patients were recruited (20 male and 31 female). Median age was 53 years (range 45–67). Flex‐rigid pleuroscopy was 96% accurate and yielded a diagnosis in 49 out of 51 patients. It was safely carried out without need for surgical intervention, blood transfusion or endotracheal intubation. Culture‐negative fever was observed in eight patients (16%), and five patients (10%) required additional analgesia for postoperative pain. Duration of chest tube drainage and length of stay for patients who underwent diagnostic pleuroscopy were 1 and 2 days, respectively, while they were both 3 days when talc poudrage was carried out. Success rates with pleuroscopic talc pleurodesis for malignant pleural effusions were 94%, 92% and 89.5% at 3, 6 and 12 months, respectively, and the 30‐day mortality was 0%.
Conclusion: Flex‐rigid pleuroscopy is a safe procedure with a high diagnostic accuracy and should be considered for the evaluation of indeterminate pleural effusion.
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