Chronic cough associated with Crohn's disease

A 62-year-old man presented with chronic dry cough. He was known to have Crohn's disease which was in remission. A plain chest radiograph demonstrated bilateral apical infiltrates. A HRCT of the chest showed normal proximal airways. Stenosis of medium size airways was present with post-stenotic dilation. These dilated peripheral bronchi appeared fluid filled. Patchy areas of consolidation were seen as well. These changes were thought to be due to Crohn's disease involving the lungs and responded well to treatment with cortico-steroids. We report this uncommon radiological association with Crohn's disease

Validation of the HULL Score clinical prediction rule (CPR) for unsuspected pulmonary embolism in ambulatory cancer patients

Background Clinical prediction rules (CPRs) developed to predict adverse outcomes of suspected pulmonary embolism (PE) and facilitate outpatient management have limitations in discriminating outcomes for ambulatory cancer patients with unsuspected PE (UPE). The HULL Score CPR uses a 5‑point scoring system incorporating performance status and self-reported new or recently evolving symptoms at UPE diagnosis. It stratifies patients into low, intermediate and high risk for proximate mortality. This study aimed to validate the HULL Score CPR in ambulatory cancer patients with UPE. Patients and methods 282 consecutive patients managed under the UPE-acute oncology service in Hull University Teaching Hospitals NHS Trust were included from January 2015 to March 2020. The primary end-point was all-cause mortality, and outcome measures were proximate mortality for the three risk categories of the HULL Score CPR. Results 30-day, 90-day and 180-day mortality rates for the whole cohort were 3.4% (n=7), 21.1% (n=43) and 39.2% (n=80), respectively. The HULL Score CPR stratified patients into low-risk (n=100, 35.5%), intermediate-risk (n=95, 33.7%) and high-risk (n=81, 28.7%) categories. Correlation of the risk categories with 30-day mortality (area under the curve (AUC) 0.717, 95% CI 0.522–0.912), 90-day mortality (AUC 0.772, 95% CI 0.707–0.838), 180-day mortality (AUC 0.751, 95% CI 0.692–0.809) and overall survival (AUC 0.749, 95% CI 0.686–0.811) was consistent with the derivation cohort. Conclusion This study validates the capacity of the HULL Score CPR to stratify proximate mortality risk in ambulatory cancer patients with UPE. The score uses immediately available clinical parameters and is easy to integrate into an acute outpatient oncology setting

Quality assurance in flexible sigmoidoscopy: Medical and nonmedical endoscopists

Purpose: The clinical assessment of position in colon and hence completion during flexible sigmoidoscopy (FS) is believed to be inaccurate. The technique of applying endomucosal clips with follow-up X-ray has previously been used for establishing completion in colonoscopy. Furthermore, we have now trained non-healthcare professionals (non-medical endoscopists, NME) to perform FS, but there is no data on assessment of their performance of FS. We performed this study with the aims of determining accuracy of endoscopists' clinical impression regarding actual position of endoscope in colon during FS, comparing medical (ME) and NME in terms of clinical accuracy, and to determine role of endomucosal clips with follow-up X-rays in documenting completion and hence quality assurance. Methods: All patients undergoing elective FS, except those with surgical resection, were included, after ethics approval. During FS, endoscopist applied an endomucosal clip at most proximal bowel reached and endoscopists recorded their independent opinion about position of clip. Post procedure, all patients underwent an abdominal X-ray, reported by consultant radiologist, blinded to outcome of FS. X-ray results were compared with endoscopist findings. Complete FS was defined as one where descending colon was reached. Results: Fifty-one patients, with median age of 55 years, participated in study. The endoscopists were accurate in their assessment of position in colon in 38 patients (75%). The attending nurse was accurate in only 31% of cases. The crude and corrected completion rates were 73% and 84%, respectively. There was no correlation between length of endoscope and its position in colon. There were no differences between NME and ME in terms of clinical accuracy. Conclusion: This study has shown that clinical impression of endoscopist during FS regarding position is not very accurate, implying need for regular quality assurance. The technique of applying endomucosal clips with follow-on abdominal X-ray is an excellent objective measure of quality assurance in FS. NME can perform FS with comparable completion rates and accuracy. © 2009 Springer Science+Business Media, LLC

Developing a complex intervention for the outpatient management of incidentally diagnosed pulmonary embolism in cancer patients

BACKGROUND: Most patients with pulmonary embolism (PE) spend 5–7 days in hospital even though only 4.5% will develop serious complications during this time. In particular, the group of patients with incidentally diagnosed PE (i-PE) includes many patients with low risk features potentially ideal for outpatient management; however the evidence for their optimal management is lacking hence relative practices may vary considerably. We describe the development process, components, links and function of a nurse-led service for the management of patients with i-PE, developed in accordance to the UK Medical Research Council complex intervention guidance. METHODS: Phase 0 (Theoretical underpinning): The Pulmonary Embolism Severity Index (PESI) was selected for patient risk assessment and the American Society of Clinical Oncology (ASCO) guideline for the management of PE in cancer patients (2007) was selected as quality measure. Historical registry and audit data from our centre regarding i-PE incidence and management for the period between 2006 and 2009 illustrating the then current practices were reviewed. Phase 1 (Modelling): Modelling of the pathway included the following: a) Identification of training needs, planning and implementation of training schemes and development of transferable competencies and training materials. b) Mapping patient pathways and flow and c) Production of key documentation and Standard Operating Procedures for the delivery of the service. RESULTS: Phase 2 (Implementation and testing of the intervention): During the initial 12 months of implementation, remedial action was taken to address identified deficiencies regarding patient referral to the pathway, compliance with treatment protocol, patient follow up, selection challenges from the use of PESI in cancer patients and challenges regarding the “first-pass” identification of i-PE. CONCLUSION: We have developed and piloted a complex intervention to manage cancer patients with incidental PE in an outpatient setting. Adherence to evidence- based care, improvement of communication between professionals and patients, and improved quality of data is demonstrated

Correction to: Prognostic assessment for patients with cancer and incidental pulmonary embolism

Following the publication of this study [1] the authors identified the following errors inadvertently introduced during the production process

Prognostic assessment for patients with cancer and incidental pulmonary embolism

Abstract Background An incidental/unsuspected diagnosis of pulmonary embolism (IPE) in cancer patients is a frequent occurrence. This single-institution analysis of uniformly managed patients investigates short and long-term outcomes and proposes a prognostic risk score, aiming to assist clinical decision-making. Methods Data from a prospectively recorded cohort of 234 consecutive cancer patients with IPE were analysed. Multivariate logistic regression and the Cox regression survival methods were used to identify factors with independent association with early (30-day, 3-month, 6-month) mortality and survival. Receiver operator characteristic analysis (ROC) was used to assess appropriate cut-offs for continuous variables and the fitness of prognostic scoring. Results 30-day, 3-month and 6-month mortality was 3.4% (n = 8), 15% (n = 35) and 31% (n = 72) respectively. Recurrence during anticoagulation occurred in 2.6% (n = 6) and major haemorrhage in 2.1% (n = 5) of the patients. A prognostic score incorporating performance status (0 vs 1–2 vs 3–4) and the presence of new or worsening symptoms, with and without the consideration of the presence of incurable malignancy, correlated with overall survival (p < .001 respectively) as well as early mortality (AUC = .821, p = .004 and AUC = .805, p = 0.006, respectively). Conclusion A simple prognostic score incorporating basic oncologic clinical assessment and self-reported symptomatology could reliably stratify the mortality risk of ambulant cancer patients and IPE. Trial registration Audit registration No. 2013.287, Hull and East Yorkshire Hospitals Trust, 29/11/2013

Textural analysis demonstrates heterogeneous [18F]-fluorodeoxyglucose uptake in radiologically normal lung in patients with idiopathic pulmonary fibrosis

Positron Emission Tomography (PET) scanning in idiopathic pulmonary fibrosis (IPF) has revealed increased [18F]-fluorodeoxyglucose ([18F]-FDG) uptake in areas of the lungs that appear normal on high resolution computed tomography (HRCT). We hypothesised that “microscopic” disease identified using PET would be heterogeneous because IPF is characterised histologically by patchy fibrosis. We applied textural analysis to PET scans to evaluate heterogeneity of [18F]-FDG uptake in lung regions that appeared normal on HRCT. We identified six textural features that demonstrated significantly more heterogeneous [18F]-FDG uptake in radiologically normal lung in IPF patients compared with controls. Textural analysis of lung PET-CT imaging is a novel approach to study early changes in IPF before HRCT abnormalities are apparent

Textural analysis demonstrates heterogeneous [F-18]-fluorodeoxyglucose uptake in radiologically normal lung in patients with idiopathic pulmonary fibrosis

status: publishe