Outcome of implantable loop recorder evaluation

Background: The aim of this study was to evaluate implantable loop recorders (ILRs) in an unselected cohort in order to determine diagnostic yield, time to pacemaker/implantable cardioverter-defibrillator (ICD) implantation, predictors thereof, safety issues, and syncope management including usage of preceding diagnostic tools. Methods: Patients who underwent ILR evaluation in any of three centers in Region Gävleborg, Swe­den, between April 2007 and April 2013 were included and their medical records retrieved. Logistic regression was used to evaluate predictors of pacemaker/ICD outcome expressed as odds ratios (ORs) and Kaplan-Meier estimates for time-dependent analysis. Results: A total of 173 patients (52.6% females) with a mean age of 56.2 years received an ILR dur­ing a mean follow-up of 605 days. In the 146 patients evaluated for syncope/presyncope, 28.1% received a pacemaker (n = 39) or ICD (n = 2). The cumulative incidence at 6, 12, and 18 months were 8.8%, 21.3%, and 26.7%, respectively. Age > 75 years was the only significant predictor for outcome (p = 0.010) and the following variables showed a tendency toward significance: abnormal elevation of the biomarker B-type natriuretic peptide (OR 2.05, p = 0.100), a history of trauma (OR 1.71, p = 0.179), and patho­logic electrocardiogram (OR 1.68, p = 0.231). A computerized tomography of the skull was performed in 52.1% of the syncope cases. Conclusions: In syncope evaluation in an unselected cohort, 28.1% were diagnosed with an arrhyth­mia necessitating a pacemaker/ICD. The only significant predictor was advanced age. Time to diag­nosis is unpredictable and prolonged ILR monitoring is warranted in addition to optimal use of other diagnostic tools

Lung cancer in the county of Gaevleborg : Epidemiology and importance of infection with Chlamydia pneumoniae

At the beginning of the 20th century lung cancer was a rare malignancy. It is in Sweden the second most common cause of cancer death in both men and women. The purpose of the studies was to investigate whether chronic infection with C pneumoniae can contribute to cancer development; to describe a complete material of lung cancer in a geographically limited area; to try to find the "hidden cases", i e all those cases which would "normally" never be diagnosed or reported; and to investigate the delays in diagnosis, both from the patient and from the doctors. In the county of GaevIeborg, Sweden, with a population 290 000, practically all cases of lung cancer will be seen by the lung department. Beginning in 1998, meetings with all the general practitioners of the county were organized, asking them to refer all suspected cases of lung carcinoma as early as possible to the lung department, also including those with a dismal prognosis. Study I and II. the aim was to investigate the occurrence of chronic Chlamydia pneumoniae infection in patients with lung cancer. In study 1, sera from 33 women and 64 men were compared to healthy civil servants and a group who underwent coronary angiography. In Study 11, 136 men and 74 women with lung cancer were included. Consecutive blood donors and currently smoking or ex-smoking 70-year olds were used as controls. Blood was obtained and a swab was taken from the posterior part of the retropharyngeal mucosa for detection of C. pneumoniae by PCR. The prevalence of specific C. pneumoniae IgG antibody titer of> 512 was 57 % in male lung cancer patients compared to 27 % in male 70-year olds and 17 % in male blood donors. The prevalence figures for specific C. pneumoniae IgA antibody titers > 64 were 69 % for lung cancer patients compared to 25 and 20 % for the respective control groups. The difference between patients and controls was highly significant (p < 0.000001). The throat specimens had a low sensitivity. Study III. patient's and doctors' delays in an unselected material of patients with lung cancer were investigated. A questionnaire recorded symptoms and when they first occurred. All dates for visits to doctors and investigations were recorded. The mean delay of the patients was 43 days (median 21) days. The GP delay was a mean of 56 days, median 33, and the specialist doctor's delay was a mean of 33 days (median 9). The time from first symptom until treatment or decision not to treat was in the mean 203 days (median 189). Study IV. is a descriptive analysis of cancer type, stage, symptoms, smoking habits etc. The first symptoms were cough and dyspnea. 60 % were smokers, 27 % ex-smokers. Only 12.8 % had never smoked. Of the men, 91.9 % were smokers or ex-smokers, and of the women, 78.4 %. The difference between the sexes were statistically highly significant (p< 0.0001). Squamous cell carcinoma was seen in 30.4 % of the men but only 19.8 of the women. Adenocarcinoma was seen in one third of the women but only 19 % of the men. 18 % were Stage 1, 2 % 11, 10 % IIIa, 28 % Illb and 42 % IV. Study V was made to study how big the proportion of all lung cancer patients which "normally" never are diagnosed or reported to official cancer registries is, in other words try to find "the hidden cases of lung cancer". The incidence of lung cancer, as published by the official cancer registries from the County of GaevIeborg and four neighbouring counties from 1985 to 1998, were compared. For the four neighbouring counties there was an average of 86 new cases per year and county prior to 1997 and an average of 96 new cases per year during 1997 and 1998, thus a slight increase (p <0.045). Comparable figures for the county of GaevIeborg were 87 new cases per year prior to 1997 and 124 cases for 1997 and 1998. After 1997 the incidence in the county remained high and in year 2000, 140 new cases were diagnosed. The number of cases in the county of GaevIeborg from 1997 onwards is significantly higher both compared to the number of cases in the four neighbouring counties during the same period of time (p < 0.000) and compared to the number of cases prior to 1997 in the county of GaevIeborg (p < 0.000). Thus, the implementation of the new routines in the county of GaevIeborg in 1997 caused a considerable increase in the incidence of lung cancer. One can thus conclude that around 20 % of all lung cancers were never registered earlier. The figures are probably similar for most Sweden. Conclusions: There is a correlation between antibodies to C. Pneumoniae and lung cancer. There can be a considerable number of patients with lung cancer who are never "normally" diagnosed. Both patients' and doctors' delays are in most instances fairly long. Adenocarcinoma incidence is increasing. A distressingly large proportion of patients is diagnosed in high stages

Intrabronchial stents in heterogenous emphysema : a highly selected material followed 5 years

Background: Endobronchial lung volume reduction (EBVR) with one-way valves introduced into the most diseased lobe of the lung is a non-invasive method to improve lung function in patients with severe heterogenous emphysema. The problem is to select the right patients for the procedure. Furthermore, the long-term effects have not been reported in most studies. Methods: EBVR was performed in 35 patients with severely handicapping emphysema and with one radiologically clearly enlarged (at least 125%) target lung lobe and clearly visible and complete interlobar fissures on CT. Most of the successful survivors have then been followed for five years. Results: Five (14%) were primary failures (defined as less than 15% increase of FEV1sec) and 10 (28%) were secondary failures (the valves were coughed up or removed for some reason). In the 21 successful 1 patients, the improvement of FEV1sec was in the mean 59%. Over the years, FEV1sec gradually decreased but was still higher 5 years later than initially. Of the successful group, 76% were still alive after 5 years, while only 50% were in the refused or failed groups. Conclusions: With careful selection of patients remarkably good results in lung function can be achieved, and these improvements will last for years though slowly decrease. In addition, the results indicate an improvement in survival with successful EBVR procedure

Refined Diagnosis of Pleural Effusions by Immunocytochemistry of Cell Blocks

Background/Aim: The main objective of microscopic examination of pleural effusions is to ascertain the presence of malignant cells. Effusions prepared routinely using May-Grunwald-Giemsa (MGG)-and Papanicolaou (PAP)-staining can, in a number of cases, provide inconclusive cytological results regarding malignancy. Patients and Methods: This report describes the refined diagnosis of such cases based on immunocytochemical analysis of pleural effusion cell blocks. Of the 340 pleural effusions obtained during 2019 at the Department of Clinical Cytology, Gavle Hospital, Sweden, 63 (18.5%) contained atypical cells of undetermined significance or potentially malignant cells. Results: This diagnosis could be refined using Epithelial Cell Adhesion Molecule/EPCAM (BEREP4) immunocytochemical analysis of effusion cell blocks, allowing previously inconclusive effusions to be classified as clearly benign 42/63 (66.7%) or malignant 21/63 (33.3%). Effusions initially diagnosed as clearly malignant (27/340; 7.9%) were all 27 (100%) BEREP4-immuno-stained. Most BEREP4-positive effusions (37/48; 77.1%) were also carcinoembryonic antigen (CEA) positive. The number of BEREP4-positive cells, however, tended to exceed that of CEA-positive cells. The BEREP4 positive effusions were further examined using different monoclonal antibodies, such as Thyroid transcription factor 1 (TTF-1) for primary pulmonary adenocarcinoma, to determine the original site of the primary tumour. Conclusion: Immunohistochemical staining of pleural effusion cell blocks significantly refines the diagnosis of serous pleural effusions, especially in cases where the preliminary diagnosis was atypical cells of undetermined significance or potentially malignant cells. Furthermore, in the cases of malignancy, the origin of the primary tumour could most often be determined

A protocol for a prospective observational study using chest and thumb ECG : transient ECG assessment in stroke evaluation (TEASE) in Sweden

Atrial fibrillation (AF) causes ischaemic stroke and based on risk factor evaluation warrants anticoagulation therapy. In stroke survivors, AF is typically detected with short-term ECG monitoring in the stroke unit. Prolonged continuous ECG monitoring requires substantial resources while insertable cardiac monitors are invasive and costly. Chest and thumb ECG could provide an alternative for AF detection poststroke. The primary objective of our study is to assess the incidence of newly diagnosed AF during 28 days of chest and thumb ECG monitoring in cryptogenic stroke. Secondary objectives are to assess health-related quality of life (HRQoL) using short-form health survey (SF-36) and the feasibility of the Coala Heart Monitor in patients who had a stroke. Methods: Stroke survivors in Region Gavleborg, Sweden, will be eligible for the study from October 2017. Patients with a history of ischaemic stroke without documented AF before or during ECG evaluation in the stroke unit will be evaluated by the chest and thumb ECG system Coala Heart Monitor. The monitoring system is connected to a smartphone application which allows for remote monitoring and prompt advice on clinical management. Over a period of 28 days, patients will be monitored two times a day and may activate the ECG recording at symptoms. On completion, the system is returned by mail. This system offers a possibility to evaluate the presence of AF poststroke, but the feasibility of this system in patients who recently suffered from a stroke is unknown. In addition, HRQoL using SF-36 in comparison to Swedish population norms will be assessed. The feasibility of the Coala Heart Monitor will be assessed by a self-developed questionnaire. Ethics and dissemination: The study was approved by The Regional Ethical Committee in Uppsala (2017/321). The database will be closed after the last follow-up, followed by statistical analyses, interpretation of results and dissemination to a scientific journal

Computer tomography-guided core biopsies in a county hospital in Sweden: Complication rate and diagnostic yield

Background: Core biopsies are valuable in obtaining sufficient tissue to ensure diagnosis of diseases in the thorax. Objective: To evaluate the complication rate and the diagnostic yield in computer tomography (CT)-guided core biopsies performed in a county hospital in Sweden. Methods: Medical journals, spirometry results, pathology reports and CT scans were reviewed in 463 consecutive cases, where a transthoracic core biopsy was performed between January 2005 and December 2010. Of these 380 (82%) were lung lesions, 48 (10%) were mediastinal lesions and 35 (8%) were pleural lesions. Results: All patients underwent a chest X-ray 4 hours post-biopsy and pneumothorax was seen in 156/463 (34%) patients: 137 after lung biopsy and 17 after mediastinal biopsy. Chest tube insertion was required for 27 (17%) of these patients (6% of all core biopsies). Small intraparenchymal hemorrhages and hemoptysis were observed with subjective difficulty in one case. The diagnostic yield for the 463 patients was 212 (46%) cases of lung cancer, 188 (41%) benign lesions and 39 (8%) pulmonary metastases. Conclusions: A transthoracic core biopsy ensures diagnosis with a low complication rate and is suitable as an outpatient procedure. An increased risk for pneumothorax was observed when the biopsied lesion was small or when emphysema was in the path of the biopsy needle. Reduced lung function pre-biopsy or emphysema in the path of the biopsy needle increased the need for chest tube treatment of pneumothorax. A CT-guided core biopsy is safe and applicable in a county hospital