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Background: This study tests the impact of the addition of autonomous computed tomography (CT) interpreting software to radiologist assessment of pulmonary nodules. Methods: Computed tomography scans for nodule assessment were identified retrospectively. Lung cancer risk factors, initial radiologist (RAD) report, Philips Lung Nodule software report (computer-aided nodule (CAD)) and radiologist report following the review of CT images and CAD (RAD + CAD) were collected. Follow-up recommendations based on current guidelines were derived from each report. Results: In all, 100 patients were studied. Median maximal diameter of the largest nodule reported by RAD and RAD + CAD were similar at 10.0 and 9.0 mm, respectively ( p = 0.06) but were reported as larger by CAD at 11.8 mm ( p Discussion: This study suggests that autonomous software use can alter radiologist assessment of pulmonary nodules such that suggested follow-up is altered.

Comorbidities in severe asthma are common and contribute to disease burden. The severe asthma phenotype and treatment response can be impacted by comorbid conditions. Real-world data on the use of mepolizumab in severe eosinophilic asthma (SEA) in the presence of comorbidities is needed to inform clinical practice.To investigate the impact of comorbid conditions on baseline phenotype in patients with SEA and assess the mepolizumab treatment effect by comorbidity status in SEA.Patients enrolled in the Australian Mepolizumab Registry (n=309) were classified into subgroups defined by the presence or absence of comorbidities, including nasal polyps, aspirin exacerbated airway disease, asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO), fungal sensitisation and obesity. Patient baseline characteristics were compared, and the impacts of comorbidity on phenotype, identified by differences in patient age and/or baseline biomarker levels and/or asthma severity, were assessed. The mepolizumab treatment effects on clinical and biological outcomes at 12 months were assessed.Across comorbidity subgroups, mepolizumab reduced the rate of clinically significant exacerbations (range 47-77%), maintenance oral corticosteroid use (dose reduction 4.2-13.3 mg/day), and improved symptom control (Asthma Control Questionnaire-5 score 1.9-2.4 point reduction) and lung function (mean 3.4-9.3 post-bronchodilator percent predicted forced expiratory volume in 1s). Peripheral blood eosinophils were reduced (mean 480-780 cells/μL). Comorbidities (nasal polyps, obesity, ACO and fungal sensitisation) modified the baseline phenotype.Mepolizumab treatment is associated with comparable clinical improvements in in patients with SEA and comorbidities. Mepolizumab effectively minimizes the disease impact and corticosteroid burden in patients with SEA.

Oral corticosteroids (OCS) carry serious health risks. Innovative treatment options are required to reduce excessive exposure and promote OCS stewardship.This study evaluated the trajectories of OCS exposure (prednisolone-equivalent) in patients with severe eosinophilic asthma before and after starting mepolizumab and the predictors of becoming OCS free after 6 months of mepolizumab therapy.This real-world observational study included 309 patients from the Australian Mepolizumab Registry who were followed up for 1 year (n = 225).Patients had a median age of 60 (interquartile range: 50, 68) years, and 58% were female. At baseline, 48% used maintenance OCS, 96% had ≥1 OCS burst, and 68% had received ≥1 g of OCS in the previous year. After commencing mepolizumab, only 55% of those initially on maintenance OCS remained on this treatment by 12 months. Maintenance OCS dose reduced from median 10 (5.0, 12.5) mg/day at baseline to 2 (0, 7.0) mg/day at 12 months (P.001). Likewise, proportions of patients receiving OCS bursts in the previous year reduced from 96% at baseline to 50% at 12 months (P.001). Overall, 137 (48%) patients required OCS (maintenance/burst) after 6 months' mepolizumab therapy. Becoming OCS free was predicted by a lower body mass index (odds ratio: 0.925; 95% confidence interval: 0.872-0.981), late-onset asthma (1.027; 1.006-1.048), a lower Asthma Control Test score (1.111; 0.011-1.220), and not receiving maintenance OCS therapy at baseline (0.095; 0.040-0.227).Mepolizumab led to a significant and sustained reduction in OCS dependence in patients with severe eosinophilic asthma. This study supports the OCS-sparing effect of mepolizumab and highlights the pivotal role of mepolizumab in OCS stewardship initiatives.

The categorisation of lung disease into obstructive ventilatory defect (OVD) and tendency to a restrictive ventilatory defect (TRVD) patterns using spirometry is used to guide both prognostication and treatment. The effectiveness of categorisation depends upon having reference ranges that accurately represent the population they describe. The Global Lung Initiative 2012 (GLI 2012) has spirometry reference ranges drawn from the largest sample size to date. This study aimed to determine whether using spirometry reference ranges from the new GLI 2012 dataset, compared to the previously used National Health and Nutritional Examination Survey III (NHANES III) dataset, resulted in a change in diagnosis between OVD, TRVD and normal ventilatory pattern (NVP). Spirometry data were collected from 301 patients, aged 18-80 years, undergoing investigation at the Gold Coast Hospital and Health Service (GCHHS) throughout February and March 2014. OVD was defined as a forced expiratory volume in 1 second (FEV1) divided by forced vital capacity (FVC) less than lower limit of normal (LLN). TRVD was defined as FEV1/FVC ≥ LLN, FEV1 < LLN, and FVC < LLN. The LLN values were determined by equations from the GLI and NHANES datasets. Spirometry interpreted using the NHANES III equations showed: 102 individuals (33.9%) with normal spirometry, 136 (45.2%) with an OVD pattern, 52 (17.3%) with a TRVD pattern, and 11 (3.7%) with a mixed pattern. When the spirometry data were interpreted using the GLI 2012 equations 2 (0.7%) individuals changed from OVD to NVP, 2 (0.7%) changed from NVP to OVD and 14 (4.7%) changed from TRVD to NVP. Using the GLI 2012 reference range resulted in a change in diagnosis of lung disease in 5.9% of the individuals included in this study. This variance in diagnosis when changing reference ranges should be taken into account by clinicians as it may affect patient management.

Introduction/Aim: Neutrophil lymphocyte ratio (NLR) has demonstrated utility in predicting prognosis in patients with solid organ malignancies, with a recent systematic review suggesting that a NLR >4 is associated with poor prognosis. The role of NLR in non-malignant disorders has not been as extensively evaluated. The utility of NLR in predicting prognosis in patients with malignant and benign pleural effusions has not been previously evaluated. Methods: Retrospective analysis was performed on all patients undergoing diagnostic pleural aspiration over a 24 month period. Data were collected from medical records, radiology and pathology databases. Pleural effusions were considered malignant if pleural cytology was positive, a tissue biopsy was positive for malignancy, or if subjects had disseminated malignancy with no alternative explanation for the effusion. Statistical analysis was performed using SPSS Version 21. Results were considered significant at p 4 or Results: We analysed data sets from 60 patients who underwent diagnostic pleural aspiration. 23 (38%) had malignant effusions and 37 (62%) had benign effusions. The NLR was not different between groups(p=0.982). An NLR >4 was associated with a longer length of stay; 13 ± 2.2 (SEM) days versus 4.6 ± 0.83 (SEM) days (p=0.005) and reduced overall survival; 8.4 ± 1.1(SEM) months versus 12.9 ± 1.5 (SEM) months (p=0.023). Conclusion: NLR is a poor prognostic marker in patients with pleural effusions. An NLR >4 is associated with a longer length of inpatient hospital stay and reduced overall survival.

Background Severe asthma is a high impact disease. Omalizumab targets the allergic inflammatory pathway; however, effectiveness data in a population with significant comorbidities are limited. Aims To describe severe allergic asthma, omalizumab treatment outcomes and predictors of response among the Australian Xolair Registry participants. Methods A web-based post-marketing surveillance registry was established to characterise the use, effectiveness and adverse effects of omalizumab (Xolair) for severe allergic asthma. Results Participants (n = 192) (mean age 51 years, 118 female) with severe allergic asthma from 21 clinics in Australia were assessed, and 180 received omalizumab therapy. They had poor asthma control (Asthma Control Questionnaire, ACQ-5, mean score 3.56) and significant quality of life impairment (Asthma-related Quality of Life Questionnaire score 3.57), and 52% were using daily oral corticosteroid (OCS). Overall, 95% had one or more comorbidities (rhinitis 48%, obesity 45%, cardiovascular disease 23%). The omalizumab responder rate, assessed by an improvement of at least 0.5 in ACQ-5, was high at 83%. OCS use was significantly reduced. The response in participants with comorbid obesity and cardiovascular disease was similar to those without these conditions. Baseline ACQ-5 ≥ 2.0 (P = 0.002) and older age (P = 0.05) predicted the magnitude of change in ACQ-5 in response to omalizumab. Drug-related adverse events included anaphylactoid reactions (n = 4), headache (n = 2) and chest pains (n = 1). Conclusion Australian patients with severe allergic asthma report a high disease burden and have extensive comorbidity. Symptomatic response to omalizumab was high despite significant comorbid disease. Omalizumab is an effective targeted therapy for severe allergic asthma with comorbidity in a real-life setting.

Background and objective: It has been suggested that pulmonary embolism (PE) is an under-recognized cause of pleural effusion. This study aimed to (i) establish the incidence and clinical relevance of pleural effusion in patients with pulmonary emboli; and (ii) determine if there is a relationship between development of pleural effusions and the location of emboli and number of pulmonary arteries involved. Methods: A retrospective analysis of all CT pulmonary angiograms (CTPA) performed over 12 months on adult patients with clinically suspected PE in a hospital which used CTPA as first-line imaging investigation for PE. Results: Of 285 CTPA, 60 patients (21%) had evidence of pulmonary emboli (38 had both central and peripheral clots and 22 peripheral emboli only). Emboli were bilateral in 39 cases and unilateral in 21 cases. Pleural effusion was present in almost one half (n = 29, 48%) of the patients with pulmonary emboli. Patients with pulmonary emboli were more likely to have a pleural effusion (OR 2.2 (95% CI: 1.1-4.7), P < 0.05) than patients without PE; however, the effusions were generally very small. Most (86%) of the effusions were present on the same side as the emboli. The location of emboli and number of arteries involved did not predict the presence of pleural effusions. Conclusions: Pleural effusion is common in patients with pulmonary emboli demonstrated on CTPA. These effusions are small and seldom alter clinical management. Clinicians should therefore have a high threshold of suspicion in attributing large or contralateral pleural effusions to embolic diseases without excluding alternative diagnoses.

Pleural procedures may cause patient discomfort and serious complications if performed inadequately. We surveyed junior doctors to provide information about training and experience.We surveyed 493 junior doctors working in departments involved in pleural procedures in three teaching hospitals via postal questionnaires in 2002.The response rate was 66%. Formal training in the performance of pleural procedures was limited at undergraduate and postgraduate levels. Theoretical training at postgraduate level in pleural aspiration, chest drain insertion, and closed pleural biopsies was reported by 34%, 40%, and 14% of respondents respectively. Practical training using animal or artificial models occurred infrequently. Pleural aspiration, chest drain insertion, and pleural biopsy had been performed at least once by 91%, 66%, and 41% of respondents respectively. Most doctors felt they needed more training in chest drain insertion and pleural biopsy. Confidence in performing procedures was related to the number of times the procedure had been performed but not to formal teaching.This study provides a comprehensive survey of the background training, experience and confidence levels of junior medical staff in performing pleural procedures. Training in pleural procedures was limited and our results suggest the need for better training programmes and supervision of junior doctors.

To determine the patient characteristics, referral patterns and delays in assessment and treatment of patients with primary lung cancer in South Auckland, New Zealand and compare with international standards.Retrospective review of the clinical records of 80 patients referred to a secondary care respiratory service and diagnosed with primary lung cancer in 2004.Eighty-five percent of inpatient referrals and 48.5% of outpatient referrals were for advanced stage lung cancers. The median interval from receipt of outpatient referral to first chest physician assessment was 18 days, with median interval from the first chest physician assessment to bronchoscopy of 17 days and for staging CT chest of 16 days. For patients requiring a CT-guided percutaneous needle aspiration for diagnosis, there was a further median delay of 37 days after the initial CT scan. The median interval from the date of receipt of initial outpatient referral to diagnosis was 38 days, but for early stage lung cancers it was 54 days. The median interval to diagnosis for inpatient admissions was 6 days after the first respiratory assessment.The intervals for initial assessment, diagnosis and treatment of lung cancer in South Auckland do not meet the recommendations of international guidelines, especially for early stage lung cancers. Organisational and resource changes are required at each point in the diagnostic and management pathway to reduce delays.

To retrospectively correlate the extent of individual diseases seen at thin-section computed tomography (CT) with pulmonary function in an initial group of patients with asbestos-related parenchymal disease (asbestosis) and to test these findings in a subsequent group of patients whose CT scans were retrospectively identified.This retrospective study had Institutional Review Board approval; informed consent was not required. The study included 133 individuals who had been exposed to asbestos. In the initial study group (81 patients; 79 men, two women; median age, 67 years), two observers used a CT scoring system to quantify the extent of pulmonary fibrosis, diffuse pleural thickening, small-airways disease, and emphysema. Multivariate equations were formulated by using independent CT variables to predict changes in total lung capacity (TLC) and carbon monoxide diffusing capacity (Dlco). The validity of these equations was then tested in a subsequent group of patients (52 patients; all men; median age, 60 years).At thin-section CT, the extent of asbestos-induced pleuropulmonary disease and emphysema correlated significantly with physiologic impairment (P.001). Combined CT variables predicted 58% and 57% of the variability in TLC and Dlco, respectively, despite considerable variation in the proportion of coexisting pathologic conditions. When predictive equations with CT variables derived from the initial study group were applied to the subsequent study group, predicted TLC (rho=0.75, P.001) and Dlco (rho=0.64, P.001) correlated strongly with measured values.The proposed CT system provides a semiquantitative method for assessing the relative contribution of asbestos-induced pleuropulmonary disease and smoking-related emphysema to functional impairment.

A technique for the extraperitoneal removal of the adrenal gland using laparoscopic instrumentation and insufflation is described. A case of Cushing's syndrome in a 42 year old female is presented with successful removal of her adrenal tumour using the laparoscopic method. This is the first report of laparoscopic adrenalectomy employing the extraperitoneal approach.