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Background The development of drugs that target lung adenocarcinoma caused by epidermal growth factor tyrosine kinase (EGFR-TK) and anaplastic lymphoma kinase (ALK) mutations has focused the need to obtain sufficient tissue at biopsy to allow the detection of such molecular markers and so improve treatment options for selected patients. To investigate this further, we looked at the diagnostic yield from various biopsy techniques in our large lung cancer unit (400 cases per year, overall histological yield 77.5%). Methods We collected data from all patients with an ultimate histological diagnosis of adenocarcinoma for the years 2014 to 2016, looking at the diagnostic method, whether tissue was analysed for molecular mutations, and whether repeat procedures were necessary for EGFR-TK and ALK testing. Results 224 patients were identified: 42 by EBUS-TBNA, 66 by CT-guided biopsy, 44 at bronchoscopy, 66 at surgical resection, 6 from pleural fluid, and 1 by lymph node FNA. For molecular testing see Table. In addition to those patients where sampling was insufficient to make the diagnosis, a further 30 had inadequate cell numbers for mutation analysis and the reporting pathologist recommended repeat procedures. Of the 10 patients who underwent this, only 2 were retested for molecular markers, and the Results were unchanged. Conclusion This study shows that all our pre-resection positive diagnostic samples for lung cancer do not always provide sufficient tissue for molecular analysis. Although insufficiency rates were similar between CT, EBUS and bronchoscopy, one third of CT-guided specimens had few cells for the definite exclusion of mutations. With the advent of new therapies for lung cancer, we need to optimise our diagnostic sampling techniques when testing for molecular mutations. more...

Introduction Liverpool is an area of high socioeconomic deprivation, with more than twice the national incidence of lung cancer. In order to benchmark our survival performance at the Liverpool Lung Cancer Unit (diagnosing about 400 new cases/year) we wanted to compare our Units performance against national figures (32% 1 year survival, and 10% 5 year survival). We were also interested in determining if our survival rates had changed over time. Methods We conducted a retrospective analysis of data for all patients diagnosed over a period of 9 years. All analyses were conducted on the entire dataset stratified on the basis of 3 years’ time intervals (2007–2009; 2010–2012; 2013–2015). Demographic data were analysed and compared using descriptive statistics. Survival analysis was conducted by Kaplan Meier survival plots and log- Rank tests. P-values less than 5% were considered statistically significant. Results 3710 patients were diagnosed, with a mean age of 71.3, 52.5% male. Performance state (PS) 0=15%, 1=29.4%, 2=22.2%, 3=19.8%, 4=6.4%. Stage at diagnosis 1=19.7%, 2=6.6%, 3=23.3%, 4=41.3%. There was no significant change in numbers, age, PS, histological subtypes and stage over the 3 time periods. However, a survival rate of 40% and 16% was observed for 1 year and 5 years respectively, which is higher than the national average (figure 1). In addition, there was an increase in survival for patients diagnosed in latter time period compared with the earlier time periods. Interestingly, only stage IV patients showed significant improvement in survival for 2013–2015(p Conclusions Survival rates for our unit are higher than the national average. An increase in oncological treatments for stage IV patients appears to have contributed to the significant improvement in survival for these patients. more...

Introduction Although the majority of cases of suspected lung cancer can be managed as outpatients where the diagnostic pathway is well developed, a proportion still present unwell via the emergency department where their subsequent journey is less certain. Along with same-day reporting for emergency scans, we have developed a rapid review service for such individuals and were interested in assessing its performance. Methods We looked at all patients with suspected lung cancer who presented through our emergency department for the first 6 months of 2017, focussing on outcome, time to be seen following admission, and the histological diagnosis rate. Results Of the 285 referrals to our lung cancer unit, 85 (32%) presented through the emergency department: 21 (25%) of these were discharged to outpatient cancer investigation. The remaining 64 (75%) were subsequently admitted to 29 different locations (8 medical specialities, surgical, vascular and orthopaedic wards). Of these, 55 (86%) were seen by the lung CNS within one working day and an appropriate management plan initiated. This was aided by our live CT database, where 50 suspicious scans were coded the same day enabling early review by the lung clinician and CNS, often before formal referral from the responsible clinical team was made. Overall 70 patients (82%) who presented as emergencies subsequently were diagnosed with a malignancy, and of these 34 (49%) had histological confirmation. Conclusions Our Results show that, by coordinating care between the emergency and radiology departments and the lung cancer team, patients presenting unwell can be managed rapidly even if they remain in hospital. In addition, by actively seeking them out we can not only provide them with timely and appropriate investigations but also early CNS intervention, facilitating symptom management and psychological support. more...

Introduction and objectives Asthma and COPD present a significant resource impact to the NHS. Earlier diagnosis may reduce morbidity and improve quality of life. In the UK, premature mortality from COPD is almost twice the European average and for asthma over 1.5 times the European average. This project sponsored by Teva Respiratory aims to identify differences in perceptions of various stakeholder groups regarding effective outcome improvements in asthma and COPD and make relevant recommendations. Methods This group met with the objective of defining consensus statements for the future development of services in asthma and COPD. These statements were tested across a broad respondent sample by questionnaire. A Delphi methodology was used to assess levels of agreement with each statement. Questionnaires were offered to health care professionals across specialties reflecting the roles of this group for completion as paper documents at Teva Respiratory sponsored UK meetings between June 2015 and January 2016. Results 184 respondents, split across varied professional roles, completed questionnaires. 24 out of 42 statement scores (57%) exceeded the 66% agreement threshold and are thus regarded as supportive of the statements. Some variance was seen in responses between care settings (Figure 1), with primary care respondents commonly indicating lower levels of agreement than their secondary care colleagues (24 out of 42 statements (57%)). Conclusions Most respondents indicate that it is possible to deliver effective care across all care settings that the patient will encounter. The need for further development of local integrated care approaches is well recognised. Respondents are ambivalent regarding the prioritisation of asthma and COPD, the variance may reflect differences in prioritisation between localities. There is strong agreement that definition of appropriate outcomes will support value-based care models and that interaction between professions is critical to effective integration of care. Respondents agreed there is a sound rationale for the use of branded inhaler therapies in asthma and COPD, which may liberate finite resources for other areas. Based on this consensus exercise, 10 key recommendations for optimising outcomes in asthma and COPD are offered. more...

The aim of this chapter is to explore how a group of adults with cystic fibrosis (N=40) manage and account for self-care. By focussing on the development of character and plot, narrative analysis will illustrate how distinct patient identities may be constructed and performed as participants defend and justify their preferred self-care practices. These stories do not, however, always fit with the prevailing master narratives on which healthcare is often premised. Drawing on exemplars of 5 distinct types of storytelling an alternative user-driven taxonomy will be suggested which not only recognizes a range of self-care practices but also affirms their legitimacy beyond the horizons of mainstream biomedicine1. more...

Introduction Burkholderia spp infection in cystic fibrosis (CF) confers a worse prognosis, with increased morbidity and mortality. Treatment can be problematic because strains are often resistant to many of the commonly available intravenous antibiotics, leading to a search for new therapies. We have studied the use of Temocillin, a derivative of Ticarcillin with promising in-vitro activitiy against Burkholderia spp, 1 in the treatment of acute exacerbations in CF patients infected with Burkholderia spp. Methods We have used Temocillin in IV form, often in combination, in acute respiratory exacerbations in CF patients attending our large adult unit who are chronically infected with Burkholderia spp. We present our two year data, looking at the subspecies treated, length of treatment, improvement in clinical parameters, and co-antibiotic use. Results Nineteen courses of IV Temocillin were administered to 7 CF patients (mean age 29 years, [range 23–42 years], 2 males, 1 infected with B Cenocepacia, 6 with B Multivorans.) All patients completed their treatment without complication. Median length of Temocillin treatment was 9.7 days (range 3–16 days), and most patients finished their therapy as outpatients (mean inpatient stay 5.2 days). All patients had clinical improvement, with all gaining weight (mean 3 kg [range 6.5 to 0.9]) and most increased spirometry (mean change in FEV1% predicted 6 [17 to -3]). As regards the efficacy of co-antibiotic use, the 11 courses accompanied by Ceftazidime had a mean 3% improvement in FEV1, 8% with Meropenem (6 courses) and 9% with Colomycin (2 courses). Discussion This clinical study has shown that Temocillin is well tolerated by CF patients and is associated with clinical improvement in those infected with Burkholderia spp when given in combination with other antibiotics. Temocillin adds to the limited antibiotic armamentarium available to treat these difficult infections in CF patients and we recommend its use to other clinicians. Reference 1 Bonacorsi S, Fitoussi F, Lhopital S, Bingen E. Comparative in vitro activities of meropenem, imipenem, temocillin, piperacillin, and ceftazidime in combination with tobramycin, rifampin or ciprofloxacin against Burkholderia cepacia isolates from patients with cystic fibrosis. Antimicrob Agents Chemother . 1999; 43 :213–217 more...

Introduction and objectives FDG PET-CT scans are a valuable tool in the diagnosis and staging of lung cancer, but their growing use in other diseases can cause resource issues, and in some cases they may be ordered by non-specialists further congesting the patient pathway. To study this further, we looked at referral patterns for PET-CT scans in the diagnosis of lung cancer at our hospital, paying particular attention to the reason for the scan and the referring clinician. Methods A retrospective audit was undertaken of all PET-CT scans performed for the investigation of suspected lung cancer in 2014 by the Liverpool Lung Cancer Unit (LLCN). The LLCN consists of Liverpool Heart and Chest Hospital, a specialist cardiothoracic centre in the North West of England and the Royal Liverpool University Hospital, a teaching hospital. Results All 253 PET-CT scans (186 for outpatients) carried out during 2014 for the investigation of suspected lung cancer were reviewed. One hundred and seventy five (69%) found malignancy. Scans ordered by lung cancer specialists were more likely to demonstrate a cancer diagnosis (145 cancer versus 52 benign) compared to those requested by non-specialists (30 cancer versus 26 benign), (Chi2 = 8.21, P The commonest causes for a negative scan result were mass 27 (34%), nodule follow up 17 (22%) and new nodule assessment 14 (18%) respectively. Of 31 patients (39%) who had a PET-CT scan for nodule assessment, 8 (26%) were Conclusions We have shown that scans arranged by lung cancer specialists are more likely to give a positive yield, and also that the guidance for their use in nodule investigation is not being strictly followed. The results indicate that there is a need for better guidelines and patient pathways to ensure the most appropriate use of expensive resources. more...

We read with interest the case report by Ledson et al 1 describing a non-cystic fibrosis individual with chronic Burkholderia cepacia bronchiectasis. Although B cepacia most commonly affects patients with cystic fibrosis, it is also known to infect patients with chronic ventilatory requirements or immunocompromised patients.2 The immunocompromised patient population who appear most vulnerable to B cepacia infection are those with chronic granulomatous disease … more...

Introduction The advent of CT scanning as a routine test in the work-up of pulmonary disease has brought with it the unexpected detection of large numbers of pulmonary nodules, most of which are of a benign aetiology, even in high risk groups. Previous lung cancer screening studies have shown that likelihood of malignancy in nodules Methods Two trained readers independently reviewed 100 randomly selected CT thorax scans from individual patients (mean age 63 years [SD 15]) and noted the number, size and characteristics of any nodules present. Economic analysis was based on costs of CT scan (low dose CT = £115) and the number of additional follow-up CT scans required. Results Overall, 249 nodules were detected in 86 patients; 9 with a solitary calcified nodule were excluded. Of the remainder, 22 (28%) had nodule (s) 8mm. Assuming that all patients were high risk, based on Fleischner guidelines the total number of CT scans required over 2 years would be 15 ( Discussion Over three quarters of our patients in this random sample had significant incidental pulmonary nodules, and their surveillance according to current guidelines would result in a significant burden to the healthcare system, not only in terms of cost but also through increased clinician time and patient anxiety. New protocols for the follow up of these low-risk patients are required if the healthcare economy is to cope with this increasing surveillance burden. more...

Splenosis represents the deposition of viable splenic tissue in a different anatomic compartment, usually following trauma. The extent of deposition is related to the severity of trauma and amount of pulp tissue released into the abdominal and pelvic cavities. Thoracic splenosis, is the deposition of splenic tissue within the thoracic cavity and occurs in about 18% of cases.1 This splenic tissue is thought to perform normal splenic functions and draws its blood supply from surrounding tissue. The condition is usually discovered … more...

Totally implantable vascular access devices (TIVADs) provide a semi-permanent route for administering intravenous medication in patients who receive repeated courses. They are relatively easy to look after and cosmetically acceptable, but may be associated with complications [1] . A 17-year-old male with cystic fibrosis while undertaking a course of home antibiotics for a pulmonary exacerbation, through a left internal jugular TIVAD (3 years old), developed pain and tenderness around the TIVAD site. At review there was a small swelling above the left clavicle. The screening linogram ( fig. 1 ) revealed the catheter had fractured where it traversed the left clavicle and the distal portion projected over the heart and left lung base, suggesting fragment embolisation. At right heart catheterisation via the femoral vein (local anaesthetic and 2-mm percutaneous access), the fragment having migrated through the pulmonary valve was within the left lower-lobe pulmonary artery and was retrieved using a goose neck snare device. It seems likely that stretching forces applied to the catheter as the patient grew, plus friction where the catheter passed over the clavicle, caused the line to wear until it cracked. This is the first report of embolisation of a catheter fragment beyond the right ventricle in an adult with cystic fibrosis. Any unusual symptoms related to the device should prompt immediate discontinuation of use and urgent imaging by means of chest radiography and screening linography. Published online: April 20, 2012 more...