EBUS audit: assessing the diagnostic performance of the service at UHL

Introduction: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an important diagnostic procedure in the lung cancer pathway. False-negative or inadequate sampling can lead to inaccurate staging or delay in diagnosis. This study was conducted to assess the performance of the Cancer EBUS service at a tertiary hospital. Method(s): We conducted a retrospective analysis of patients who underwent EBUS-TBNA for suspected cancer between 1st June 2021 to 31st May 2022. Request forms, CT reports, EBUS reports and pathology reports were reviewed for analysis. Result(s): 205 EBUS-TBNA procedures were performed. All patients had an appropriate staging CT prior to procedure. The mean time to test was 10.5 days (7.4). 77 (38%) had tests within 7 days of request. 293 lymph nodes and 10 mass lesions were sampled. The mean time to pathological results being received was 2.9 days (1.8). Final histology showed 39 (19%) cases of lung adenocarcinomas, 3 (1%) lung non-small cell carcinomas, 25 (12%) lung squamous cell carcinomas, 25 (12%) small cell cancers, 4 (2%) lung NOS, 3 (1%) pulmonary carcinoid, 2 (1%) lymphoma, 12 (6%) other cancers, 12 granulomata and 1 thyroid tissue (6%). 43 (21%) cases showed lymphoid tissue and 28 (14%) were reported as inadequate. No samples were taken in 8 cases (4%). Adequate tissue for predictive marker testing was available in 93% (66) of cases of non-small cell lung cancer (NSCLC). Complications were encountered in 9 cases (4%). Only 3 cases (1.5%) required any form of intervention. [Figure presented] Conclusion(s): Our data provides assurance of safety while also highlighting specific areas for attention regarding performance and time to test that can be addressed and our sensitivity was comparable to national standards. The increased waiting times may be partly related to COVID-19 precautions and will require reauditing at a later date. Disclosure: No significant relationships.Copyright © 2023 Elsevier B.V.

Has the impact of the COVID-19 pandemic on uptake andusage of indwelling pleural catheters reduced its cost-effectiveness?

During the COVID pandemic, the British Thoracic Society recommended first-line indwelling pleural catheter (IPC)insertion or therapeutic aspiration for malignant pleural effusion (MPE) instead of admission for chest drain and talcpleurodesis to minimise hospital visits. This study aimed to review the uptake and usage of IPCs during and followingthe pandemic and its potential cost-effectiveness.Retrospective data analysis of IPCs between 2020-2021 was performed. Data collection included patient sex, age,WHO performance status (PS), indication and duration of IPC.187 IPCs were inserted;91% for MPE. 75% elected for IPC as first-line. 57% patients were PS 0-1 and 77% werePS 0-2. In 2020, 30% patients were self-draining compared to 12% in 2021. Mean duration IPC in-situ was 87 days(median 68 days). The pandemic saw increased use of first-line IPCs (75% 2020 vs 52% 2019) particularly in patients with good PS. This reduced initial hospitalisation (4.08 bed days) with an estimated cost saving of 1200 (300/day) per patient. Self-drainage rates also increased from 13% (2019) to 30% (2020) but have returned to pre-pandemic levels of selfdrainage at 12% in 2021 with need for district nurse visits for up to 3 months. Current practice of widespread first-line IPC use in the COVID endemic era may not be cost-effective and needs to be reviewed alongside the pre-existing evidence base.

Has COVID-19 affected complication rate ofIPC placements?

The COVID pandemic increased uptake of indwelling pleural catheters (IPC) as first-line management of malignant and non-malignant pleural effusions. This study reviewed the complication rate in view of this and its associated impact. Retrospective data analysis of IPCs between 2020-2021 was performed. Data collection included patient demographics, indication, treatment, and complication rate. 187 IPCs were inserted in 180 patients. Pneumothorax rate was low (1%). Common complications were incomplete drainage at point of IPC removal, IPC-related infection, and chronic pain. Despite incomplete drainage in 54 (29%) patients, only 8 required further procedures (1 IPC, 7 therapeutic aspirations). 80 patients received chemotherapy or immunotherapy. 11% developed IPC-related infection: 7% pleural infection and 4% cellulitis. 100 patients did not receive immunosuppressive treatment: 2% had pleural infection. Pleural infection occurred 8 weeks post-insertion (median 63 days) requiring 19 bed days per patient and 1 IPC removal. 2 IPCs were removed due to intractable chronic pain. Overall, complications associated with IPC in our practice were lower than recently published data. IPC-related infection is a problem;however, our study was underpowered, and the effect of immunosuppressive treatment could not be analysed. Despite this, most patients required conservative treatment only and did not require IPC removal, allowing ongoing usage of the IPC.

S6 Timing of pneumothorax post-CT-guided thoracic biopsy in a tertiary referral centre: implications for the ambulatory pneumothorax pathway

S6 Table 1Study population characteristicsn % Total number of procedures 641 - Male 371 57.9% Female 270 42.1% Median age (years) 71.0 - Lesion site RUL 177 27.61% RML 22 3.43% RLL 109 17.00% LUL 151 23.56% LLL 104 16.22% Anterior mediastinal 29 4.52% Pleural 40 6.24% Chest wall 9 1.40% Median lesion size (mm) 41 - Total pneumothorax incidence 223 34.8% Timing of pneumothorax T = 0 hours 186 83.41% T = 0-2 hours 37 16.59% T = 2 hours - 7 days 0 0.00% Pneumothorax management(% of n=223) Conservative 144 64.57% Aspiration 47 21.08% Chest drain 31 13.90% Pleural vent 1 0.45% Total pneumothorax needing intervention (% of n=223) 79 35.43% Immediate pneumothorax management (% of n=186) Conservative 111 59.68% Aspiration 46 24.73% Chest drain 28 15.05% Pleural vent 1 0.54% Immediate pneumothorax needing intervention (% of n=186) 75 33.63% Delayed pneumothorax management (% of n=37) Conservative 33 89.19% Aspiration 1 2.70% Chest drain 3 8.11% Pleural vent 0 0.00% Delayed pneumothorax needing intervention (% of n=37) 4 10.81% ConclusionsThis study demonstrates that the incidence of delayed-onset pneumothorax requiring intervention is low in a tertiary centre setting. The optimal time for patient observation post-CTGB remains unknown. The authors acknowledge a high incidence of pneumothorax in the study cohort, which they postulate may be due to a higher volume of complex procedures in a tertiary setting, higher sensitivity of CT for reporting trivial post-biopsy pneumothorax, and the diversion of more complex lung cancer patients to the CTGB route during the COVID pandemic to avoid aerosol-generating procedures.ReferenceHeerink WJ, de Bock GH, de Jonge GJ, Groen HJ, Vliegenthart R, Oudkerk M. Complication rates of CT-guided transthoracic lung biopsy: meta-analysis. Eur Radiol 2017;Jan;27(1):138–148.

SARS-COV-2 – a major risk factor for pulmonary embolism, a retrospective observational study from a single tertiary care hospital

P46 Table 1Incidence of pe by gender and covid status COVID POSITIVE (309) COVID NEGATIVE (621) TOTAL (930) PE 41 (13.3%) 95 (15.3%) 136 (14.6%) Male 28 (9.1%) 52 (8.4%) 80(8.6%) Female 13(4.2%) 43 (6.9%) 56(6.0%) No PE 268 (86.7%) 526(84.7%) 794 (85.4%) Male 161 (52.1%) 218(35.1%) 379 (40.8%) Female 107 (34.6%) 308(49.6%) 415(44.6%) Total 309 (100%) 621 (100%) 930(100%) ConclusionCovid-19 has been identified as a significant risk factor for PE. These patients must be anti-coagulated in order to avoid various complications, including life-threatening arrhythmias, severe hypoxemia, shock, even death.ReferencesJevnikar M, et al. Prevalence of pulmonary embolism in patients with COVID-19 at the time of hospital admission. European Respiratory Journal 2021 Jul 1;58(1).Katsoularis I, et al. Risks of deep vein thrombosis, pulmonary embolism, and bleeding after covid-19: nationwide self-controlled cases series and matched cohort study. BMJ 2022 Apr 6;377.

Teleophthalmology case study: Sankara Nethralaya, India

Both current and new patients at Sankara Nethralaya Eye Hospital can use free community-based teleophthalmology services as well as paid online services, even if they do not have personal internet access. The first eye hospital in India to use teleophthalmology to offer primary eye treatment to patients in remote communities was Chennai's Sankara Nethralaya Eye Hospital in 2003. This free service provides thorough eye exams as well as screening for cataracts and diabetic retinopathy utilizing a satellite link put on the roof of a mobile eye care van. It quickly became apparent that more people not simply those in rural areas would need teleophthalmology services with the COVID-19 pandemic's arrival in 2020. The Indian government's practice guidelines for telemedicine, which it released at the start of the COVID-19 pandemic offered a framework for the control and expansion of teleconsultation services in the nation. Sankara Nethralaya set up three new teleophthalmology access points for new patients, current patients, and patients who do not have access to the internet but can visit an optical store in response to this and in addition to its current service in rural areas. A patient can consult an ophthalmologist directly from home using this paradigm, which uses not many resources. An electronic medical records system, teleconsultation capabilities (audio/video calling), and a payment portal are necessities for the hospital. After their eligibility has been verified at the hospital, clients who are unable to pay can receive free teleophthalmology services. Patients utilizing this model must have a smartphone and an internet connection (mobile internet or otherwise). Patients without smartphones are unable to share medical records or photographs, but they can still seek advise from doctors by making audio calls and sending short messages (SMS), as well as visiting an optical store that is affiliated with the hospital, if one is close. Teleconsultations are useful for pre-operative counseling, second opinions, evaluating uploaded patient records, and monitoring post-operative patients. Orthoptic, contact lens, poor vision, rehabilitation, and genetic counseling services can all be provided via teleconsultations. The quality management staff will be able to provide better services by gathering patient input after each teleconsultation and responding quickly to complaints.

Diagnostic conundrum in a patient with small cell lung cancer (SCLC)

Introduction: It is rare for pulmonary SCLC to present as a cavitating lesion unlike non-small-cell-cancer (NSCLC). Hence, if a cavitating lesion is found with histo-pathology showing SCLC, it is important to rule out alternate diagnosis e.g., infection [1]. Case: We present the case of a 41-year-old-male of Bangladeshorigin. He was referred on 2ww-pathway to UHL Glenfield hospital lung cancer team for haemoptysis. Clinical assessment (05/12/2019) revealed that he had 4kg weight loss/haemoptysis/anorexia/fatigue. He was a current smoker (10 pack-years) with no significant past/ family history. He worked in a restaurant. Clinical examination was unremarkable. Chest x-ray showed left-hilar-mass. CT scan revealed 3.2cm mass with peripheral cavitation and mild focal enhancement without calcification/mediastinal-lymphadenopathy. Differentials included cancer/rheumatoid arthritis/infection. Bloods including ANCA/ANA/rheumatoid factor and bronchial-washings microbiology/cytology were unremarkable. He was given antibiotics. He did not attend subsequent 2 out-patient-appointments. Repeat CT scan (March 2020) showed growing lesion with focally dilated vessel. CT-guided biopsy was advised but he declined it due to COVID19 pandemic. In May 2020, he agreed to undergo CT-guided biopsy. However, pre-procedure CT scan showed possible pseudoaneurysm. CT-guided biopsy was deemed high-risk and not attempted. Lung cancer MDT advised lobectomy given diagnostic dilemma. Patient declined surgery. CT in November 2020 showed progressive lesion. Patient still was not keen for surgery. He was admitted in June 2021 with haemoptysis. CT scan showed progressive cavitating disease with necrotic left hilar/mediastinal lymph nodes. He underwent EBUS-TBNA that confirmed SCLC. Given cavitating lesion and long history, left lower lobe lesion was deemed unlikely to be due to SCLC. He was referred to infectious disease (ID) clinic. Blood parasitology screen revealed positive Hydatid ELISA. He did not attend subsequent outpatient appointments in Oncology/ID clinics and has been discharged. Learning points: There were two pathologies: hydatid cyst (Fig. 1a);SCLC developed between November 2020 and June 2021 (Fig. 1b). 1) To look for cause of a cavitating lesion even if SCLC is diagnosed. 2) To consider hydatidcyst in lung-cavity differentials.(Figure Presented) Fig. 1

Dental pain, parental SARS-CoV-2 fear and distress on quality of life of 2 to 6 year-old children during COVID-19.

BACKGROUND: Coronavirus disease (COVID-19) has crippled life, families and oral healthcare delivery in India due to nationwide lockdown. AIM: Through cross-sectional design, we investigated the impact of child's dental pain, caregiver's fear of SARS-CoV-2 and parental distress on oral health-related quality of life (OHRQOL) of preschoolers during the nationwide COVID-19 pandemic lockdown. DESIGN: Preschool children self-reported their pain using Pieces of Hurt scale; caregiver SARS-CoV-2 fear was assessed using Fear of COVID-19 scale and parental distress evaluated using 4-item scale. Child's oral health was assessed using the dmft index and OHRQOL evaluated using early childhood oral health impact scale. Bivariate, multivariate regression analysis was conducted to identify predictors; statistical significance was set at 5%. RESULTS: Sample mean age was 4.58 years, and about 69% were boys. Children reporting higher pain scores (OR = 1.9) due to decayed teeth and having dmft > 5 (OR = 4.25), followed by greater parental distress (OR = 4.13) and fear of SARS-CoV-2 (OR = 3.84), were significantly associated with poor OHRQOL during the COVID-19 pandemic. CONCLUSIONS: Greater parental distress and fear of COVID-19 among caregivers, higher self-perceived dental pain among children and caries experience are associated with poor OHRQOL of preschool children during the COVID-19 pandemic.