High-fidelity simulation self-training enables novice bronchoscopists to acquire basic bronchoscopy skills comparable to their moderately and highly experienced counterparts.

BACKGROUND: We sought to determine whether a self-training program on a high-fidelity flexible bronchoscopy (FB) simulator would allow residents who were novices in bronchoscopy to acquire competencies similar to those of experienced bronchoscopists as concerns the visualization of the bronchial tree and the identification of its anatomical elements. METHODS: We performed a prospective cohort study, categorizing bronchoscopists into three groups according to their experience level: novice (Group A, no FBs performed, n = 8), moderate (Group B, 30 ≤ FBs performed ≤200, n = 17) or high (Group C, > 200 FBs performed, n = 9). All were initially evaluated on their ability to perform on a high-fidelity FB simulator a complete visualization/identification of the bronchial tree in the least amount of time possible. The residents in Group A then completed a simulation-based self-training program and underwent a final evaluation thereafter. RESULTS: The median total procedure time for Group A fell from 561 s (IQR = 134) in the initial evaluation to 216 s (IQR = 257) in the final evaluation (P = 0.002). The visualization and identification scores for Group A also improved significantly in the final evaluation. Resultantly, the overall performance score for Group A climbed from 5.9% (IQR = 5.1) before self-training to 25.5% (IQR = 26.3) after (P = 0.002), thus becoming comparable to the overall performance scores of Group B (25.3%, IQR = 13.8) and Group C (22.2%, IQR = 5.5). CONCLUSIONS: Novice bronchoscopists who self-train on a high-fidelity simulator acquire basic competencies similar to those of moderately or even highly experienced bronchoscopists. High-fidelity simulation should be rapidly integrated within the learning curriculum and replace traditional, in-patient learning methods.

Encuesta sobre la broncoscopia en los hospitales públicos de la Comunidad de Madrid y de Guadalajara: situación actual / No disponible

Introducción: La broncoscopia es una técnica de gran utilidad en el estudio y tratamiento de las enfermedades respiratorias. Ha experimentado un avance relevante en los últimas décadas con el desarrollo de nuevos dispositivos y procedimientos. La incorporación de estas nuevas técnicas ha sido paulatina y, de forma asimétrica, en los diferentes centros dependiendo de su complejidad, demanda y recursos. El Grupo de Trabajo de Técnicas y Oncología de Neumomadrid se propuso realizar una encuesta para conocer con exactitud cuál es la situación actual de las técnicas broncoscópicas en la Comunidad de Madrid y Guadalajara. Material y métodos: Se remitió una encuesta a 26 hospitales públicos de la Comunidad de Madrid y de Guadalajara, dirigida a la jefatura de servicios y responsables de broncoscopia de los Servicios de Neumología, Cirugía Torácica, Pediatría y Cirugía Pediátrica sobre la actividad realizada en 2014. Se preguntó por el número aproximado de broncoscopias anuales, especialistas que la realizan, número de broncoscopistas a dedicación parcial y completa, existencia de broncoscopista de guardia, ubicación de la broncoscopia, sedación durante la técnica y especialista que la realiza, disponibilidad de enfermería especializada, especialidad que realiza intubación con broncoscopio y las técnicas intervencionistas disponibles. La encuesta fue respondida mediante correo ordinario y correo electrónico. Resultados: Se realiza broncoscopia en adultos en 25 centros de la Comunidad de Madrid (CAM) y de Guadalajara, con una actividad total de 14.051 broncoscopias al año. El 92% de los centros tienen una sala específica para la realización de broncoscopias. Los neumólogos son los responsables de la broncoscopia flexible (BF) en todos los centros (100%), pero solo en el 28% hay broncoscopista con dedicación completa. La broncoscopia rígida (BR) se realiza en el 32% de los hospitales por neumólogos y en el 32% por cirujanos torácicos, siempre en centros de alta complejidad y en quirófano. Únicamente el 20% de los centros disponen de broncoscopista de guardia. En el 96% de los centros realiza sedación para la broncoscopia flexible, siendo el neumólogo el responsable de la sedación en el 84% de los hospitales. En el 60% de los hospitales se realiza alguna técnica mediante BF, la más extendida es la ecobroncoscopia (EBUS), que está disponible en el 40% de los centros. La experiencia media de los centros que realizan EBUS es de 3,5 años. Con respecto a la broncoscopia pediátrica, en el 40% de los centros en la CAM la realizan. La variabilidad en el nº de broncoscopias flexibles/año es grande, ya que 3 realizan más de 100 y 4 efectúan menos de 10. El nº de broncoscopias rígidas realizadas es significativamente menor que el de flexibles. Tanto especialistas de adultos como pediátricos realizan broncoscopia pediátrica pero estos últimos son los únicos actores en los hospitales infantiles. Los responsables de la sedación/anestesia general son los anestesistas o intensivistas pediátricos por lo que los procedimientos se realizan en el quirófano o en la UCI. Diversas técnicas de broncoscopia terapéutica o intervencionista se han ido incorporando progresivamente a la práctica pediátrica, como el uso de láser e implantación de endoprótesis. Conclusiones: La broncoscopia flexible es una técnica consolidada en los hospitales de la Comunidad de Madrid y de Guadalajara, tanto en hospitales de referencia como de menor complejidad. La broncoscopia intervencionista se realiza, fundamentalmente, en centros de referencia. Los centros de mayor complejidad disponen de personal con dedicación completa a la broncoscopia, a pesar de lo cual, no se dispone de broncoscopista de guardia en todos ellos. La sedación durante la broncoscopia se utiliza de forma rutinaria en la mayoría de los hospitales y la suele realizar el neumólogo en adultos y el anestesista en niños. La EBUS es la técnica broncoscópica de mayor difusión en los hospitales encuestados. La broncoscopia pediátrica se realiza, fundamentalmente, en centros de referencia; la BF pediátrica está en manos de diferentes especialistas con formación específica (cirugía pediátrica, neumólogos pediátricos y de adultos y ORL), mientras la BR pediátrica se realiza, en su mayoría, por cirujanos pediátricos

Introduction: Bronchoscopy is a useful technique in the study and treatment of respiratory diseases. It has experienced a significant progress in recent decades with the development of new devices and procedures. The incorporation of these new techniques has been done gradually and asymmetrically at different locations depending on their complexity, demand and resources. Neumomadrid Techniques and Oncology Workgroup proposed a survey to know exactly what the current situation of bronchoscopic techniques in Autonomous Community of Madrid and Guadalajara is. Methods: A survey was sent to 26 public hospitals in the Autonomous Community of Madrid and Guadalajara addressed to the head of service and responsible for bronchoscopy (Pneumology, Thoracic Surgery, Pediatrics and Pediatric Surgery Services) about their activity in 2014. The questionnaire included the approximate number of annual bronchoscopies, the specialists who perform them, the bronchoscopists half-time and full time employed and bronchoscopist on call, the allocation of the bronchoscopy room and whether sedation during the technique is performed, the specialist who would perform sedation, the availability of trained nursing, the specialtist who performs bronchoscopic intubation and the available interventional techniques in each center. The survey was answered by regular mail and email. Results: Bronchoscopy is performed on adults in 25 centers in Madrid and Guadalajara, with a total activity of 14,051 bronchoscopy/year. 92% of the centers have a specific room for performing bronchoscopy. Pulmonologists are responsible for flexible bronchoscopy (FB) in every hospital (100%) but only 28% of the centers have full time bronchoscopist. Rigid bronchoscopy (RB) is performed in 32% of hospitals by pulmonologists and 32% by thoracic surgeons, always carried out in high complexity centers and operating theaters. Only 20% of the centers have bronchoscopist on call. The 96% of the centers perform sedation for flexible bronchoscopy; pulmonologist is responsible for sedation in 84% of the hospitals. Advanced FB is performed in 60% of the hospitals, the most widespread technique is the endobronchial ultrasound (EBUS) which is available in 40% of the centers. The average experience time of centers performing EBUS is 3.5 years. Pediatric bronchoscopy is performed in 40% of the centers in Madrid. There is a wide variability in the number of FB performed, 3 centers carried out over 100 procedures but 4 done less than 10. There are significantly fewer RB procedures than FB ones. Both adult and pediatric specialists perform pediatric bronchoscopy but pediatric specialists are the only actors in children’s hospitals. Sedation in paediatric patients is performed by anesthesiologists and pediatric intensive care thus the procedures are done in the operating room or Intenseive Care Units. Various techniques of therapeutic or interventional bronchoscopy have been incorporated progressively in pediatric practice such as the use of laser and stenting. Conclusions: Flexible bronchoscopy is an established technique at the hospitals in Madrid and Guadalajara, in referral hospitals as well as in less complex hospitals. Interventional bronchoscopy is performed mainly in referral centers. The high complex centers have full time bronchoscopists, however not all of them have bronchoscopist on call. Sedation during bronchoscopy is routinely used in most of the hospitals and is usually performed by pulmonologist in adults and by anesthesiologist in children. EBUS is the most widely used advanced bronchoscopic technique in surveyed hospitals. Pediatric bronchoscopy is performed mainly in referral centers; pediatric FB is held by different specialists with specific training for it (pediatric surgery, pediatric and adult pulmonologists and ENT) while pediatric RB is done mostly by pediatric surgeons

Utilidad de la tomografía por emisión de positrones en la detección de metástasis ocultas extratorácicas en el carcinoma broncogénico no células pequeñas / Use of Positron Emission Tomography in Assessing Hidden Extrathoracic Metastasis in Non Small Cell Lung Cancer

IntroducciónLa tomografía de emisión de positrones asociada a la tomografía axial computerizada (PET/TC) se utiliza en la estadificación del carcinoma broncogénico no microcítico (CBNM). El objetivo de este trabajo es describir la utilidad de la PET/TC en la estadificación clínica del CBNM para la detección de metástasis extratorácicas insospechadas en una población operable con un tumor aparentemente resecable antes de la evaluación ganglionar mediastínica pretoracotomía.Pacientes y métodoEstudio prospectivo y concurrente de todos los casos de CBNM recogidos entre junio 2004 y noviembre 2006, a los que se realizo una PET/TC tras considerar al paciente operable y al tumor resecable tras realizar broncoscopia, TC toracoabdominal, y TC cerebral o gammagrafía ósea si hubiesen datos clínicos sugerentes de metástasis a esos niveles. La metástasis fueron confirmadas por evidencia citohistológica o por la evolución.ResultadosSe realizó una PET/TC a 91 pacientes con CBNM. En 24 pacientes (26%) se objetivo la existencia de, al menos, una captación extratorácica. En 7 pacientes (7,7%) la captación correspondió a una metástasis extratorácica del CBNM, oculta a la estadificacion convencional. En 3 casos (3,2%) la captación extratorácica correspondió a lesiones premalignas o a un segundo tumor primario. En 12 pacientes (13,1%) el hallazgo correspondía a lesiones benignas, y finalmente en 2 casos (2,2%) no se pudo determinar el origen de la captación.ConclusionesLa PET/TC indicada en pacientes operables con CBNM potencialmente resecables supone un elemento diagnóstico de utilidad en la detección de metástasis ocultas que afecta a la toma de decisiones terapéuticas(AU)

IntroductionPositron emission tomography combined with computed axial tomography (PET/CT) is used for staging non small cell lung cancer (NSCLC). This study aims to describe PET/CT findings of unsuspected extrathoracic metastasis when used in mediastinal evaluation of patients with apparently resectable NSCLC.Patients and methodProspective and concurrent study including all NSCLC patients between June 2004 and November 2006 who underwent PET/CT after considering them as candidates for surgery, with resectable disease after bronchoscopy, thorax and abdominal CT, brain CT and bone gammagraphy evaluation, if metastasis at these locations were suspected. Metastasis were confirmed histopathologically or assumed when they had a compatible evolution.ResultsA total of 91 patients with NSCLC underwent PET/CT. In 24 of them (26%) at least one suspicious extrathoracic uptake was seen. In 7 patients (7.7%) those uptakes were NSCLC extrathoracic metastasis hidden from conventional staging. In 3 of these cases (13.1%) extrathoracic uptakes corresponded to metacrhonous tumours or pre-malignant conditions. Benign lesions were found in 12 patients (13.1%), and in 2 cases (2.2%) the uptake origins were undetermined.ConclusionsPET/CT is a complementary diagnosis method for assessing hidden metastases which could modify the therapeutical approach in patients otherwise suitable for surgery(AU)

Sign of the changing times: CPT 1999.

Although CPT 1999 contains fewer changes than in past years, coders should take some time to learn them by: familiarizing themselves with the new symbols + and [symbol: see text] reviewing Appendix A for a complete list of modifiers as well as modifiers used in the ambulatory surgery center hospital outpatient setting; reviewing Appendix E for a complete list of add-on codes; reviewing Appendix F for a list of modifier-51-exempt codes; consulting the excludes note found above code 69,990 to identify procedures exempt from the use of the new operating microscope code; examining the specific codes used to identify bronchoscopic procedures; reviewing the parenthetical notes found after code 15,001, directing the coder to also assign the appropriate code for lesion excision; reviewing the changes associated with the coding of destruction of lesions understanding the changes in immunization code assignment; consulting payers for specific reimbursement guidelines.