The utility of heart failure registries: a descriptive and comparative study of two heart failure registries

Background and aim

Registries are useful to address questions that are difficult to answer in clinical trials. The objective of this study was to describe and compare two heart failure (HF) cohorts from two Spanish HF registries.

Methods

We compared the RICA and EAHFE registries, both of which are prospective multicentre cohort studies including patients with decompensated HF consecutively admitted to internal medicine wards (RICA) or attending the emergency department (EAHFE). From the latter registry we only included patients who were admitted to internal medicine wards.

Results

A total of 5137 patients admitted to internal medicine wards were analysed (RICA: 3287 patients; EAHFE: 1850 patients). Both registries included elderly patients (RICA: mean (SD) age 79 (9) years; EAHFE: mean (SD) age 81 (9) years), with a slight predominance of female gender (52% and 58%, respectively, in the RICA and EAHFE registries) and with a high proportion of patients with preserved ejection fraction (58% and 62%, respectively). Some differences in comorbidities were noted, with diabetes mellitus, dyslipidaemia, chronic renal failure and atrial fibrillation being more frequent in the RICA registry while cognitive and functional impairment predominated in the EAHFE registry. The 30-day mortality after discharge was 3.4% in the RICA registry and 4.8% in the EAHFE registry (p<0.05) and the 30-day readmission rate was 7.5% in the RICA registry (readmission to hospital) and 24.0% in the EAHFE registry (readmission to emergency department) (p<0.001).

Conclusions

We found differences in the clinical characteristics of patients admitted to Spanish internal medicine wards for decompensated HF depending on inclusion in either the RICA or EAHFE registry.

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Use of spaced education to deliver a curriculum in quality, safety and value for postgraduate medical trainees: trainee satisfaction and knowledge

Purpose

Quality, patient safety and value are important topics for graduate medical education (GME). Spaced education delivers case-based content in a structured longitudinal experience. Use of spaced education to deliver quality and safety education in GME at an institutional level has not been previously evaluated.

Objectives

To implement a spaced education course in quality, safety and value; to assess learner satisfaction; and to describe trainee knowledge in these areas.

Methods

We developed a case-based spaced education course addressing learning objectives related to quality, safety and value. This course was offered to residents and fellows about two-thirds into the academic year (March 2014) and new trainees during orientation (June 2014). We assessed learner satisfaction by reviewing the course completion rate and a postcourse survey, and trainee knowledge by the per cent of correct responses.

Results

The course was offered to 1950 trainees. A total of 305 (15.6%) enrolled in the course; 265/305 (86.9%) answered at least one question, and 106/305 (34.8%) completed the course. Fewer participants completed the March programme compared with the orientation programme (42/177 (23.7%) vs 64/128 (50.0%), p<0.001). Completion rates differed by specialty, 80/199 (40.2%) in non-surgical specialties compared with 16/106 (24.5%) in surgical specialties (p=0.008). The proportion of questions answered correctly on the first attempt was 53.2% (95% CI 49.4% to 56.9%). Satisfaction among those completing the programme was high.

Conclusions

Spaced education can help deliver and assess learners' understanding of quality, safety and value principles. Offering a voluntary course may result in low completion. Learners were satisfied with their experience and were introduced to new concepts.

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Cutaneous manifestations of familial hypercholesterolaemia

A 12-year-boy presented with multiple soft tissue swelling over the buttocks and feet, progressively increasing for last 4 years. Examination revealed multiple tuberous xanthomas of various sizes (2–8 cm diameter) studded over the buttocks (figure 1A; black arrows), multiple planar xanthomas over bilateral elbows and knees (figure 1B, C; white arrows), multiple tendinous xanthomas over the Achilles tendon, dorsum and lateral aspect of both feet (figure 1D; hollow black arrows), small xanthoma over the back of the left ear (figure 1F; hollow white arrow), xanthelasma over the lateral aspect of the right eyelid (figure 1G; hollow white arrow) and bilateral corneal arcus. Systemic examination was normal. Investigations showed elevated total cholesterol (TC) (15.98 mmol/L), elevated low-density lipoprotein (LDL) (12.92 mmol/L), normal triglycerides (0.89 mmol/L) and high-density lipoprotein (HDL) (0.98 mmol/L) normal glycaemia, liver and renal function. Echocardiography was normal. Mildly increased intima–media thickness of left common...

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Residents narrative feedback on teaching performance of clinical teachers: analysis of the content and phrasing of suggestions for improvement

Objectives

High-quality teaching performance is important to ensure patient safety and encourage residents' learning. This study aims to explore the content and phrasing of suggestions for improvement that residents provide to support excellent teaching performance of their supervisors.

Methods

From February 2010 to November 2011, 577 residents were invited to evaluate 501 teachers from both surgical and medical residency training programmes from 20 hospitals. Feedback was collected through a validated formative feedback system named System for Evaluation of Teaching Qualities. Two researchers independently coded the suggestions for improvement with literature-based coding schemes on (1) content and (2) linguistic characteristics. Besides these qualitative outcomes, descriptive statistics were calculated using SPSS.

Results

In total, 422 residents (73%) evaluated 488 teachers (97%), yielding 4184 evaluations. Of all teachers, 385 (79%) received suggestions for improvement focusing on teaching skills (TS), 390 (80%) on teaching attitude (TA) and 151 (31%) on personal characteristics. For 13%–47% of the suggestions for improvement, residents added (1) the location or situation where the observed TS or TA had taken place, (2) concrete examples of what teachers could do to improve or (3) (expected) effects of what the change in TS or TA would mean for residents.

Conclusions

Residents provide mainly relevant suggestions for improvement that mirror important aspects of teaching performance. However, these comments often lack specific phrasing limiting their value for performance improvement. Therefore, residents are recommended to increase the specificity of the suggestions for improvement. The paper provides directions to phrase narrative feedback.

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Predictors of inhospital mortality following out-of-hospital cardiac arrest: Insights from a single-centre consecutive case series

Purpose of the study

Out-of-hospital cardiac arrest (OHCA) has a poor prognosis despite bystander resuscitation and rapid transfer to hospital. Optimal management of patients after arrival to hospital continues to be contentious, especially the timing of emergency coronary angiography±revascularisation. Robust predictors of inhospital outcome would be of clinical value for initial decision-making.

Study design

A retrospective analysis of consecutive patients who presented to a university hospital following OHCA over a 70-month period (2008–2013). Patients were identified from the emergency department electronic patient registration and coding system. For those patients who underwent emergency percutaneous coronary intervention, details were crosschecked with national databases.

Results

We identified 350 consecutive patients who were brought to our hospital following OHCA. Return of spontaneous circulation (ROSC) for >20 min was achieved either before arrival or inhospital in 196 individuals. From the 350 subjects, 114 (32.6%) survived to hospital discharge. When sustained ROSC was achieved, either before or inhospital, survival to discharge was 58.2% (114 of 196). Non-shockable rhythm, absence of bystander cardiopulmonary resuscitation, 'downtime' >15 min and initial pH ≤7.11 were predictors of inhospital death. 12% patients who underwent angiography in the presence of ST elevation had no acute coronary occlusion. 21% patients with acute coronary occlusion at angiography did not have ST elevation.

Conclusions

In our cohort of patients with OHCA, those who achieve ROSC had a survival-to-discharge rate of 58.2%. We identified four predictors of inhospital death, which are readily available at the time of patient presentation. Reliance on ST elevation to decide about coronary angiography and revascularisation may be flawed. More data are required.

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It is time to relax

About 15% of basic specialist trainees (ST1–ST3) in paediatrics leave the specialty.1 The single most important factor for staff retention is overall job satisfaction which is influenced by a variety of factors.2 We aimed to explore the views of paediatricians on job satisfaction, with a view to identifying modifiable factors.

We conducted a web-based survey across the East of England deanery for paediatricians, addressing trainees across the 17 Trusts of the Deanery and consultants in 2 Trusts. The questionnaire used was designed locally and pilot-tested internally for validity. A descriptive analysis of the data was carried out. A total of 105 paediatric doctors, out of 240 of the cohort, responded to our survey which gave us a response rate of 44%. Totally, 90 of the respondents, with completed questionnaires, were included in analyses. The clinical grade of the respondents, 70% female, is shown in figure...

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Out-of-hospital cardiac arrest: should everyone go to the cath lab?

About 60 000 people have an out-of-hospital cardiac arrest (OHCA) in the UK each year.1 Frustratingly, despite major advances in medical technology only around 8% of patients admitted to hospital survive to discharge;2 furthermore, around a half of survivors have significant cognitive impairment.34 Identifying which patients are likely to survive and then which survivors are most likely to enjoy a reasonable quality of life is a major clinical challenge, particularly when attempting to make an assessment in the emotionally charged circumstances of an emergency admission.

OHCA encompasses a broad spectrum. Most patients have an unwitnessed arrest without early bystander cardiopulmonary resuscitation (CPR) and an initial non-shockable rhythm (pulseless electrical activity or asystole). The outcome in this group is very poor, with <2% surviving to discharge, and only 0.6% having a good neurological outcome.5 Better outcomes are seen in patients with a...

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Assessment of Boron Doped Diamond Electrode Quality and Application to In Situ Modification of Local pH by Water Electrolysis

A protocol is described for the characterization of the key electrochemical parameters of a boron doped diamond (BDD) electrode and subsequent application for in situ pH generation experiments.

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Estimating local noise power spectrum from a few FBP-reconstructed CT scans

Purpose:

Traditional ways to estimate 2D CTnoise power spectrum (NPS) involve an ensemble average of the power spectrums of many noisy scans. When only a few scans are available, regions of interest are often extracted from different locations to obtain sufficient samples to estimate the NPS. Using image samples from different locations ignores the nonstationarity of CTnoise and thus cannot accurately characterize its local properties. The purpose of this work is to develop a method to estimate local NPS using only a few fan-beam CT scans.

Methods:

As a result of FBP reconstruction, the CT NPS has the same radial profile shape for all projection angles, with the magnitude varying with the noise level in the raw data measurement. This allows a 2D CT NPS to be factored into products of a 1D angular and a 1D radial function in polar coordinates. The polar separability of CT NPS greatly reduces the data requirement for estimating the NPS. The authors use this property and derive a radial NPS estimation method: in brief, the radial profile shape is estimated from a traditional NPS based on image samples extracted at multiple locations. The amplitudes are estimated by fitting the traditional local NPS to the estimated radial profile shape. The estimated radial profile shape and amplitudes are then combined to form a final estimate of the local NPS. We evaluate the accuracy of the radial NPS method and compared it to traditional NPS methods in terms of normalized mean squared error (NMSE) and signal detectability index.

Results:

For both simulated and real CT data sets, the local NPS estimated with no more than six scans using the radial NPS method was very close to the reference NPS, according to the metrics of NMSE and detectability index. Even with only two scans, the radial NPS method was able to achieve a fairly good accuracy. Compared to those estimated using traditional NPS methods, the accuracy improvement was substantial when a few scans were available.

Conclusions:

The radial NPS method was shown to be accurate and efficient in estimating the local NPS of FBP-reconstructed 2D CTimages. It presents strong advantages over traditional NPS methods when the number of scans is limited and can be extended to estimate the in-plane NPS of cone-beam CT and multislice helical CT scans.

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Comparative performance evaluation of automated segmentation methods of hippocampus from magnetic resonance images of temporal lobe epilepsy patients

Purpose:

Segmentation of the hippocampus from magnetic resonance(MR)images is a key task in the evaluation of mesial temporal lobe epilepsy (mTLE) patients. Several automated algorithms have been proposed although manual segmentation remains the benchmark. Choosing a reliable algorithm is problematic since structural definition pertaining to multiple edges, missing and fuzzy boundaries, and shape changes varies among mTLE subjects. Lack of statistical references and guidance for quantifying the reliability and reproducibility of automated techniques has further detracted from automated approaches. The purpose of this study was to develop a systematic and statistical approach using a large dataset for the evaluation of automated methods and establish a method that would achieve results better approximating those attained by manual tracing in the epileptogenic hippocampus.

Methods:

A template database of 195 (81 males, 114 females; age range 32–67 yr, mean 49.16 yr) MRimages of mTLE patients was used in this study. Hippocampal segmentation was accomplished manually and by two well-known tools (FreeSurfer and hammer) and two previously published methods developed at their institution [Automatic brain structure segmentation (ABSS) and LocalInfo]. To establish which method was better performing for mTLE cases, several voxel-based, distance-based, and volume-based performance metrics were considered. Statistical validations of the results using automated techniques were compared with the results of benchmark manual segmentation. Extracted metrics were analyzed to find the method that provided a more similar result relative to the benchmark.

Results:

Among the four automated methods, ABSS generated the most accurate results. For this method, the Dice coefficient was 5.13%, 14.10%, and 16.67% higher, Hausdorff was 22.65%, 86.73%, and 69.58% lower, precision was 4.94%, −4.94%, and 12.35% higher, and the root mean square (RMS) was 19.05%, 61.90%, and 65.08% lower than LocalInfo, FreeSurfer, and hammer, respectively. The Bland–Altman similarity analysis revealed a low bias for the ABSS and LocalInfo techniques compared to the others.

Conclusions:

The ABSS method for automated hippocampal segmentation outperformed other methods, best approximating what could be achieved by manual tracing. This study also shows that four categories of input data can cause automated segmentation methods to fail. They include incomplete studies, artifact, low signal-to-noise ratio, and inhomogeneity. Different scanner platforms and pulse sequences were considered as means by which to improve reliability of the automated methods. Other modifications were specially devised to enhance a particular method assessed in this study.

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Energy dependent calibration of XR-QA2 radiochromic film with monochromatic and polychromatic x-ray beams

Purpose:

This work investigates the energy response and dose-response curve determinations for XR-QA2 radiochromic film dosimetry system used for synchrotron radiation work and for quality assurance in diagnostic radiology, in the range of effective energies 18–46.5 keV.

Methods:

Pieces of XR-QA2 films were irradiated, in a plane transverse to the beam axis, with a monochromatic beam of energy in the range 18–40 keV at the ELETTRA synchrotron radiation facility (Trieste, Italy) and with a polychromatic beam from a laboratory x-ray tube operated at 80, 100, and 120 kV. The film calibration curve was expressed as air kerma (measured free-in-air with an ionization chamber) versus the net optical reflectance change (netΔR) derived from the red channel of the RGB scanned film image. Four functional relationships (rational, linear exponential, power, and logarithm) were tested to evaluate the best curve for fitting the calibration data. The adequacy of the various fitting functions was tested by using the uncertaintyanalysis and by assessing the average of the absolute air kerma error calculated as the difference between calculated and delivered air kerma. The sensitivity of the film was evaluated as the ratio of the change in net reflectance to the corresponding air kerma.

Results:

The sensitivity of XR-QA2 films increased in the energy range 18–39 keV, with a maximum variation of about 170%, and decreased in the energy range 38–46.5 keV. The present results confirmed and extended previous findings by this and other groups, as regards the dose response of the radiochromic film XR-QA2 to monochromatic and polychromatic x-raybeams, respectively.

Conclusions:

The XR-QA2 radiochromic film response showed a strong dependence on beam energy for both monochromatic and polychromatic beams in the range of half value layer values from 0.55 to 6.1 mm Al and corresponding effective energies from 18 to 46.5 keV. In this range, the film response varied by 170%, from a minimum sensitivity of 0.0127 to a maximum sensitivity of 0.0219 at 10 mGy air kerma in air. The more suitable function for air kerma calibration of the XR-QA2 radiochromic film was the power function. A significant batch-to-batch variation, up to 55%, in film response at 120 kV (46.5 keV effective energy) was observed in comparison with published data.

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Computer-aided diagnosis for classifying benign versus malignant thyroid nodules based on ultrasound images: A comparison with radiologist-based assessments

Purpose:

To develop a semiautomated computer-aided diagnosis (cad) system for thyroid cancer using two-dimensional ultrasoundimages that can be used to yield a second opinion in the clinic to differentiate malignant and benign lesions.

Methods:

A total of 118 ultrasoundimages that included axial and longitudinal images from patients with biopsy-confirmed malignant (n = 30) and benign (n = 29) nodules were collected. Thyroid cad software was developed to extract quantitative features from these images based on thyroid nodule segmentation in which adaptive diffusion flow for active contours was used. Various features, including histogram, intensity differences, elliptical fit, gray-level co-occurrence matrixes, and gray-level run-length matrixes, were evaluated for each region imaged. Based on these imaging features, a support vector machine (SVM) classifier was used to differentiate benign and malignant nodules. Leave-one-out cross-validation with sequential forward feature selection was performed to evaluate the overall accuracy of this method. Additionally, analyses with contingency tables and receiver operating characteristic (ROC) curves were performed to compare the performance of cad with visual inspection by expert radiologists based on established gold standards.

Results:

Most univariate features for this proposed cad system attained accuracies that ranged from 78.0% to 83.1%. When optimal SVM parameters that were established using a grid search method with features that radiologists use for visual inspection were employed, the authors could attain rates of accuracy that ranged from 72.9% to 84.7%. Using leave-one-out cross-validation results in a multivariate analysis of various features, the highest accuracy achieved using the proposed cad system was 98.3%, whereas visual inspection by radiologists reached 94.9% accuracy. To obtain the highest accuracies, "axial ratio" and "max probability" in axial images were most frequently included in the optimal feature sets for the authors' proposed cad system, while "shape" and "calcification" in longitudinal images were most frequently included in the optimal feature sets for visual inspection by radiologists. The computed areas under curves in the ROC analysis were 0.986 and 0.979 for the proposed cad system and visual inspection by radiologists, respectively; no significant difference was detected between these groups.

Conclusions:

The use of thyroid cad to differentiate malignant from benign lesions shows accuracy similar to that obtained via visual inspection by radiologists. Thyroid cad might be considered a viable way to generate a second opinion for radiologists in clinical practice.

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Stability of symptom patterns in Australian Gulf War veterans: 10-year longitudinal study

Objectives

Previously we established that symptoms reported by 1990–1991 Gulf War veterans were correlated and exhibited a pattern with 3 factors (psychophysiological distress, somatic distress and arthroneuromuscular distress), and this pattern was similar to that observed in a military comparison group. In this follow-up study, we examined whether the patterns of symptomatology have changed over time.

Methods

Using data on 56 symptoms that was collected in 2000–2003 (wave 1) and 2011–2012 (wave 2) from an Australian cohort of Gulf War veterans (veterans) and a military comparison group, exploratory factor analysis was conducted and Tucker's Congruence Coefficient (TCC) was used to determine factor structure similarity across study groups and waves.

Results

The results showed that the 3 factors observed at wave 1 were still present at wave 2, and factor structures across study groups and study waves were fairly similar, with TCC ranging 0.86–0.92. Veterans consistently reported more symptoms across all 3 factors. Veterans' symptomatology specific to psychophysiological distress increased between waves 1 and 2 (ratio of means 1.15; 95% CI 1.07 to 1.25) but psychophysiological distress symptomatology was constant in the comparison group (ratio of means 0.97; 95% CI 0.89 to 1.06). Somatic and arthroneuromuscular distress symptomatology significantly increased over time for both study groups, although at a similar rate.

Conclusions

While the symptom groupings (measured by the 3 factors) remained unchanged at 10 years of follow-up, and remained comparable between Gulf War and comparison group, symptomatology continued to be elevated in Gulf War veterans than in the comparison group, and was most evident for psychophysiological distress.

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Persistent musculoskeletal pain and productive employment; a systematic review of interventions

A systematic analysis of the literature was undertaken to determine which characteristics of workplace interventions are most effective in assisting people with persistent musculoskeletal pain (PMP) to remain productively employed. Databases of Medline, PsychINFO, CINAHL and Embase were searched using MeSH and other relevant terms. Studies that reported on interventions at, or involving, the workplace were included. Interventions were considered as either focused on the individual or multilevel. Outcome measures assessed included: job loss, productivity, sick leave, pain and cost benefit. A quality assessment was undertaken using GRADE criteria with development of impact statements to synthesise the results. Eighteen relevant articles (14 studies) were identified for inclusion in the review. No high-level evidence for workplace interventions to assist people with PMP were identified. Low numbers of participants and limited studies resulted in downgrading of evidence. However, individually focused interventions will probably reduce job loss and sick leave, but are unlikely to reduce pain. Multilevel focused interventions will probably result in decreased sick leave and provide some cost benefit. The evidence on productivity was limited and of poor quality. Further research is required because sustainable employment for individuals with PMP is important and understanding what works is necessary to ensure effective workplace interventions are developed.

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Physical workload and risk of long-term sickness absence in the general working population and among blue-collar workers: prospective cohort study with register follow-up

Objective

To determine the prospective association between physical workload—in terms of specific physical exposures and the number of exposures—and long-term sickness absence (LTSA).

Methods

Using cox-regression analyses, we estimated the risk of register-based incident LTSA (at least 3 consecutive weeks) from self-reported exposure to different physical workloads among 11 908 wage earners from the general working population (Danish Work Environment Cohort Study year 2000 and 2005).

Results

The incidence of LTSA was 8.9% during two-year follow-up. Spending 25% or more of the total work time with a bent or twisted back (HR 1.59 (95% CI 1.39 to 1.83)), arms above shoulder height (HR 1.35 (95% CI 1.14 to 1.59)), squatting or kneeling (HR 1.30 (95% CI 1.09 to 1.54)), pushing/pulling or lifting/carrying (HR 1.40 (95% CI 1.22 to 1.62)) and standing in the same place for 50% or more of total work time (HR 1.19 (95% CI 1.00 to 1.42), were risk factors for LTSA when adjusted for baseline age, gender, psychosocial work environment, lifestyle, musculoskeletal and mental disorders, and socioeconomic status. HR increased from 1.25 (95% CI 1.04 to 1.51) for one to 1.94 (95% CI 1.56 to 2.41) for four combined physical workloads. Results largely remained stable in subgroup analyses including only blue-collar workers (n=5055). Population attributable risks for LTSA from one or more physical workloads were 26% and 40% in the general working population and among blue-collar workers, respectively.

Conclusions

Several of the investigated types of physical workload were risk factors for LTSA when exceeding 25% of the work time. A higher number of combined physical workloads was associated with progressively increased risk. Our study underscores the importance of physical workload as risk factors for LTSA in the general working population as well as among blue-collar workers.

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Work as treatment? The effectiveness of re-employment programmes for unemployed persons with severe mental health problems on health and quality of life: a systematic review and meta-analysis

Given the importance of unemployment in health inequalities, re-employment of unemployed persons into paid employment may be a powerful intervention to increase population health. It is suggested that integrated programmes of vocational reintegration with health promotion may improve the likelihood of entering paid employment of long-term unemployed persons with severe mental health problems. However, the current evidence regarding whether entering paid employment of this population will contribute to a reduction in health problems remains unambiguous. This systematic review and meta-analysis aimed to assess the effects of re-employment programmes with regard to health and quality of life. Three electronic databases were searched (up to March 2015). Two reviewers independently selected articles and assessed the risk of bias on prespecified criteria. Measures of effects were pooled and random effect meta-analysis of randomised controlled trials was conducted, where possible. Sixteen studies were included. Nine studies described functioning as an outcome measure. Five studies with six comparisons provided enough information to calculate a pooled effect size of –0.01 (95% CI –0.13 to 0.11). Fifteen studies presented mental health as an outcome measure of which six with comparable psychiatric symptoms resulted in a pooled effect size of 0.20 (95% CI –0.23 to 0.62). Thirteen studies described quality of life as an outcome measure. Seven of these studies, describing eight comparisons, provided enough information to calculate a pooled effect size of 0.28 (95% CI 0.04 to 0.52). Re-employment programmes have a modest positive effect on the quality of life. No evidence was found for any effect of these re-employment programmes on functioning and mental health.

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Pediatric Rectal Exam: Why, When, and How

Abstract

The digital rectal examination (DRE) is performed in children less often than is indicated. Indications for the pediatric DRE include diarrhea, constipation, fecal incontinence, abdominal pain, gastrointestinal bleeding, and anemia. Less well-recognized indications may include abdominal mass, urinary symptoms, neurologic symptoms, urogenital or gynecologic symptoms, and anemia. Indeed, we believe that it should be considered part of a complete physical examination in children presenting with many different complaints. Physicians avoid this part of the physical examination in both children and adults for a number of reasons: discomfort on the part of the health care provider; belief that no useful information will be provided; lack of adequate training and experience in the performance of the DRE; conviction that planned "orders" or testing can obviate the need for the DRE; worry about "assaulting" a patient, particularly one who is small, young, and subordinate; anticipation that the exam will be refused by patient or parent; and concern regarding the time involved in the exam. The rationale and clinical utility of the DRE will be summarized in this article. In addition, the components of a complete pediatric DRE, along with suggestions for efficiently obtaining the child's consent and cooperation, will be presented.

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Monitoring of Lung Involvement in Rheumatologic Disease

The monitoring of lung involvement in patients with connective tissue diseases is central to optimal long-term management and is directed towards: (a) the detection of supervening lung involvement not present at presentation and (b) the identification of disease progression in established lung disease. For both goals, accurate surveillance requires multi-disciplinary evaluation with the integration of symptomatic change, serial pulmonary function trends and imaging data. Evaluated in isolation, each of these monitoring domains has significant limitations. Symptomatic change may be confounded by a wide variety of systemic factors. Pulmonary function tests provide the most reliable data, but are limited by measurement variability, the heterogeneity of functional patterns and the confounding effects of non-pulmonary factors. Chest radiography is insensitive to change but may provide rapid confirmation of major disease progression or alert the clinician to respiratory co-morbidities. Although high-resolution computed tomography has a central role in assessing disease severity, it should be used very selectively as a monitoring tool due to the associated radiation burden. Ancillary tests include echocardiography and exercise testing to proactively identify cases of pulmonary hypertension and worsening of oxygenation. In summary, a multi-disciplinary approach is essential for the identification of disease progression and prompt treatment of comorbidities that severely impact on the morbidity and mortality of disease.
Respiration

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Preferential Attachment of Specific Fluorescent Dyes and Dye Labeled DNA Sequences in a Surface Enhanced Raman Scattering Multiplex

Analytical Chemistry

DOI: 10.1021/acs.analchem.5b02776

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Imaging and Functional Analysis of γ-Secretase and Substrate in a Proteolipobead System with an Activity-Based Probe

Analytical Chemistry

DOI: 10.1021/acs.analchem.5b03762

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