Background We investigate bronchopulmonary colonization patterns in Spanish people with CF (pwCF), gathering clinical, demographic, and microbiological data to supplement nine years of registry information, comparing 2021 findings with a similar multicenter study conducted in 2013. Methods Sixteen CF units from 14 hospitals across Spain participated, each randomly recruiting around 20 patients. Patients provided sputum samples for culture. The clinical, demographical, microbiological, and treatment data from the previous year were recorded. Results Overall, 326 patients (48.5% females) were recruited: 185 adult and 141 pediatrics, with a median age [q3–q1] of 30 [38–24] and 12 [16–6] years, respectively. p.Phe508del mutation was present in 30.6% and 46.4% of patients with homozygosis or heterozygosis, respectively. Median FEV1 (%) was significantly lower in adults (62%, range 75–43%) compared with pediatrics (90%, range 104–81%) (p<0.001). Pancreatic insufficiency was observed in 77.3%, carbohydrate metabolism alteration in 27.3%, and CF-related diabetes in 19.6% of patients. Lower prevalence of Staphylococcus aureus and Pseudomonas aeruginosa colonization were noted compared to 2013, along with a significantly lower correlation in lung function among pwCF colonized by P. aeruginosa (p<0.001). Half of pwCF (51%) exhibited a single pathogen in culture, two in 30%, and three or more in 2.4%. Co-colonization of P. aeruginosa and S. aureus (36.1%) was the most prevalent combination. High resistance rates were observed in P. aeruginosa and methicillin resistant S. aureus isolates. Conclusions We provide a valuable and representative current insight into the observed evolution in the clinical, demographic, and microbiological aspects in recent years among pwCF in Spain.

BackgroundLung ultrasound (LUS) has proven to be useful in the evaluation of lung involvement in COVID-19. However, its effectiveness for predicting the risk of severe disease is still up for debate. The aim of the study was to establish the prognostic accuracy of serial LUS examinations in the prediction of clinical deterioration in hospitalised patients with COVID-19.MethodsProspective single-centre cohort study of patients hospitalised for COVID-19. The study protocol consisted of a LUS examination within 24 h from admission and a follow-up examination on day 3 of hospitalisation. Lung involvement was evaluated by a 14-area LUS score. The primary end-point was the ability of LUS to predict clinical deterioration defined as need for intensive respiratory support with high-flow oxygen or invasive mechanical ventilation.Results200 patients were included and 35 (17.5%) of them reached the primary end-point and were transferred to the intensive care unit (ICU). The LUS score at admission had been significantly higher in the ICU group than in the non-ICU group (22 (interquartile range (IQR) 20–26)versus12 (IQR 8–15)). A LUS score at admission ≥17 was shown to be the best cut-off point to discriminate patients at risk of deterioration (area under the curve (AUC) 0.95). The absence of progression in LUS score on day 3 significantly increased the prediction accuracy by ruling out deterioration with a negative predictive value of 99.29%.ConclusionSerial LUS is a reliable tool in predicting the risk of respiratory deterioration in patients hospitalised due to COVID-19 pneumonia. LUS could be further implemented in the future for risk stratification of viral pneumonia.

The fact than more and more Cyber-Physical or IoT systems are integrated in vehicle fleets, coupled with the growing connectivity of these devices, poses a higher risk of cyber attacks, due to the increased attack surface. To mitigate this problem, we propose and test a collaborative system of Security Information and Event Management (SIEM) systems, where each node has its own autonomous SIEM-allowing the execution of mitigation actions even when the node is isolated-but it shares its context information with the nearby nodes, improving the correlation intelligence to make better informed decisions. The SIEMs are organised in a hierarchy, following the architecture of the monitoring system, where higher SIEMs collect events and alarms from lower SIEMs to make more general decisions and raise alarms. These alarms are forwarded to lower SIEMs to mitigate or prevent attacks on other nodes in the system. This system has been implemented as part of the CPSoSaware project and tested in three scenarios: local, area and global, focusing the demonstrations on the different layers of the project architecture.

Background: Chronic infection from PA in patients with BE is associated with worse outcomes and faster disease progression, hence eradication after first isolation is recommended. Although different PAE schemes have been proposed, none has demonstrated clear superiority. Our study aims at evaluating the efficacy of PAE therapy with OC alone in a longitudinal cohort of BE patients with primary infection by PA. Methods: We retrospectively evaluated BE patients attending respiratory outpatient clinic of Hospital Universitari de la Vall d'Hebron, Barcelona (ES) with a primary infection by PA diagnosed between 2009 and 2019, and at least 3 years of microbiological follow-up. Data were collected about eradication (≥3 negative sputum cultures in the year after treatment), and reinfection rate (new positive sputum culture after eradication) and correlated with demographic and clinical data. Results: We identified 85 patients, mean age of 65 years old, 63% females (54/85). Eradication was observed in 30 of the 41 cases treated with 21 days of OC (71%). In 21 more cases, it was achieved with other antibiotic strategies. In 55% of PAE (28/51) reinfection was observed with variable latency, from 13 to 109 months (mean 38). No correlation was found with exposure to quinolones or azithromycin chronic treatment. Conclusion: Our data suggest that OC is a successful eradication strategy in a majority of BE patients. However, concern is raised by the elevated rate of reinfections, even after years from the first episode. Genotype studies could establish when reinfection is sustained by the same PA strain, while clinical data are needed to identify risk factors for unsuccessful eradication or reinfection.

The authors regret < Departament of Medicine, Universitat Autònoma de Barcelona [email protected] >. The authors would like to apologise for any inconvenience caused. New opacities in lung allograft after transbronchial cryobiopsyRespiratory MedicineVol. 170PreviewThe occurrence of radiological opacities post-transbronchial cryobiopsy may pose serious difficulties in differential diagnosis and management of lung allografts. This prospective study evaluated the frequency, characteristics, and evolution of new lung opacities after performing transbronchial cryobiopsy. Full-Text PDF Open Archive

Background Transbronchial lung cryobiopsy is an emerging technique for diagnosing pulmonary rejection. However, no prospective studies of this procedure for critically ill lung transplant recipients who require mechanical ventilation in the intensive care unit (ICU) have been performed. Methods From March 2017 to January 2020, we performed a prospective, randomised, comparative study to assess the diagnostic yield, histological quality and safety of transbronchial lung biopsy using biopsy forceps, a 1.9-mm cryoprobe or a 2.4-mm cryoprobe. Results 89 out of 129 consecutive transbronchial biopsy procedures (forceps group, 28 procedures; 1.9-mm cryoprobe group, 31 procedures; 2.4-mm cryoprobe group, 30 procedures) were randomised. Compared with lung samples from the forceps and 1.9-mm cryoprobe groups, lung samples from the 2.4-mm cryoprobe group allowed the most definitive diagnoses (p<0.01 and p=0.02, respectively), the most diagnoses of acute lung rejection (p<0.01 and p=0.01, respectively) and the most diagnoses of rejection severity (p<0.01 and p<0.01, respectively). These samples were larger (p<0.01 and p=0.04, respectively), had the most adequate alveolar tissue (p<0.01 and p=0.02, respectively), had more vessels per procedure (p<0.01 and p=0.01, respectively) and had no significant crush artefacts. Moderate bleeding was observed in 23% of cases (p=0.01 and p=0.08, respectively). No severe bleeding was observed. Conclusions Transbronchial lung biopsy using a 2.4-mm cryoprobe allows the safe collection of lung tissue samples from critically ill lung transplant recipients who require mechanical ventilation in the ICU and has good diagnostic performance.

Background: Protease-antiprotease impaired balance is crucial in the pathophysiology of BE, contributing to airways (AW) inflammation. AAT represents one of the main protease inhibitors, contrasting the effect of proteases such as Neutrophil Elastase, but little is known about its concentration in AW or its role in BE as a biomarker. We hypothesize that AAT levels in sputum (AATs) could correlate with BE severity, and represent a marker of airways disease activity. Methods: We collected spontaneous sputum and blood from stable BE patients, along with most relevant clinical data. AAT levels were measured in sputum supernatant by ELISA, and in blood with nephelometry. AATs was also measured in 9 healthy non-smokers controls. Results: We recruited 34 patients, mostly women(74%), mean age 63±11.9 years old, mean FEV1 86±20.5%. Significantly lower values of AATs were observed in BE compared with healthy controls (0.086mg/dl versus 0.126mg/dl, p=0.005). Level of AATs had inverse correlation with radiological extension (number of involved lobes, r=-0.45, p=0.016; Reiff score, r=-0.58; p=0.001). No correlation was found with severity (BSI and FACED), FEV1, dyspnoea, age or BMI. We calculated the ratio between AATs and AAT in blood (SBAAT) in 24 patients: correlation with Reiff index was confirmed (p=0.016). Lower SBAAT was associated with chronic Pseudomonas infection (p= 0.039) and sputum purulence (p=0.040). Conclusions: Our results suggest a possible correlation between AATs and disease extension. SBAAT and its correlation with sputum characteristics (purulence and chronic infection) seems to indicate higher consumption of AAT in airways that could correspond to an increased disease activity and protease imbalance.

Bronchiectasis (BE) is a chronic respiratory disease with heterogeneous clinical manifestations. In a variable percentage of BE patients, chronic respiratory comorbidities can also be described, including asthma, chronic obstructive pulmonary disease (COPD), and chronic rhinosinusitis. This association can lead to greater burden of symptoms, increased severity, and worse prognosis.The most recent guidelines, mostly based on expert opinions, state that all individuals with bronchiectasis should undergo a minimum bundle of tests which should be tailored to each patient. The determination of the etiology of bronchiectasis can guide treatment and influence prognosis. Unfortunately, no official guidelines or recommendations have been produced yet to guide clinical management of these clinical associations. This narrative review focuses on diagnosis and management of airways diseases in BE patients, trying to keep a practical approach to support decision making in a clinical setting.

Background: Interstitial lung sequelae are increasingly being reported in survivors of COVID-19 pneumonia. An early detection of these lesions may help prevent the development of irreversible lung fibrosis. Lung ultrasound (LUS) has shown high diagnostic accuracy in interstitial lung disease (ILD) and could likely be used as a first-line test for post-COVID-19 lung sequelae.Methods: Single-center observational prospective study. Follow-up assessments of consecutive patients hospitalized for COVID-19 pneumonia were conducted 2–5 months after the hospitalization. All patients underwent pulmonary function tests (PFTs), high-resolution computed tomography (HRCT), and LUS. Radiological alterations in HRCT were quantified using the Warrick score. The LUS score was obtained by evaluating the presence of pathological B-lines in 12 thoracic areas (range, 0–12). The correlation between the LUS and Warrick scores was analyzed.Results: Three hundred and fifty-two patients who recovered from COVID-19 pneumonia were recruited between July and September 2020. At follow-up, dyspnea was the most frequent symptom (69.3%). FVC and DLCO alterations were present in 79 (22.4%) and 234 (66.5%) patients, respectively. HRCT showed relevant interstitial lung sequelae (RILS) in 154 (43.8%) patients (Warrick score ≥ 7). The LUS score was strongly correlated with the HRCT Warrick score (r = 0.77) and showed a moderate inverse correlation with DLCO (r = −0.55). The ROC curve analysis revealed that a LUS score ≥ 3 indicated an excellent ability to discriminate patients with RILS (sensitivity, 94.2%; specificity, 81.8%; negative predictive value, 94.7%).Conclusions: LUS could be implemented as a first-line procedure in the evaluation of Post-COVID-19 interstitial lung sequelae. A normal LUS examination rules out the presence of these sequelae in COVID-19 survivors, avoiding the need for additional diagnostic tests such as HRCT.

Service providers, 5G network operators and, more generally, vertical industries face today a dangerous shortage of highly skilled cybersecurity experts. Along with the escalation and growing sophistication of cyber-attacks, 5G networks require the training of skilled and highly competent cyber forces. To meet these requirements, the SPIDER cyber range focuses specifically on 5G, and is based on three pillars, (i) cyber security assessment, (ii) training cyber security teams to defend against complex cyber-attack scenarios, and (iii) evaluation of cyber risk. The SPIDER cyber range replicates a customized 5G network, enabling the execution of cyber-exercises that take advantage of hands-on interaction in real time, the sharing of information between participants, and the gathering of feedback from network equipment, as well as the development and adaptation of advanced operational procedures. This aims to help 5G security professionals improve their ability to collaboratively manage and predict security incidents, complex attacks, and propagated vulnerabilities. The SPIDER cyber range is validated in two relevant use case scenarios aimed at demonstrating, in a realistic, measurable, and replicable way the transformations SPIDER will bring to the cybersecurity industry.

Background: Following severe acute respiratory syndrome coronavirus 2-induced pneumonia, some patients develop diffuse interstitial lung disease (DILD). However, no histological study has confirmed this alteration. This study describes the histological findings of transbronchial cryobiopsy (TBC) specimens obtained with single-use flexible bronchoscope (FB) and cryoprobe from these patients. Methods: 1996 patients were referred to a specialized consultation for assessment for post-COVID-19 sequelae, and to date 757 patients have already been visited. TBC through FB was recommended when radiological alterations suggestive of DILD were observed and in addition there were clinical criteria, based on the Modified Medical Research Council Dyspnea Scale, or functional criteria (forced vital capacity and/or DLCO between 40-70% of theoretical value, or desaturation in 6MWT). Results: 50 patients were included. There were no significant complications in any procedure. A histological diagnosis was obtained for all patients, showing organizing pneumonia in 16 (32%) patients, interstitial pneumonitis in 9 (18%) patients, hypersensitivity pneumonitis in 4 (8%) patients, and patchy interstitial fibrosis in 4 (8%) patients. In the remaining 17 (34%) patients, the histological findings were normal or with mild nonspecific changes or related to smoking. Conclusions: This study has evaluated histologically patients with suspected DILD after COVID-19 and confirm it in 66% of them. Modification of the usual TBC technique using single-use FB and cryoprobe is safe and provides a high diagnostic yield.

The use of cyber ranges to train and develop cybersecurity skills and awareness is attracting more attention, both in public and private organizations. However, cyber ranges typically focus mainly on hands-on exercises and do not consider aspects such as courses, learning goals and learning objectives, specific skills to train and develop, etc. We address this gap by proposing a method for developing courses and training material based on identified roles and skills to be trained in cyber ranges. Our method has been used by people with different background grouped in academia, critical infrastructure, research, and service providers who have developed 22 courses including hands-on exercises. The developed courses have been tried out in pilot studies by SMEs. Our assessment shows that the method is feasible and that it considers learning and educational aspects by facilitating the development of courses and training material for specific cybersecurity roles and skills.

Clinical case of unusual presentation is introduced, with evidence of cerebellar ataxia and Guillain-Barre syndrome of axonal type, in a pediatric patient, related to the appearance of SARS-CoV-2 infection. We also carry out a review of recent medical literature. © 2021 Sociedad Neurologica Argentina

Introduction: Comorbidities in patients with bronchiectasis are common and have a significant impact on clinical outcomes, contributing to lower quality of life, lung function, and exacerbation frequency. At least 13 comorbidities have been associated with a higher risk of mortality in bronchiectasis patients. Nonetheless, the kind of relationship between bronchiectasis and comorbidities is heterogeneous and poorly understood. Areas covered: different biological mechanisms leading to bronchiectasis could have a role in the development of the associated comorbidities. Some comorbidities could have a causal relationship with bronchiectasis, possibly through a variable degree of systemic inflammation, such as in rheumatic disorders and bowel inflammatory diseases. Other comorbidities, such as COPD or asthma, could be associated through airway inflammation and there is an uncertain cause-effect relationship. Finally, shared risk factors could link different comorbidities to bronchiectasis such as in the case of cardiovascular diseases, where the known link between chronic systemic inflammation and pulmonary infection could play a significant role. Expert opinion: Although different tools have been developed to assess the role of comorbidities in bronchiectasis , we believe that the implementation of current strategies to manage them is absolutely necessary and could significantly improve long-term prognosis in patients with bronchiectasis.

: There is an urgent need for highly skilled cybersecurity professionals, and at the same time there is an awareness gap and lack of integrated training modules on cybersecurity related aspects on all school levels. In order to address this need and bridge the awareness gap, we propose a method to train and evaluate the cybersecurity skills of participants in cyber ranges based on cyber-risk models. Our method consists of five steps: create cyber-risk model, identify risk treatments, setup training scenario, run training scenario, and evaluate the performance of participants. The target users of our method are the White Team and Green Team who typically design and execute training scenarios in cyber ranges. The output of our method, however, is an evaluation report for the Blue Team and Red Team participants being trained in the cyber range. We have applied our method in three large scale pilots from academia, transport, and energy. Our initial results indicate that the method is easy to use and comprehensible for training scenario developers (White/Green Team), develops cyber-risk models that facilitate real-time evaluation of participants in training scenarios, and produces useful feedback to the participants (Blue/Red Team) in terms of strengths and weaknesses regarding cybersecurity skills.

Background: The occurrence of radiological opacities post-transbronchial cryobiopsy may pose serious difficulties in differential diagnosis and management of lung allografts. This prospective study evaluated the frequency, characteristics, and evolution of new lung opacities after performing transbronchial cryobiopsy. Methods: From February 2018 to June 2018, 22 of 51 consecutive patients with an indication for transbronchial cryobiopsy underwent computed tomography (CT) of the thorax before and at 1, 4, and 8 weeks post-cryobiopsy. New CT images, required by the transplant team, were also evaluated during the next 6 months. Histological findings of transbronchial cryobiopsy and microbiological studies on bronchoalveolar lavage were evaluated as risk factors for opacities. Results: After obtaining 112 cryobiopsy samples, 46 opacities >10 mm, including ground-glass, solid, cavitated, or a combination of these lesions were observed in 20 (91%) patients on post-cryobiopsy CT. All ground-glasses opacities on CT disappeared at 4 weeks. A single cavitated opacity persisted at 6 months. The remaining opacities disappeared or were decreased to <10 mm by 8 weeks. No correlations of the number, type, or evolution of opacities with the number or volume of cryobiopsy samples obtained, or with the histological diagnosis, type of transplant, or microbiologic culture results were observed. Conclusion: New pulmonary opacities >10 mm occur frequently after transbronchial cryobiopsy; a few may persist beyond 6 months. CT studies are recommended before implementing transbronchial cryobiopsy, whenever possible.

Background. Previous studies suggest that transbronchial lung biopsy using a cryoprobe is superior to transbronchial lung biopsy using forceps for evaluating lung grafts, although the technique can be associated an increase in complications. Because cryoprobe experience is limited, assessment of a greater number of cases is warranted. This prospective study evaluates the diagnostic yield, complications, and risk factors associated with the cryoprobe technique. Methods. From April 2013 to April 2016, 321 consecutive cryoprobe transbronchial biopsies were indicated in single or bilateral lung transplant patients with acute or chronic clinical lung injury or in asymptomatic patients before hospital discharge after lung transplantation. Results. With a mean of 4.32 lung parenchyma specimens per procedure, adequate alveolar lung parenchyma was obtained in 96.6% (84.27 +/- 44.14 mm(2)) of cases. Obtaining at least 4 samples increased the histological diagnostic certainty (P < .001). Moderate to severe bleeding was observed in 7.48% of patients and was significantly more frequent in patients with unilateral transplantation (odds ratio, 0.10; 95% confidence interval, 0.02-0.30; P < .001) and in those with high blood pressure during scanning (odds ratio, 0.31; 95% confidence interval, 0.12-0.86; P = .019). Pneumothorax was observed in 7.7% of the patients, but only 3.7% of these patients required pleural drainage. Conclusions. Obtaining 4 or more cryobiopsy samples is valuable and safe for lung allograft monitoring. Being a recipient of a unilateral lung transplant or having arterial hypertension during bronchoscopy seem to be risk factors associated with increased bleeding. (C) 2019 by The Society of Thoracic Surgeons