BACKGROUND Light chain (AL) and transthyretin (ATTR) amyloid fibrils are deposited in the extracellular space of the myocardium, resulting in heart failure and premature mortality. Extracellular expansion can be quantified by computed tomography, offering a rapid, cheaper, and more practical alternative to cardiac magnetic resonance, especially among patients with cardiac devices or on renal dialysis. OBJECTIVES This study sought to investigate the association of extracellular volume fraction by computed tomography (ECVCT), myocardial remodeling, and mortality in patients with systemic amyloidosis. METHODS Patients with confirmed systemic amyloidosis and varying degrees of cardiac involvement underwent electrocardiography-gated cardiac computed tomography. Whole heart and septal ECVCT was analyzed. All patients also underwent clinical assessment, electrocardiography, echocardiography, serum amyloid protein component, and/or technetium-99m (Tc-99m) 3,3-diphosphono-1,2-propanodicarboxylic acid scintigraphy. ECVCT was compared across different extents of cardiac infiltration (ATTR Perugini grade/AL Mayo stage) and evaluated for its association with myocardial remodeling and all-cause mortality. RESULTS A total of 72 patients were studied (AL: n = 35, ATTR: n = 37; median age: 67 [IQR: 59-76] years, 70.8% male). Mean septal ECVCT was 42.7% +/- 13.1% and 55.8% +/- 10.9% in AL and ATTR amyloidosis, respectively, and correlated with indexed left ventricular mass (r = 0.426; P < 0.001), left ventricular ejection fraction (r = 0.460; P < 0.001), N-terminal pro-B-type natriuretic peptide (r = 0.563; P < 0.001), and high-sensitivity troponin T (r = 0.546; P < 0.001). ECVCT increased with cardiac amyloid involvement in both AL and ATTR amyloid. Over a mean follow-up of 5.3 +/- 2.4 years, 40 deaths occurred (AL: n = 14 [35.0%]; ATTR: n = 26 [65.0%]). Septal ECVCT was independently associated with all-cause mortality in ATTR (not AL) amyloid after adjustment for age and septal wall thickness (HR: 1.046; 95% CI: 1.003-1.090; P = 0.037). CONCLUSIONS Cardiac amyloid burden quantified by ECVCT is associated with adverse cardiac remodeling as well as all-cause mortality among ATTR amyloid patients. ECVCT may address the need for better identification and risk stratification of amyloid patients, using a widely accessible imaging modality. (J Am Coll Cardiol Img 2022;15:2082-2094) (c) 2022 by the American College of Cardiology Foundation.

CT-guided percutaneous biopsy (CTGB) is an important diagnostic modality in thoracic disease, and carries a 25% risk of pneumothorax.1 Ambulatory pneumothorax management with early discharge is increasingly endorsed post-iatrogenic pneumothorax. This study aims to determine whether observation for 2 hours after CTGB is needed, by looking at the incidence of 'delayed' pneumothorax requiring intervention in a tertiary centre performing complex procedures. Method Online records were used to recruit all patients undergoing CTGB in Glenfield Hospital, Leicester, a tertiary centre staffed by a team of specialist thoracic radiologists, from 15/03/2017–15/03/2021. Records were analysed for demographic data, size and location of biopsy target, timing of post-procedure pneumothorax as delineated on CTGB report or post-procedure chest X-ray (CXR), and intervention required. Delayed pneumothorax was defined as any pneumothorax diagnosed at 2 hours or later following CTGB. Results 641 patients underwent CTGB during the 4-year study period. Characteristics are summarised in table 1. Of these, 223 (34.8%) developed post-procedure pneumothorax. Of the 223, 83.4% were diagnosed during the procedure, and 37 (16.6%) were delayed-onset. No patients were admitted with a diagnosis of pneumothorax after a negative 2-hour check CXR. 79/223 (35%) of all pneumothoraces required intervention. 33.63% of immediate-onset pneumothoraces required intervention, the majority of which was on-table aspiration, compared to 10.8% of the delayed-onset group. The number of delayed-onset pneumothorax patients requiring intervention totalled 0.6% of the total study population. Conclusions This 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. Reference Heerink 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.

Introduction Microbiological testing for atypical pathogens in patients attending hospital with community acquired pneumonia (CAP) is recommended for moderate or severe disease (NICE CG191 2014) or for patients failing to respond to treatment. Although it is unclear whether testing improves outcome even in severe disease, many patients have such tests performed regardless of severity. Having revised our pathways for assessment, treatment and documentation of patients with community acquired pneumonia we hypothesised that testing for atypical organisms has no impact on treatment decisions for these patients. Method We retrospectively identified all patients with a diagnosis of CAP who had investigations for atypical microbiology, September 2013 to May 2014, via our pneumonia database. We assessed CURB-65 score, atypical microbiology results and laboratory costings. The notes for all patients with positive atypical microbiological results were reviewed. Results 343 patients were identified for whom 329 were analysed. 329 patients generated 991 samples in total (825 serum, 165 urine antigen, 1 urine virology) at a laboratory cost of £5,594.29. Five samples were positive, one for urine legionella antigen. Greater than 50% of serological samples had no second (paired) sample sent. There was no correlation between CURB-65 scores and requesting of atypical microbiology requesting. One patient with positive legionella antigen had prolongation of treatment from 5 days to 14 days. No other patients had treatment changes as a consequence of atypical microbiological testing. Conclusion Atypical microbiological testing, in hospital, for CAP patients is commonly performed at significant cost with minimal clinical utility. We recommend that non-selective serological sampling is abandoned. The impact of legionella urinary antigen testing on outcome in moderate and severe cases requires a prospective study. Abstract P260 Table 1 Results by CURB score Score <1/16 1/16 1/32 1/64(+ve) 1/128 (+ve) Not detected (in urine) Detected (in urine) No result or comment Total CURB 0 65 5 5 0 0 17 0 12 104 CURB 1 57 5 5 1 0 19 0 9 96 CURB 2 72 13 2 0 0 20 0 13 120 CURB 3 62 12 3 0 0 15 0 11 103 CURB 4 14 0 2 0 0 5 0 3 24 CURB 5 3 0 0 0 0 0 0 0 3 Not recorded 305 49 15 2 1 86 1 61 520 Not in database 14 3 0 0 0 2 0 2 21 TOTAL 592 87 32 3 1 164 1 111 991

Introduction EBUS-TBNA has avoided the need for patients to undergo mediastinoscopy and can be done under conscious sedation with minimal complications for mediastinal lymph node sampling for lung cancer. The sample analysis varies depending on local expertice. Objective To compare histology (core biopsy) vs. needle washing cytology in achieving a diagnosis of malignancy. Comparing biopsy results using 21G and 22G EBUS-TBNA needles. Methods We reviewed all EBUS procedures performed at Glenfield Hospital, UK from 11 June 2008 till 24 April 2013. The results were then filtered to exclude the 1st 10 procedures in view of the learning curve in performing the procedure and EBUS from 1 January 2010–31 December 2010 (period when the EBUS-TBNA needles were changed from 22G to 21G). Only confirmed diagnosis of malignancy from the remainder were analysed for the study. Results 543 EBUS procedures were done in the 2 periods of which 234 yielded a diagnosis of malignancy (69 and 165 respectively). 68% of 22G needle core samples provided cell type morphology vs. 87% using the 21G needle. Needle washing only provided cell typing in 30% and 28%. The main cell types for the core biopsies were squamous cell carcinoma (19), adenocarcinoma (14) and small cell carcinoma (10) and in the 21G study adenocarcinoma (47), small cell carcinoma (34) and squamous cell carcinoma (28). Summary The results show that switching from 22G to 21G EBUS-TBNA needles yielded a better diagnostic result in this study. Diagnosis based on cell types were also better using the 21G needles. Core biopsies gave better results compared to cytology from needle washings. Potentially depending on local practices we could consider performing diagnostic sampling analysis on needle core biopsies only and 21G EBUS-TBNA needles gave a better diagnostic yield.

Introduction Currently the same threshold value is used to identify a positive D-dimer result for all patients presenting to our ambulatory clinic with suspected pulmonary emboli (PE). It has been suggested that adjusting the threshold value according to the pre-test probability would exclude PE in more patients than using the same cut-off point regardless of clinical probability. Methods Data from 362 consecutive patients presenting to the ambulatory PE clinic was collected. A pre-test probability of PE was recorded for all patients and those with a high pre-test probability had radiological investigations. Patients with a low or intermediate pre-test probability had a latex agglutination D-dimer test. If this result was =0.5 μg/ml they had further investigations, otherwise they were discharged. The diagnosis of PE was made if a VQ scan showed ventilation/perfusion mismatch or CTPA report demonstrated PE. Receiver operating characteristic curve analysis was performed separately for patients with low and intermediate probability and the optimum cut-off value to exclude PE determined. Sensitivity, specificity, negative predictive value and positive predictive value for different cut-off points were determined. Results 362 patients were included in the analysis, 207 (57%) had low, 129 (36%) intermediate and 26 (7%) high pre-test probability. Prevalence of PE was 2% in the low probability group, 14% in the intermediate probability group and 42% in the high probability group. No patients with a D-dimer of <0.5 μg/ml who were discharged without further tests have re-presented with similar symptoms. In the low pre-test probability group, a cut-off point of 1.07 improved the specificity from 64% to 89% while maintaining a sensitivity of 100% and negative predictive value of 100%. Analysis in patients in the intermediate risk group suggested that a cut-off of 0.5 μg/ml was appropriate. By adjusting the D-dimer threshold to >1.0 μg/ml in the low probability group, a further 53 patients could have been discharged home without need for radiological investigation. Conclusion The diagnostic accuracy of D-dimer testing may be improved in patients with a low pre-test probability by adjusting the cut-off threshold.

Introduction Suspected Pulmonary Embolism (PE) is a significant cause of admission to hospital. The objective of this study was to establish the feasibility and safety of managing suspected and proven PE in an out-patient setting. Methods Criteria for low risk patients with suspected PE suitable for treatment in an ambulatory setting were established based on modified Pulmonary Embolism Severity Score (PESI) criteria. Patients deemed low risk were referred to a nurse-led clinic. Clinical pre-test probability of PE was recorded for all patients and those with a low/intermediate probability had D-dimer testing. Patients with a high pre-test probability or D-dimer=0.5 μg/ml had radiological investigations. Data were collected prospectively. Missing information was completed from pathology, imaging systems and case-note review. Results 362 patients (Median age 46, Female 70%) with suspected PE were referred to the ambulatory clinic in 12 months from June 2010. 269 (74%) patients presented with chest pain. 145 patients (40%) had a negative D-dimer and were discharged. 210 patients (58%) had subsequent imaging in the form of 65 (31%) VQ scan, 138 (66%) CT scan, 7 (3%) both. Median time to imaging was 1 day (range 0–5 days). 34 patients were diagnosed with PE (9%). 11 patients (3%) were admitted, of which 5 (45%) were due to right heart strain. Likelihood of PE correlated strongly to clinical probability (low 2%, intermediate 14%, high 42%). One patient with a negative D-Dimer and intermediate clinical probability was diagnosed with PE. 294 (81%) patients were discharged with no follow-up, 28 (8%) patients were followed-up by consultant care. One patient admitted as they did not meet criteria for ambulatory care (tachycardia) had a cardiorespiratory arrest as an inpatient due to massive PE but was successfully resuscitated. To date three patients have (0.8%) died since attending the clinic, no death was related to PE. Savings to PCTs were estimated at £120 000 over 12 months. Conclusion Selected patients with suspected and proven PE may be managed safely in an ambulatory PE clinic setting resulting in significant savings to the healthcare community.

P.J. Barnes, London E.D. Bateman, Cape Town E. Brambilla, Grenoble S. Bilaceroglu, Izmir P. Camus, Dijon M. Cazzola, Rome P.N. Chhajed, Mumbai U. Costabel, Essen K. Dorrington, Oxford A. Foresi, Sesto San Giovanni M.E. Froudarakis, Alexandroupolis G. Hoheisel, Leipzig M. Humbert, Clamart M. Kneussl, Vienna J.G. Mastronarde, Columbus, Ohio L.E. Nery, São Paulo A. Palla, Pisa H.-B. Ris, Lausanne J.L. Robotham, Seattle, Wash. F. Rodriguez Panadero, Tomares International Journal of Thoracic Medicine

Background: Conventional transbronchial needle aspiration (TBNA) is a cheap, minimally invasive tool for lung cancer staging and diagnosis. Endobronchial ultrasound-guided TBNA (EBUS-TBNA) is more sensitive but is more expensive and less widely available. We describe a prospective analysis of TBNA diagnostic, staging and cost utility in a centre in the UK. Objectives: To illustrate the potential diagnostic, staging and cost utility of a low cost conventional TBNA service. Methods: A prospective analysis of 79 TBNA procedures over a 2-year period was performed looking at performance and cost utility in a ‘mixed’ cohort with variable pre-test probability of malignancy (year 1) followed by a high probability cohort (year 2). Results: TBNA avoided mediastinoscopy in 25% of the cases overall (37% in high probability vs. 13% in the ‘mixed’ cohort, p = 0.03). The overall prevalence of malignancy was 84%, sensitivity 79%, negative predictive value 58% and accuracy 85%. Diagnostic utility varied with pre-test probability and nodal station. TBNA down-staged 8% of lung cancer patients to receive surgery and confirmed the pre-treatment stage (inoperability) in 74%. TBNA led to theoretical cost savings of GBP 560 per patient. Conclusions: TBNA can achieve a high diagnostic sensitivity for cancer in high probability patients and stage the majority appropriately, thereby avoiding unnecessary mediastinoscopies and reducing costs. It may also down-stage a minority to have surgery. TBNA is cheap, routinely available and learnable. As EBUS-TBNA will take time to develop due to its costs, all respiratory centres should perform TBNA at flexible bronchoscopy in suspected lung cancer with accessible mediastinal adenopathy.

Introduction: Local anaesthetic video-assisted thoracoscopy (LAVAT) is a safe, reliable and therapeutic procedure used by respiratory physicians in the management of pleural disease, especially pleural malignancy. We describe a prospective analysis of a UK LAVAT service set up in a tertiary respiratory centre to complement an existing large surgical video-assisted thoracic surgery (VATS) service.Methods: A prospective analysis of 125 LAVAT procedures over a 34-month period was performed looking at a variety of quality control endpoints comparing them to national thoracic surgical VATS standards.Results: Talc pleurodesis was effective in over 86% of cases and this did not significantly lengthen bed stay (median 4.5 days). Bed stay was also unchanged between the ages of 60-89 years. Over 77% of the 48 patients with proven metastatic pleural lung malignancy or mesothelioma received either surgical decortication or oncological treatment (palliative chemotherapy in 57%). In only 6% were biopsies not possible because of technical factors. LAVAT biopsies had a diagnostic accuracy of 97.4%, sensitivity 95.4%, specificity 100%, positive predictive value 100%, and negative predictive value 94.7%. Our complication rate was 4% and mortality rate 0.8%.Discussion: Our LAVAT service meets surgical VATS standards for diagnosis and safety with a good pleurodesis efficacy rate. It complements our surgical VATS service, offering a pleural diagnostic service for patients with non-complex pleural exudates or too frail for VATS. Our data demonstrate there is a demand and potential for respiratory physicians dealing with pleural malignancy to develop LAVAT and enhance their local lung cancer and pleural diagnostic pathway. (C) 2009 Elsevier Ireland Ltd. All rights reserved.

BACKGROUNDCorrect service costing is essential but may not always be done accurately.AIMTo assess the accuracy of Healthcare Resource Group (HRG) coding allocation for patients undergoing local anaesthetic video-assisted thoracoscopy (LAVAT) against predicted codes under Payment by Results (PbR).DESIGNSingle centre retrospective study. Tertiary respiratory centre in Leicestershire.METHODSOne hundred twenty-five patients undergoing LAVAT from July 2005 to July 2008.MAIN OUTCOME MEASURESPredicted and actual revenue per LAVAT episode based on predicted and actual HRG codes allocated.RESULTSAmong 125 patients undergoing LAVAT, the actual HRG code matched the predicted code in only 39 cases (31.2%), odds ratio (OR) 0.002, 95% confidence intervals (CIs) 0.0001-0.03, P < 0.0001. In 51 cases (40.8%), this resulted in a median (interquartile range) excess of PbR revenue of 574 pounds (574-1366) per episode; a total estimated overspend of 29,274 pounds. In 35 cases (28.0%), this resulted in a median underspend of --1093 pounds (-1285 to -851) per episode; a total estimated underspend of 38,529 pounds, with a total estimated financial error of 67,529 pounds. The net median (interquartile range) difference for PbR-related revenue was 0 pounds (-89 to + 574). Factors associated with coding discrepancy were longer length of stay (OR = 2.52, 95% CIs = 1.09-5.81, P = 0.03) and talc pleurodesis (OR = 2.25, 95% CI = 1.01-4.99, P = 0.06).CONCLUSIONHRG coding allocation errors occur frequently. The potential financial implications of this are significant for providers and commissioners. Future strategies are required at multiple levels (NHS Trust, Primary Care Trust and Department of Health) to minimize future discrepancies and financial error.

A 64-year-old man presented with 3-month history of persistent dyspnoea following a flu-like illness. He had been exposed to asbestos in the building trade and had a 20 pack year smoking history. Investigations revealed a …

BACKGROUND:New innovative techniques can improve patient care but may not be appropriately funded. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS) offers a minimally invasive mediastinal staging and diagnostic method for suspected lung cancer.AIM:We report the performance and cost analysis of a newly established EBUS service in a prospective real world cohort of patients to assess the impact of Payment by Results (PbR).DESIGN:Prospective cohort study.METHODS:Fifty-four patients between June 2008 and April 2009 underwent EBUS for evaluation of unexplained mediastinal lymphadenopathy on CT. Cost analysis was performed from local Trust financial data and 2008-09 tariffs.RESULTS:EBUS had an 89% sensitivity, 75% negative predictive value and 92% accuracy for malignancy. EBUS coding was inaccurate in 15.6% of cases. The actual cost of an EBUS is 1252-1433 pounds but is coded as a standard bronchoscopy (561 pounds). EBUS reduces health community costs by 107824 pounds/year, as a result of a Primary Care Trust cost saving of 113968 pounds/year and a Trust cost deficit of 6144 pounds/year. Coding inaccuracies further alter the Primary Care Trust costs.CONCLUSION:Medical innovation is fundamental to improved patient care. EBUS can potentially reduce morbidity for lung cancer patients and save health community costs. However, with PbR the service provider delivers this at a loss as the tariffs do not reflect innovation and because of coding inaccuracies. We suggest tariffs for innovative procedures need to reflect the true cost.