BTS Guidelines Research Articles

Incidental pulmonary nodules - current guidelines and management.

Due to the greater use of high-resolution cross-sectional imaging, the number of incidental pulmonary nodules detected each year is increasing. Although the vast majority of incidental pulmonary nodules are benign, many early lung carcinomas could be diagnosed with consistent follow-up. However, for a variety of reasons, the existing recommendations are often not implemented correctly. Therefore, potential for improvement with respect to competence, communication, structure, and process is described. This article presents the recommendations for incidental pulmonary nodules from the current S3 guideline for lung cancer (July 2023). The internationally established recommendations (BTS guidelines and Fleischner criteria) are compared and further studies on optimized management were included after a systematic literature search in PubMed. In particular, AI-based software solutions are promising, as they can be used in a support capacity on several levels at once and can lead to simpler and more automated management. However, to be applicable in routine clinical practice, software must fit well into the radiology workflow and be integrated. In addition, "Lung Nodule Management" programs or clinics that follow a high-quality procedure for patients with incidental lung nodules or nodules detected by screening have been established in the USA. Similar structures might also be implemented in Germany in a future screening program in which patients with incidental pulmonary nodules could be included. · Incidental pulmonary nodules are common but are often not adequately managed. · The updated S3 guideline for lung cancer now includes recommendations for incidental pulmonary nodules. · Competence, communication, structure, and process levels offer significant potential for improvement. · Glandorf J, Vogel-Claussen J, . Incidental pulmonary nodules - current guidelines and management. Fortschr Röntgenstr 2024; 196: 582 - 590.

Solitary Pulmonary Nodule: Is It Benign or Malignant?

Solitary pulmonary nodules (SPN) are round-shaped opacities with or without firm borders and ≤3 cm in diameter. 40% of solitary pulmonary nodules in high-risk populations are malignant and >10 mm in diameter. With the high incidence of pulmonary cancer, diagnosing pulmonary nodules is essential for clinicians. This review aims to discuss more solitary pulmonary nodules based on multiple recommendations for diagnosis and management. Malignancy probability assessment is the first step in evaluating each patient with new pulmonary nodules, as it significantly affects the prognosis of the disease. The assessment depends on the risk factors present in the patient, which are cigarettes, age, history of cancer, and family history. Radiological evaluation is the second phase in pulmonary nodule evaluation. Predictors of malignant nodules that should be assessed are nodule size, growth rate, nodule morphology, location, and enhancement. Many guidelines have been published regarding treating solitary pulmonary nodules, including the Fleischner Society, ACCP, and BTS guidelines.

Higher agreement between readers with deep learning CAD software for reporting pulmonary nodules on CT

PurposeThe aim was to evaluate the impact of CAD software on the pulmonary nodule management recommendations of radiologists in a cohort of patients with incidentally detected nodules on CT. MethodsFor this retrospective study, two radiologists independently assessed 50 chest CT cases for pulmonary nodules to determine the appropriate management recommendation, twice, unaided and aided by CAD with a 6-month washout period. Management recommendations were given in a 4-point grade based on the BTS guidelines. Both reading sessions were recorded to determine the reading times per case. A reduction in reading times per session was tested with a one-tailed paired t-test, and a linear weighted kappa was calculated to assess interobserver agreement. ResultsThe mean age of the included patients was 65.0 ± 10.9. Twenty patients were male (40 %). For both readers 1 and 2, a significant reduction of reading time was observed of 33.4 % and 42.6 % (p < 0.001, p < 0.001). The linear weighted kappa between readers unaided was 0.61. Readers showed a better agreement with the aid of CAD, namely by a kappa of 0.84. The mean reading time per case was 226.4 ± 113.2 and 320.8 ± 164.2 s unaided and 150.8 ± 74.2 and 184.2 ± 125.3 s aided by CAD software for readers 1 and 2, respectively. ConclusionA dedicated CAD system for aiding in pulmonary nodule reporting may help improve the uniformity of management recommendations in clinical practice.

Specialist pneumonia intervention nurse service improves pneumonia care and outcome

BackgroundA specialist pneumonia intervention nursing (SPIN) service was set up across a single National Health Service Trust in an effort to improve clinical outcomes. A quality improvement evaluation was performed...

BTS guideline for the use of long-term macrolides

<h3>Abstract</h3> Standing balance is relatively more unstable when visually pursuing a moving target than when fixating a stationary one. These effects are common across age groups if the head is...

P194 Implementation of a cystic fibrosis-specific virtual pulmonary rehab program

Objectives: Pulmonary rehabilitation (PR) is a key management strategy for people with chronic respiratory disease (BTS Guidelines, 2013). However, in cystic fibrosis (CF), despite the benefits of regular exercise being well documented (Radtke et al, 2017), there is limited uptake. Concerns regarding infection control, lack of CF education, and participating with an older age group may be contributing factors. A pilot study demonstrated good clinical benefits to participants in a CF-specific PR program (Bowen et al, 2019) and current CF Foundation guidelines advise that patients with advanced lung disease should be offered such programs (Kapnadak et al, 2020). We aimed to establish a CF-specific PR program at Manchester Adult CF Centre, as part of the CF Trust Physiotherapy Fellowship service development project. Method: Patients completed a bespoke 8-week program, comprised of biweekly 1:1 virtual exercise sessions. Each session included aerobic and strength training linked to patient goals and was progressed according to reported Borg and muscle fatigue scores. A 1-minute sit to stand test (STS) was performed pre-program and repeated at the end. Enrolled patients had access to an online educational website, which covered a range of CF-specific topics. Patient feedback was collected at the end of the program. Results: [Table Preseteed] Patient feedback indicated that 100% of participants felt their goals had been met and that they would recommend the program to other people with CF (PWCF). Conclusion: Some of the program design was in accordance with what was achievable during the COVID-19 pandemic. Alteration of outcome measures may be required as clinical services normalise. Although a small sample, initial feedback has been extremely positive, indicating that a virtual PR approach may be suitable in engaging PWCF in physical activity. Further data is needed to demonstrate if the program is of clinical benefit and to identify the optimum time-frame of the intervention.

Survey on the rationality and standardization of clinical oxygen therapy in a general hospital in Shanghai

Objective To survey the current status of oxygen therapy in a comprehensive hospital in Shanghai and to assess its rationality and standardization. Methods Cluster sampling method was adopted in selecting in-patients who received oxygen therapy from various departments in Changhai Hospital from March 2018 to June 2018. General information such as gender, age, and department were recorded. The self-developed Oxygen Therapy Form for Inpatients was used to collect clinical data such as admission diagnosis, oxygen therapy indications, oxygen therapy orders, and related parameters. BTS guideline for Oxygen use in adults in Health care and Emergency Settings was used to assess the rationality and standardization of oxygen therapy. Results In this survey, 464 patients were assessed for their oxygen treatment orders. According to the guidelines, the overall reasonable rate of oxygen therapy was 92.2% (428/464); the standardization rate of oxygen therapy was 22.4% (104/464). Among them, the reasonable rate of oxygen therapy in internal medicine ward (64.7%, 46/71) was lower than that in surgery ward (98.3%, 304/309) and in wards of other specialties (92.8%, 78/84) (χ2=91.09, P<0.01); while the reasonable rate of general ward (90.9%, 362/398) was lower than that of ICU (100.0%, 66/66) (χ2=6.47, P<0.05). In the standardization assessment, the wards of other specialties (54.8%, 46/84) were better than the internal medicine ward (26.8%, 19/71) and the surgery ward (12.6%, 39/309) (χ2=68.35, P<0.01); while the ICU (65.2%, 43/66) was superior to the general ward (15.3%, 61/398) (χ2=80.81, P<0.01). Conclusions The rationality of oxygen therapy in the general hospital is acceptable, but the standardization needs to be improved. There are some differences in the rationality and standardization of oxygen therapy orders among different departments and different levels of wards. Key words: Oxygen inhalation therapy; Cross-sectional studies; Clinical audit

The Use of Lung Ultrasound in Acute Medicine

POCUS (Point of Care Ultrasound) refers to ultrasound performed by clinicians as part of their initial patient evaluation, often with the aim of answering a specific question as opposed to being a comprehensive assessment. Such ultrasound is noninvasive, involves no radiation and can be rapidly performed at the bedside. It is also widely practiced in emergency and intensive care medicine leading to earlier and more accurate diagnoses for a wide range of presentations such as shock, renal failure and dyspnoea. POCUS has evolved from cardiological or radiological studies, reduced in complexity and scoped for clinician use. Lung ultrasound (LUS) has been largely developed by acute care clinicians and is a more recent addition to POCUS. Procedural LUS is widely recommended to improve the safety profile of pleural catheter placement (referring to BTS guidelines) but in the UK diagnostic LUS is not widely practiced despite good evidence and guideline support for its use. In this article we briefly review and describe the role of diagnostic LUS as applied to acute medicine. Potential advantages of LUS include a decreased time to diagnosis, improved diagnostic accuracy, a reduction in radiation exposure and unnecessary expensive tests. Studies have shown that at least one diagnosis was missed in around a fifth of patients with acute respiratory symptoms, resulting in increased length of stay and mortality in a third of patients.

An audit of pulmonary nodule workload and a proposed pathway in response to the recent BTS guidelines

An audit of pulmonary nodule workload and a proposed pathway in response to the recent BTS guidelines

P3.11-13 Liverpool Identifies the Hard to Reach Population at Risk of Developing Lung Cancer.

The Liverpool Healthy Lung Programme (LHLP) is an initiative aimed at improving respiratory health and diagnosing respiratory disease at a more treatable stage, taken by the Liverpool Clinical Commissioning Group (CCG) working with communities across Liverpool. Liverpool has one of the highest respiratory morbidity rates in England, with double the national lung cancer incidence, particularly in lower socioeconomic groups. The Liverpool Healthy Lung Programme was initiated in response to both the clinical problem and the health inequality. General practice records targeted ever-smokers and subjects with chronic obstructive pulmonary disease (COPD), 58-70y and were invited for 45-minute lung health check. Positive lifestyle messages were promoted; 5-year personal lung cancer risk calculated (www.MyLungRisk.org using LLPv2 risk model). Those who trigger the 5% threshold were offered a LDCT-scan. Spirometry was used to assess lung function (FEV1/FVC); those with abnormal results referred for potentially definitive diagnosis of COPD. Smoking advice and referrals to smoking cessation clinics were provided. Patients CT detected nodules were managed, based on BTS guidelines; referred to MDT for work-up and significant other findings (SoF) were analysed in detail. 3,591 Healthy Lung Programme consultations (consented). 11,526 people were invited, 4,566 (40%) attended. 1,853 (52%) were male, 2,897 (81%) in the most deprived IMD quintile. 832 (23%) subjects had an existing diagnosis of COPD and 527 (15%) had a previous diagnosis of cancer. 1,173 (33%) subjects had a family history of cancer. 1,548 (99.3% meeting LLPv2 5% risk criterion) were offered CT scan. 119 (9%) patients required further investigations (follow-up CT scan at 3 or 12 months, or immediate MDT referral), 25 (1.9% undergoing CT scan) were diagnosed with lung cancer (11 have suspected lung cancer, undergoing further investigations). Analysis of a sub-set of the SoF findings were followed up and indicated benefit to participants. The results suggest that it is feasible to achieve similar clinical outcome benefits to those observed in the US trial of LDCT screening for lung cancer, with lesser harms in terms of unnecessary diagnostic activity. However, this needs confirmation with extended follow-up, larger numbers of lung cancers diagnosed, and the addition of mortality data. Additional randomised trial results would also add to the precision of estimation of benefits and harms, in particular mortality results from the large European trial, NELSON. In the meantime, the results of LHLP suggest that it is succeeding in early detection of both COPD and lung cancer.

British Thoracic Society Guideline for the initial outpatient management of pulmonary embolism

The following is a summary of the recommendations and good practice points for the BTS Guideline for the initial outpatient management of pulmonary embolism. Please refer to the full guideline...

Development and validation of the Knowledge and Clinical Reasoning of Acute Asthma Management in Emergency Department (K-CRAMED)

Introduction : Asthma is a common non-communicable and chronic respiratory illness that affects individuals regardless of age. Suboptimal management of asthma will burden and restrict daily activities of affected individuals, unfortunately, approximately 40% of asthmatic patients received suboptimal management. Therefore, this study aimed to develop a tool to assess knowledge and clinical reasoning of healthcare providers on acute asthmatic management in emergency setting. Method : The tool was developed via three phases: 1) domain identification, 2) domain blueprinting based the GINA and BTS guidelines, and 3) item generation for each domain for assessing knowledge and clinical reasoning. Three forms of validity evidence related to content, response process and internal structure were appraised. Content validity index (CVI), face validity index (FVI) and intraclass correlation coefficient (ICC) estimate the content validity, response process and internal structure of the tool. Results : A new tool was developed, named as K-CRAMED, which assesses knowledge and clinical reasoning on three domains related to management of acute asthma – diagnosis, treatment and disposition. CVI values for the three domains were more than 0.83. FVI values for the three domains among doctors and paramedics were at least 0.83. The ICC between scores given by emergency specialists was 0.989 (CI 95% 0.982, 0.994, p-value < 0.001). Conclusion : The newly developed tool, named as K-CRAMED, is a valid tool to assess knowledge and clinical reasoning of healthcare providers who manage patients with acute asthma. Further validation is required to verify its validity in other setting.

COPD: A healthcare challenge

British Journal of Healthcare ManagementVol. 23, No. 6 Respiratory MedicineCOPD: A healthcare challengeJo RileyJo RileySearch for more papers by this authorJo RileyPublished Online:14 Jun 2017https://doi.org/10.12968/bjhc.2017.23.6.252AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References All Party Parliamentary Group on Respiratory Health (2014) Report on Inquiry into Respiratory Deaths. Available at: https://www.networks.nhs.uk/nhs-networks/london-lungs/documents/appg-report-on-inquiry-into-respiratory-deaths-june-2014/ (accessed 23 May 2017) Google ScholarAssociation for Respiratory Technology and Physiology (2013) A Guide to performing Quality Assured Diagnostic Spirometry. Available at: http://www.artp.org.uk/en/professional/artp-standards/index.cfm/QADS%20Apr%202013 (accessed 23 May 2017) Google ScholarBritish Lung Foundation (2015) COPD Statistics. Available at: https://statistics.blf.org.uk/copd (accessed 23 May 2017) Google ScholarBritish Lung Foundation (2016) The Battle for Breath Report. Available at: http://tinyurl.com/m3hrckq (accessed 23 May 2017) Google ScholarBritish Thoracic Society (2013) BTS Guideline on Pulmonary Rehabilitation in Adults. Thorax 68(Suppl 2): ii1–30 Crossref, Google ScholarBritish Thoracic Society (2014) BTS Quality Standards for Pulmonary Rehabilitation in Adults. BTS, London Google ScholarBritish Thoracic Society (2016) Improving the Quality of Diagnostic Spirometry in Adults: The national Register of certified professionals and operators. Available at: https://www.brit-thoracic.org.uk/document-library/delivery-of-respiratory-care/spirometry/improving-the-quality-of-diagnostic-spirometry-(2016)/ (accessed 23 May 2017) Google ScholarD'Ancona G (2015) Inhaled Corticosteroids: Managing side effects. The Pharmaceutical Journal 7851: 294; 247–49 Google ScholarDepartment of Health (2011) An Outcomes Strategy for Chronic Obstructive Pulmonary Disease (COPD) and Asthma in England. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216139/dh_128428.pdf (accessed 23 May 2017) Google ScholarFletcher CM (1960) MRC Dyspnoea Scale. BMJ 2:1662 Google ScholarGlobal Initiative for Chronic Obstructive Lung Disease (2017) Global Initiative for Chronic Obstructive Lung Disease (GOLD). Available at: http://goldcopd.org (accessed 23 May 2017) Google ScholarHealth and Safety Executive (2017) Chronic Obstructive Pulmonary Disease (COPD). Available at: www.hse.gov.uk/statistics/causdis/copd/ (accessed 23 May 2017) Google ScholarJones PW, Harding G, Berry P et al. (2009) Development and first validation of the COPD Assessment Test. Eur Respir J 34(3): 648–54 Crossref, Google ScholarNational Institute for Health and Care Excellence (2010) Chronic Obstructive Pulmonary Disease in Over 16's: Diagnosis and management. CG101. Available at: https://www.nice.org.uk/Guidance/CG101 (accessed 23 May 2017) Google ScholarOffice of national Statistics (2015) Number of deaths where the underlying cause was chronic obstructive pulmonary disease by month of occurrence, England and Wales, deaths that occurred between 2001 and 2014. Available at: https://tinyurl.com/ybjpzvxn (accessed 23 May 2017) Google ScholarPublic Health England (2012) NHS Atlas of Variation in Healthcare for People with Respiratory Disease. Available at: http://fingertips.phe.org.uk/profile/atlas-of-variation (accessed 23 May 2017) Google ScholarRoyal College of Physicians (2015) Pulmonary Rehabilitation: Time to Breathe Better. Available at: https://www.rcplondon.ac.uk/projects/outputs/pulmonary-rehabilitation-steps-breathe-better (accessed 23 May 2017) Google ScholarScullion J (2017) Standards and Competencies to improve inhaler technique. Independent Nurse. February: 17–20 Google ScholarSuissa S, Patenaude V, Lapi F et al. (2013) Inhaled corticosteroids in Chronic Obstructive Pulmonary Disease and the risk of side effects. Thorax 68(11): 1029–36. doi: https://doi.org/10.1136/thoraxjnl-2012-202872 Crossref, Google ScholarUK Inhaler Group (2016) Inhaler Standards and Competency Document. Available at: www.respiratoryfutures.org.uk/programmes/uk-inhaler-group/ (accessed 23 May 2017) Google Scholar FiguresReferencesRelatedDetails 2 June 2017Volume 23Issue 6ISSN (print): 1358-0574ISSN (online): 1759-7382 Metrics History Published online 14 June 2017 Published in print 2 June 2017 Information© MA Healthcare LimitedPDF download

BTS guideline for oxygen use in adults in healthcare and emergency settings.

Abbreviations and symbols used in this guideline Executive summary Summary of recommendations Section 1 Introduction Section 2 Methodology of guideline production Section 3 Normal values and definitions

The Impact of Asthma on congenital anomalies, prematurity, birth centiles and infant feeding: retrospective population cohort analysis 2004-2010

ABSTRACT&#x0D; Objectives9.4% of pregnant women in Wales are prescribed medicines for asthma. Prescription of asthma medicines in early pregnancy is associated with increased prevalence of congenital anomalies (aOR 1.20, 1.08 - 1.34). The literature offers less consensus on more common adverse outcomes: premature delivery (&lt;37 weeks), small for gestational age (&lt;10th growth centile) (SGA), and failure to breastfeed.&#x0D; ApproachRoutinely collected data from the all-Wales health and social care linked electronic databank (the Secure Anonymised Information Linkage [SAIL]) were interrogated. Data from the Office of National Statistics birth and deaths registry, the National Community Child Health Database (NCCHD), the Patient Episode Database for Wales, primary care prescription records and the Congenital Anomaly Register (CARIS) 2000-2010 were linked. Growth centiles were calculated from WHO standards. Prescriptions were classified using ATC categories and BTS guidelines. We included live born singletons without congenital anomalies. We excluded infants exposed to medicines known to carry higher risks than asthma medicines: insulin, AEDs, coumarins. Odds ratios, with 95% CIs, were calculated for use of asthma medicines 1 year either side of pregnancy.&#x0D; Results357,989 pregnancies were identified in NCCHD 2000-2010. Data were available on 117,717 at delivery and 38,665 on breastfeeding at birth and 6-8 weeks 2004-2010. Data loss was due to suboptimal GP participation.Delivery before 37 weeks’ gestation and SGA were more common in those prescribed: any short acting beta2 agonists (SABA) (OR 1.12[CI 1.04-1.20], 1.15[1.08-1.28]); inhaled corticosteroids (ICS) (1.07[0.97-1.19], 1.18[1.09-1.29]); systemic corticosteroids (1.34[1.13-1.60], 1.23[1.06-1.43]).&#x0D; At birth and 6-8 weeks, breastfeeding was less prevalent amongst those prescribed: SABAs (OR 0.90[CI 0.86-0.95], 0.87[0.82-0.93]); ICS (0.88[0.82-0.95], 0.85[0.78-0.93]); systemic corticosteroids (0.86 [0.76-0.98], 0.80[CI 0.69-0.94]).&#x0D; ConclusionPrescription of asthma medicines is associated with higher prevalence of conditions predisposing to childhood ill-health. While routinely collected data is unable to account for confounding by indication, and the impact of asthma cannot be disentangled from that of its treatment, these findings indicate that prescription of asthma medicines offer a useful marker to target additional support throughout pregnancy and lactation.&#x0D; FundingThis paper was developed from the EUROmediCAT project.

Prevalence of Tuberculosis among Community Acquired Pneumonia Diagnosed Patients

Aim: To evaluate the proportion of pulmonary TB among patients hospitalized with suspected communityacquired pneumonia (CAP). Methods: Consecutive patients diagnosed with community acquired pneumonia (CAP) admitted to a tertiary care centre over a 2 year period was studied prospectively. Systematic investigation of samples of sputum and blood cultures was performed. A subset of patients had urine antigen tests and serum serology. Results: We enrolled 104 CAP suspected patients in the study group according to the BTS guidelines for CAP. Among these patient’s sputum AFB smear positivity was observed in 21 cases (20.19%). 18 (17.30%) patients turned out to be sputum gram stain positive, but their respective cultures didn’t show any growth. 65 (62.50%) of them turned out to be gram stain and culture positive for bacteriological aetiology. The Commonest cause for CAP among sputum and blood culture positive cases was Streptococcus pneumoniae (19/65) followed by, Klebsiella pneumoniae (17/65), Staphylococcus aureus (13/65), Pseudomonas aeruginosa (8/65), Escherichia coli (4/65), Acinetobactor spp. (3/65). Conclusion: Tuberculosis is one of the leading causes of CAP in TB-prevalent areas. Our diagnostic index may help clinicians identify pulmonary TB cases immediately from CAP and initiate appropriate isolation and optimal treatment.

Do radiology reports follow BTS guidelines for pulmonary nodules?

Do radiology reports follow BTS guidelines for pulmonary nodules?

Return of the pulmonary nodule: the radiologist's key role in implementing the 2015 BTS guidelines on the investigation and management of pulmonary nodules.

The British Thoracic Society has published new comprehensive guidelines for the management of pulmonary nodules. These guidelines are significantly different from those previously published, as they use two malignancy prediction calculators to better characterize the risk of malignancy. There are recommendations for a higher nodule size threshold for follow-up (≥5 mm or ≥80 mm(3)) and a reduction of the follow-up period to 1 year for solid pulmonary nodules; both of these will reduce the number of follow-up CT scans. PET-CT plays a crucial role in characterization also, with an ordinal scale being recommended for reporting. Radiologists will be the key in implementing these guidelines, and routine use of volumetric image-analysis software will be required to manage patients with pulmonary nodules correctly.

Predictors, Outcome, Profile of Anti-tubercular Drug-Induced Hepatitis: A Prospective Nested Case-Control Study in a South Indian Tertiary Hospital

OBJECTIVES: This study was conducted to determine the incidence of anti-tubercular drug (ATT) induced hepatitis and to study the clinical risk factors, clinical, laboratory profile and outcome of patients with ATT induced hepatitis. METHODOLOGY: This case-control study was nested in a cohort of patients from Christian Medical College, Vellore. It was carried out from April 2014 to May 2015. All patients newly diagnosed to have tuberculosis, started on ATT were eligible for this study. All patients who present with suspected ATT related hepatotoxicity were also enrolled in the study. All patients were clinically assessed for symptoms of hepatitis at every visit until completion of treatment. Once the patient developed ATT induced hepatitis, all hepatotoxic drugs were stopped and a non-hepatotoxic regimen was continued. Once the liver function tests normalized, patients were re- introduced with first line regimen as per decision of the treating physician and followed up till the completion of treatment. The incidence of ATT induced hepatitis was obtained from the cohort. The identification of risk factors of ATT induced hepatitis was based on a case control design nested in the cohort study. A descriptive study of clinical profile and outcome of patients with ATT induced hepatitis was also conducted. The risk factors for ATT induced hepatitis were identified by bivariate analysis and logistic regression analysis with odds ratio and 95 % confidence interval. RESULTS: A total of 393 patients were eligible for our study which included 5 patients presenting with ATT induced hepatitis. In the cohort, 61% were male and 81% were in the age group 20-59. HIV infection was found in 72 patients (18.3%). One hundred and fourteen patients (29%) were started on DOTS regimen and the remaining 279 patients (71%) were treated with weight based daily regimen. Patients on DOTS regimen had lower rates of HIV infection and disseminated disease but had greater undernutrition when compared with patients on daily regimen. Majority of the patients (38.9 %) patients had sputum positive pulmonary tuberculosis. A total of 281 patients (72%) had localized disease and 112 patients (28%) had disseminated disease. Forty three patients out of 393 patients developed DILI. The incidence of anti-tubercular drug induced liver injury was 9.7 % (95% C.I 7-13.2%) with lower incidence among patients on DOTS regimen (DOTS 3.5% (95% C.I 2.4%-4.8%) Vs Daily 14% (95% C.I 7.9 – 22.4%)). HIV infection (OR 2.84, p value 0.002, 95% C.I 1.42 – 5.67), daily regimen (OR 4.46, p value 0.003, 95% C.I 1.55 – 12.81), disseminated disease (OR 1.769, p value 0.006, 95% C.I 1.23-2.55), hypoalbuminemia ( OR 1.92, p value 0.045, 95% C.I 1.01 – 3.68) and chronic liver disease (OR 4.72, p value 0.004, 95% C.I 1.5-14.82) were independent risk factors for development of drug induced liver injury. On multivariate logistic regression analysis, HIV infection, hypoalbuminemia, chronic liver disease and daily regimen were found to be significant risk factors for DILI. A prediction score based on the above risk factors is suggested to identify patients who will develop DILI. A score of > 5 will predict DILI with a sensitivity and specificity of 74% and 67%. Vomiting was the most common symptom seen in 58.1% of patients with drug induced hepatitis followed by jaundice in 30.2 % of patients. Four patients developed acute liver failure. The majority of patients (77%) developed drug induced liver injury within first 2 months. The mean time duration for normalization of liver function was 22 days ranging from 3 to 81 days. Fifteen patients (35%) had severe hepatitis. All cause mortality in DILI was 4.7 % (2 patients). 36 patients (84%) had complete resolution of hepatitis. At least 1 drug was successfully rechallenged in 28 out of 29 patients. Rechallenge by both ATS and BTS guidelines had similar successful rechallenge. The rates of rechallenge hepatitis were similar in patients who were rechallenged according to both ATS and BTS guidelines (13.3% Vs 13% respectively). CONCLUSION: Incidence of ATT induced hepatitis from our study was 9.7% (95% C.I 7-13.2%) with lower incidence among patients on DOTS regimen. HIV infection, daily regimen, disseminated disease, hypoalbuminemia and chronic liver disease were independent risk factors for development of DILI. Mortality rate was low (4.3%) among patients who developed DILI. Rechallenge by both ATS and BTS guidelines had similar successful rate. The predictive scoring system proposed from our study needs to be validated by a well designed prospective study. The study suggests that the combination of risk factors of extensive TB disease, HIV and undernutrition increase the vulnerability to drug induced liver disease particularly with daily TB treatment regimen, emphasizing the role of acquired risk factors in the development of DILI.

Systematic lymph node sampling at operation results in more node positive staging in NSCLC

It has been shown that the survival of patients with NSCLC is related to nodal involvement. Both BTS and SIGN guidelines recognise that simple nodal sampling is not adequate to accurately stage NSCLC and recommend at least systematic sampling of mediastinal nodes. In the West of Scotland all patients with node positive disease are considered for adjuvant chemotherapy. This requires accurate staging of lymph nodes.