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Among the most discussed issues in the field of pulmonary function testing are reference equations and standardised methods of interpreting pulmonary function test (PFT) results. The Global Lung Function Initiative (GLI) task force gathered information from multiple countries with diverse ethnicities to create a multi-ethnic reference formula suitable for a broad age range. Their first output was the GLI-2012 spirometry reference equations. Together with the GLI-2012 reference equations, the GLI document recommended the use of z-scores to standardise the interpretation of PFT results. Z-scores were introduced as an alternative to per cent predicted and fixed thresholds in interpreting PFTs. After more than a decade, there is still debate on which method of interpretation is better., Competing Interests: Conflict of interest: R. Ong-Salvador has nothing to disclose. P. Laveneziana reports payment or honoraria for lectures, presentations, manuscript writing or educational events from CHIESI, AstraZeneca and GSK, outside the submitted work. F. de Jongh reports payment or honoraria for lectures, presentations, manuscript writing or educational events from European Respiratory Society; support for attending meetings from European Respiratory Society; and a leadership role with the European Respiratory Society, all disclosures made outside the submitted work., (Copyright ©ERS 2024.)

Coronavirus disease 2019 (COVID-19) has negatively affected the delivery of respiratory diagnostic services across the world due to the potential risk of disease transmission during lung function testing. Community prevalence, reoccurrence of COVID-19 surges and the emergence of different variants of SARS-CoV-2 have impeded attempts to restore services. Finding consensus on how to deliver safe lung function services for both patients attending and for staff performing the tests are of paramount importance. This international statement presents the consensus opinion of 23 experts in the field of lung function and respiratory physiology balanced with evidence from the reviewed literature. It describes a robust roadmap for restoration and continuity of lung function testing services during the COVID-19 pandemic and beyond. Important strategies presented in this consensus statement relate to the patient journey when attending for lung function tests. We discuss appointment preparation, operational and environmental issues, testing room requirements including mitigation strategies for transmission risk, requirement for improved ventilation, maintaining physical distance and use of personal protection equipment. We also provide consensus opinion on precautions relating to specific tests, filters, management of special patient groups and alternative options to testing in hospitals. The pandemic has highlighted how vulnerable lung function services are and forces us to re-think how long-term mitigation strategies can protect our services during this and any possible future pandemic. This statement aspires to address the safety concerns that exist and provide strategies to make lung function tests and the testing environment safer when tests are required., Competing Interests: Conflict of interest: A. McGowan has nothing to disclose. Conflict of interest: P. Laveneziana reports personal fees from Novartis France, Chiesi France and Boehringer France, outside the submitted work. Conflict of interest: S. Bayat has nothing to disclose. Conflict of interest: N. Beydon has nothing to disclose. Conflict of interest: P.W. Boros has nothing to disclose. Conflict of interest: F. Burgos reports participation on a scientific advisory board for Medical Graphics Coorporation Diagnostics. Conflict of interest: M. Fležar has nothing to disclose. Conflict of interest: M. Franczuk reports personal fees from AstraZeneca, Boehringer Ingelheim and Chiesi, outside the submitted work. Conflict of interest: M-A. Galarza has nothing to disclose. Conflict of interest: A.H. Kendrick has nothing to disclose. Conflict of interest: E. Lombardi reports nonfinancial support from AbbVie, personal fees from Angelini and Boehringer, personal fees and nonfinancial support from Chiesi, personal fees from GSK, nonfinancial support from Lusofarmaco, personal fees and nonfinancial support from Novartis, personal fees from Omron, grants and nonfinancial support from Restech, grants and personal fees from Sanofi, personal fees and nonfinancial support from Vertex, and personal fees from Vifor, outside the submitted work. Conflict of interest: J. Makonga-Braaksma has nothing to disclose. Conflict of interest: M.C. McCormack reports royalties from UpToDate, and personal fees from Vera Med, GlaxoSmithKline and Celgene, outside the submitted work. Conflict of interest: L. Plantier has nothing to disclose. Conflict of interest: S. Stanojevic has nothing to disclose. Conflict of interest: I. Steenbruggen has nothing to disclose. Conflict of interest: B. Thompson has nothing to disclose. Conflict of interest: A.L. Coates has nothing to disclose. Conflict of interest: J. Wanger has nothing to disclose. Conflict of interest: D.W. Cockcroft reports participation on a medical advisory board for Pharmaxis. Conflict of interest: B. Culver has nothing to disclose. Conflict of interest: K. Sylvester has nothing to disclose. Conflict of interest: F. de Jongh has nothing to disclose., (Copyright ©The authors 2022.)

Background: The Hexoskin is a smart shirt that can take continuous and objective measurements and could be part of a potential telemonitoring system., Objective: The aim of this study was to determine the accuracy of the calibrated Hexoskin in measuring tidal volumes (TVs) in comparison to spirometry during various tasks., Methods: In a cross-sectional study, the TV of 15 healthy subjects was measured while performing seven tasks using spirometry and the Hexoskin. These tasks were performed during two sessions; between sessions, all equipment was removed. A one-time spirometer-based calibration per task was determined in session 1 and applied to the corresponding task in both sessions. Bland-Altman analysis was used to determine the agreement between TV that was measured with the Hexoskin and that measured with spirometry. A priori, we determined that the bias had to be less than ±5%, with limits of agreement (LOA) of less than ±15%. Lung volumes were measured and had to have LOA of less than ±0.150 L., Results: In the first session, all tasks had a median bias within the criteria (±0.6%). In the second session, biases were ±8.9%; only two tasks met the criteria. In both sessions, LOA were within the criteria in six out of seven tasks (±14.7%). LOA of lung volumes were greater than 0.150 L., Conclusions: The Hexoskin was able to correctly measure TV in healthy subjects during various tasks. However, after reapplication of the equipment, calibration factors were not able to be reused to obtain results within the determined boundaries., Trial Registration: Netherlands Trial Register NL6934; https://www.trialregister.nl/trial/6934., (©Denise Mannée, Frans de Jongh, Hanneke van Helvoort. Originally published in JMIR Formative Research (https://formative.jmir.org), 18.10.2021.)

Purpose: The diagnosis and treatment of cancer negatively affect patients' physical, functional and psychological wellbeing. Patients' needs for care cannot be addressed unless they are recognized by healthcare providers (HCPs). The use of quality of life (QoL) assessments with feedback to HCPs might facilitate the identification and discussion of QoL-topics., Methods: 113 patients with stage I-IIIB breast cancer treated with chemotherapy were included in this randomized controlled trial. Patients were randomly allocated to receive either usual care, or usual care with an intervention consisting of a QoL-monitor assessing QoL, distress and care needs before every chemotherapy cycle visit. Patients completed questionnaires regarding QoL, illness perceptions, self-efficacy, and satisfaction with communication. From the 2nd visit onwards, patients in the intervention arm and their HCPs received a copy of the QoL overview and results were shown in patients' medical files. Audio-recordings and patients' self-reports were used to investigate effects on communication, patient management and patient-wellbeing. A composite score for communication was calculated by summing the number of QoL-topics discussed during each consultation., Results: Use of the QoL-monitor resulted in a higher communication score (0.7 topics increase per visit, p = 0.04), especially regarding the disease-specific and psychosocial issues (p < 0.01). There were no differences in patient management, QoL, illness perceptions or distress. Patients in the experimental arm (n = 60) had higher scores on satisfaction with communication (p < 0.05)., Conclusions: Use of a QoL-monitor during chemotherapy in patients with early breast cancer might result in a more frequent discussion of QoL-topics, associated with high levels of patients' satisfaction.

Telemonitoring becomes more important in pulmonary research. It can be used to decrease the pressure on the health care system, to lower the costs of health care and to increase quality of life of patients. Previous studies show contradictory results regarding the effectiveness of telemonitoring. According to multiple researchers, inefficiency can be a result of poor study design, low data quality and usability issues. To counteract these issues, this review proves for an in-depth explanation of four (potential) telemonitoring systems in terms of work principle, accuracy, disturbing factors and usability. The evaluated systems are portable spirometry/breath-by-breath analyzers, respiratory inductance and magnetic plethysmography and electrical impedance tomography. These insights can be used to select the optimal technique for a specific purpose in future studies., (Copyright © 2020 Mannée, de Jongh and van Helvoort.)

Introduction: Exhaled-breath analysis of volatile organic compounds could detect lung cancer earlier, possibly leading to improved outcomes. Combining exhaled-breath data with clinical parameters may improve lung cancer diagnosis., Methods: Based on data from a previous multi-centre study, this article reports additional analyses. 138 subjects with non-small cell lung cancer (NSCLC) and 143 controls without NSCLC breathed into the Aeonose. The diagnostic accuracy, presented as area under the receiver operating characteristic curve (AUC-ROC), of the Aeonose itself was compared with 1) performing a multivariate logistic regression analysis of the distinct clinical parameters obtained, and 2) using this clinical information beforehand in the training process of the artificial neural network (ANN) for the breath analysis., Results: NSCLC patients (mean±sd age 67.1±9.1 years, 58% male) were compared with controls (62.1±7.0 years, 40.6% male). The AUC-ROC of the classification value of the Aeonose itself was 0.75 (95% CI 0.69-0.81). Adding age, number of pack-years and presence of COPD to this value in a multivariate regression analysis resulted in an improved performance with an AUC-ROC of 0.86 (95% CI 0.81-0.90). Adding these clinical variables beforehand to the ANN for classifying the breath print also led to an improved performance with an AUC-ROC of 0.84 (95% CI 0.79-0.89)., Conclusions: Adding readily available clinical information to the classification value of exhaled-breath analysis with the Aeonose, either post hoc in a multivariate regression analysis or a priori to the ANN, significantly improves the diagnostic accuracy to detect the presence or absence of lung cancer., Competing Interests: Conflict of interest: S. Kort reports an unrestricted research grant paid to her institution by The eNose Company, Zutphen, during the conduct of the study. Conflict of interest: M. Brusse-Keizer has nothing to disclose. Conflict of interest: J.W. Gerritsen is an employee of The eNose Company, Zutphen. Conflict of interest: J.H. Schouwink has nothing to disclose. Conflict of interest: E. Citgez has nothing to disclose. Conflict of interest: F.H.C. de Jongh has nothing to disclose. Conflict of interest: J. van der Maten has nothing to disclose. Conflict of interest: S. Samii has nothing to disclose. Conflict of interest: M. van den Bogart has nothing to disclose. Conflict of interest: J. van der Palen has nothing to disclose., (Copyright ©ERS 2020.)

Background: Increasing evidence suggests that severe skeletal muscle index (SMI) loss (sarcopenia) is associated with poor overall survival in metastatic colorectal cancer patients, but its mechanisms are unknown. We recently found, using data of the randomized phase 3 CAIRO3 study, that SMI loss was related with shorter time to disease progression and overall survival during first-line maintenance treatment with capecitabine + bevacizumab (CAP-B) or observation and during more intensive capecitabine + oxaliplatin + bevacizumab (CAPOX-B) reintroduction treatment. As a potential risk factor for reduced survival, we explored whether sarcopenia and SMI loss were associated with dose-limiting toxicities (DLTs) during CAP-B and CAPOX-B., Methods: Sarcopenia status and SMI loss were assessed by using consecutive computed tomography scans. DLTs were defined as any dose delay/reduction/discontinuation of systemic treatment because of reported CTCAE (version 3.0) toxicities at the start or during treatment. Poisson regression models were used to study whether sarcopenia and body mass index (BMI) at the start of treatment and SMI and BMI loss during treatment were associated with DLTs., Results: One hundred eighty-two patients (mean age 63.0 ± 8.8 years, 37% female) received CAP-B, and 232 patients (mean age 63.0 ± 9.0 years, 34% female) received CAPOX-B. At the start of CAP-B and CAPOX-B, 54% and 46% of patients were sarcopenic, respectively. Mean BMI was lower in sarcopenic patients, although patients were on average still overweight (sarcopenic vs. non-sarcopenic at the start of CAP-B 25.0 ± 3.9 vs. 26.7 ± 4.1 and CAPOX-B 25.8 ± 3.8 vs. 27.1 ± 3.8 kg/m 2 ). Sarcopenia at the start of CAP-B was not associated with DLTs [relative risk 0.87 (95% confidence interval 0.64-1.19)], whereas patients with >2% SMI loss had a significantly higher risk of DLTs [1.29 (1.01-1.66)]. At the start of subsequent CAPOX-B, 25% of patients received a dose reduction, and the risk of dose reduction was significantly higher for patients with preceding SMI loss [1.78 (1.06-3.01)] or sarcopenia [1.75 (1.08-2.86)]. After the received dose reductions, sarcopenia or SMI loss was not significantly associated with a higher risk of DLTs during CAPOX-B [sarcopenia vs. non-sarcopenic: 0.86 (0.69-1.08) and SMI loss vs. stable/gain: 0.83 (0.65-1.07)]. In contrast, BMI (loss) at the start or during either treatment was not associated with an increased risk of DLTs., Conclusions: In this large longitudinal study in metastatic colorectal cancer patients during palliative systemic treatment, sarcopenia and/or muscle loss was associated with an increased risk of DLTs. BMI was not associated with DLTs and could not detect sarcopenia or SMI loss. Prospective (randomized) studies should reveal whether normalizing chemotherapeutic doses to muscle mass or muscle mass preservation (by exercise and nutritional interventions) increases chemotherapeutic tolerance and improves survival., (© 2019 The Authors Journal of Cachexia, Sarcopenia and Muscle published by John Wiley & Sons Ltd on behalf of Society on Sarcopenia, Cachexia and Wasting Disorders.)

Obstructive Sleep Apnea (OSA) is recognized as an increasing health risk, leading to daytime sleepiness and various medical conditions, such as hypertension and heart failure. Polysomnography (PSG), the gold standard to diagnose OSA, is a resource-intensive and expensive investigation confined to the hospital.Portable home monitoring, i.e. pulse oximetry, may become an acceptable OSA screening method. The novel nasal pulse oximeter sensor (Xhale Alar) adds the possibility of combining pulse oximetry (SpO2) with airflow analysis by an integrated thermistor, which might increase the diagnostic accuracy.In the Alar pilot study, 39 adults were measured during an overnight PSG recording together with the Alar sensor. This study aims to investigate the additional value of an airflow signal compared to SpO2 analysis in OSA screening. Both time and spectral features were extracted from SpO2 and airflow signals recorded with the Alar sensor. Leave one out cross-validation was used to develop Random Forest models in screening for apnea-hypopnea index (AHI) thresholds 5 and 10. Using both AHI ≥ 5 and AHI ≥ 10 as the diagnostic cutoff, the airflow signal shows respectively an AUC of 89% and 80% compared to 78% and 77% with SpO2 analysis, showing a higher performance using an airflow signal in screening adults for OSA.

Following the first point-prevalence study in Dutch nursing homes conducted each November from 2007 to 2009, we conducted a follow-up point-prevalence study of healthcare-associated infections (HCAIs) each November from 2010 to 2017. Similar methods and criteria were used. Resident characteristics were recorded, data collection was performed by the attending elderly care physicians via an online survey, as well as via a specifically designed App from 2012. As of the same year, information on incontinence was added. Between 2010 until 2017 on average 1786 residents per year were included, ranging from 1571 to 2185. HCAI prevalence with respect to age (mean: 83 years) and sex (31% men and 69% women) were similar over all the years. The overall mean prevalence rate in the first four years was 6.7% versus 2.2% in the last six years. Urinary tract infection was the most prevalent HCAI (1.5%). Most HCAIs occurred among residents of rehabilitation units. The prevalence of HCAI varied by nursing home (0.0-37.0%). The average use of antibiotics was stable over the years (6.0%) irrespective of HCAI rate. Use of incontinence materials was on average 73.5% with 64.3% of residents being reported as incontinent. Those implementing improvement of infection control and surveillance within a new setting do need to continue for multiple years before seeing the success of their endeavour., (Copyright © 2018 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

DL,CO measurements are often used to evaluate and monitor lung diseases as well as cardiovascular diseases. Whether the combination of DL,CO and DL,NO will improve the management of cardiovascular diseases needs to be investigated. It is hoped that the standardization of the DL,NO measurement will facilitate research. Scientific evidence that DL,NO can provide more accurate information than DL,CO alone, can take away the barriers that prevents DL,NO to become a routine test in pulmonology., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Oncogenic osteomalacia (or tumour-induced osteomalacia) is a rare paraneoplastic syndrome caused by overproduction of fibroblastic growth factor 23 (FGF-23) by tumours. Excessive production of FGF-23 can lead to severe, symptomatic hypophosphataemia. The majority of cases have been associated with benign tumours of bone or soft tissue, such as haemangiopericytomas or other neoplasms of mesenchymal origin. We present a case of a 68-year-old woman with an FGF-23 producing B cell non-Hodgkin's lymphoma. Treatment with immunochemotherapy resulted in normalisation of serum FGF-23 and phosphate levels., (2016 BMJ Publishing Group Ltd.)

Aim: Anthracycline-induced cardiotoxicity is (partly) mediated by free radical overload. A randomized study was performed in breast cancer patients to investigate whether free radical scavenger super oxide dismutase (SOD) protects against anthracycline-induced cardiotoxicity as measured by changes in echo, electrocardiography and an array of biomarkers., Method and Results: Eighty female, chemotherapy-naïve breast cancer patients (median age 49, range 24-67 years) scheduled for four or five courses of adjuvant 3 weekly doxorubicin plus cyclophosphamide (AC) chemotherapy, were randomly assigned to receive 80 mg PC-SOD (human recombinant SOD bound to lecithin) or placebo, administered intravenously (i.v.) immediately prior to each AC course. The primary end point was protection against cardiac damage evaluated using echocardiography, QT assessments and a set of biochemical markers for myocardial function, oxidative stress and inflammation. Assessments were performed before and during each course of chemotherapy, and at 1, 4 and 9 months after completion of the chemotherapy regimen. In all patients cardiac effects such as increases in NT-proBNP concentration and prolongation of the QTc interval were noticed. There were no differences between the PC-SOD and placebo-treated patients in systolic or diastolic cardiac function or for any other of the biomarkers used to assess the cardiac effects of anthracyclines., Conclusion: PC-SOD at a dose of 80 mg i.v. is not cardioprotective in patients with breast carcinoma treated with anthracyclines., (© 2014 The British Pharmacological Society.)

Symbiotic algae in coral species distributed over a large depth range are confronted with major differences in light conditions. We studied the genetic variation of Symbiodinium in the coral genus Madracis over depth (5-40 m) and at two different colony surface positions. Using polymerase chain reaction-denaturing gradient gel electrophoresis ITS2 nuclear ribosomal DNA analyses, we consistently identified three symbiont genotypes with distributions that reveal patterns of host specificity and depth-based zonation. ITS2 type B7 Symbiodinium is the generalist type, occurring in all zooxanthellate Madracis corals and at all depths. Type B13 is restricted to the shallow water specialist Madracis mirabilis. Type B15 is typical of deep reef environments and replaces B7 in the depth generalist Madracis pharensis. Contrasting with variation over depth, we found strong functional within-colony uniformity in symbiont diversity. Relating symbiont distributions to measured physical factors (irradiance, light spectral distribution, temperature), suggests depth-based ecological function and host specificity for Symbiodinium ITS2 types, even among closely related coral species.

In this (CAMOXI) study, three carbon monoxide (CO) monitors and salivary cotinine are assessed regarding their ability to distinguish smokers from nonsmokers, both in chronic obstructive pulmonary disease (COPD) and healthy people. Twenty-six healthy smokers, 25 healthy nonsmokers, 25 smoking, and 25 former smoking stable COPD patients (age 40-72 years) were included based on self-report (N = 101). All volunteers were measured following a 12-h abstinence period. Sensitivity, specificity, and predictive values of a positive and negative test result were assessed for a range of cutoff points for both CO and salivary cotinine. The prescribed 9-ppm cutoff point of the Breath CO generates a sensitivity of 68% and 42% for COPD patients and healthy people, respectively. Using the prescribed cutoff point (10 ppm) the Smokelyzer produces 56% sensitivity for COPD patients and 23% for healthy people. Both monitors generate 100% specificity in both groups. The cutoff point for the Micro CO meter (5 ppm) generates 88% sensitivity and 92% specificity for COPD patients, and for healthy people 92% and 88%, respectively. The optimal cutoff points depend upon the goal of the test. Salivary cotinine has a 100% sensitivity, specificity, positive predictive value, and negative predictive value over the range of 15 ng/mL through 40 ng/mL for healthy participants and at 10 ng/mL for COPD patients. The prescribed cutoff points for all three CO monitors generate misleading results concerning the determination of the smoking status in both populations. Salivary cotinine measurement outperforms CO measurements and a combination of the two tools is recommended.

The dazzling diversity of the phytoplankton has puzzled biologists for decades. The puzzle has been enlarged rather than solved by the progressive discovery of new phototrophic microorganisms in the oceans, including picocyanobacteria, pico-eukaryotes, and bacteriochlorophyll-based and rhodopsin-based phototrophic bacteria. Physiological and genomic studies suggest that natural selection promotes niche differentiation among these phototrophic microorganisms, particularly with respect to their photosynthetic characteristics. We have analysed competition for light between two closely related picocyanobacteria of the Synechococcus group that we isolated from the Baltic Sea. One of these two has a red colour because it contains the pigment phycoerythrin, whereas the other is blue-green because it contains high contents of the pigment phycocyanin. Here we report theory and competition experiments that reveal stable coexistence of the two picocyanobacteria, owing to partitioning of the light spectrum. Further competition experiments with a third marine cyanobacterium, capable of adapting its pigment composition, show that this species persists by investing in the pigment that absorbs the colour not used by its competitors. These results demonstrate the adaptive significance of divergence in pigment composition of phototrophic microorganisms, which allows an efficient utilization of light energy and favours species coexistence.

A 62-year-old man, known for some years due to lymphoplasmacytic lymphoma, was admitted with progressive dyspnoea. Multiple lung infiltrates were found upon X-ray examination. Because of the suspicion of an infection, a bronchoscopy with bronchoalveolar lavage was performed. No infectious cause could be established. Upon cytological examination, a highly increased level of kappa-positive B-lymphoid cells was found, as is seen in cases of lymphoplasmacytic lymphoma (Waldenström's macroglobulinaemia). Following chemotherapy, the dyspnoea lessened and the pulmonary infiltrates disappeared. In patients with a lymphoproliferative disorder, pulmonary infiltrates due to infection are found relatively frequently. This case report highlights a rare complication of the disease, namely pulmonary infiltrates caused by infiltration of lymphoplasmacytic cells, emphasising the importance of cytological examination of broncho-alveolar lavage fluid.

One hundred medical charts of patients of a psychogeriatric nursing home with 'possible' (senile) dementia of the Alzheimer type were reviewed. Eighty-seven patients had died and 13 were alive at the time of analysis. The aim of the study was to obtain epidemiological information and to investigate (co)morbidity and mortality of these patients. All the data of this group of nursing home patients appeared to have a wide range. The process of dementia started at a mean age of about 75 years and patients remained in their homes for more than five years before admission. The average time spent in the nursing home was 3.0 years. These patients had a shorter life expectancy, counted from the time of admission, compared with the Dutch population. At admission a large percentage of patients suffered from circulatory system disease, musculoskeletal and connective tissue disease and/or sensory deprivation. During the stay the most frequent diseases were urinary and respiratory tract infections, constipation and chronic ulcers of the skin. Symptoms specific of Alzheimer's disease also occurred: feeding problems, disorders of gait and neurological symptoms such as paratonia. A large percentage of patients showed adverse effects of drugs or suffered from the consequences of trauma. Patients died of cachexia or bronchopneumonia. It is unclear whether the population studied is representative of the total population of Alzheimer patients.