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Pleural biopsy findings offer greater diagnostic sensitivity in malignant pleural effusions compared with pleural fluid. The adequacy of pleural biopsy techniques in achieving molecular marker status has not been studied, and such information (termed "actionable" histology) is critical in providing a rational, efficient, and evidence-based approach to diagnostic investigation.What is the adequacy of various pleural biopsy techniques at providing adequate molecular diagnostic information to guide treatment in malignant pleural effusions?This study analyzed anonymized data on 183 patients from four sites across three countries in whom pleural biopsy results had confirmed a malignant diagnosis and molecular profiling was relevant for the diagnosed cancer type. The primary outcome measure was adequacy of pleural biopsy for achieving molecular marker status. Secondary outcomes included clinical factors predictive of achieving a molecular diagnosis.The median age of patients was 71 years (interquartile range, 63-78 years), with 92 of 183 (50%) male. Of the 183 procedures, 105 (57%) were local anesthetic thoracoscopies (LAT), 12 (7%) were CT scan guided, and 66 (36%) were ultrasound guided. Successful molecular marker analysis was associated with mode of biopsy, with LAT having the highst yield and ultrasound-guided biopsy the lowest (LAT vs CT scan guided vs ultrasound guided: LAT yield, 95%; CT scan guided, 86%; and ultrasound guided, 77% [P = .004]). Biopsy technique and size of biopsy sample were independently associated with successful molecular marker analysis. LAT had an adjusted OR for successful diagnosis of 30.16 (95% CI, 3.15-288.56; P = .003) and biopsy sample size an OR of 1.18 (95% CI, 1.02-1.37) per millimeter increase in tissue sample size (P .03).Although previous studies have shown comparable overall diagnostic yields, in the modern era of targeted therapies, this study found that LAT offers far superior results to image-guided techniques at achieving molecular profiling and remains the optimal diagnostic tool.

Introduction: The travel burden for cancer patients increases with centralisation of cancer services (Peake MD, Thorax, 2015;70:108-109) and may result in diagnostic and treatment delay (Ambroggi et al, The Oncologist, 2015;20:1378-1385). Our hospital in the South East London Cancer Network diagnosed 227 cases in 2018, and has historically relied upon centralised investigations at a regional Cancer Centre. Aims: We investigated patients diagnosed with lung cancer, to determine distance travelled from home to any of the following prior to first treatment: appointments; CT; PET; bronchoscopy; EBUS; IR guided biopsy and pleural diagnostics. Methods: Retrospective data collection from our lung cancer registry and electronic patient records from the first 6 months of 2018. Residential postcode, location and number of appointments, investigations and their location, TNM staging at diagnosis were recorded. The distance travelled for each encounter was determined using Google maps by driving distance between postcodes. Results: 110 patients were included, 62 male, 48 female. Mean age 72, range 39-98. Mean distance (miles) to: appointment(s) 7.9; CT 3.6; PET 11.6; bronchoscopy 3.7; EBUS 10.3; IR biopsy 5.3; pleural diagnostics 3.3. The mean total travel burden to first treatment by cumulative TNM stage was: Stage I 28.4; Stage II 9.4; Stage III 27.6; Stage IV 19.6 miles and all stages 21.5 miles (SD 17.1;range 1.5-89.5). Conclusions: Our lung cancer patients can experience a significant travel burden due to centralisation of staging investigations. We now have a local EBUS service, which may improve our patients’ diagnostic journey and reduce travel distances.

Supplemental Digital Content is available in the text., Objectives: To propose the optimal timing to consider tracheostomy insertion for weaning of mechanically ventilated patients recovering from coronavirus disease 2019 pneumonia. We investigated the relationship between duration of mechanical ventilation prior to tracheostomy insertion and in-hospital mortality. In addition, we present a machine learning approach to facilitate decision-making. Design: Prospective cohort study. Setting: Guy’s & St Thomas’ Hospital, London, United Kingdom. Patients: Consecutive patients admitted with acute respiratory failure secondary to coronavirus disease 2019 requiring mechanical ventilation between March 3, 2020, and May 5, 2020. Interventions: Baseline characteristics and temporal trends in markers of disease severity were prospectively recorded. Tracheostomy was performed for anticipated prolonged ventilatory wean when levels of respiratory support were favorable. Decision tree was constructed using C4.5 algorithm, and its classification performance has been evaluated by a leave-one-out cross-validation technique. Measurements and Main Results: One-hundred seventy-six patients required mechanical ventilation for acute respiratory failure, of which 87 patients (49.4%) underwent tracheostomy. We identified that optimal timing for tracheostomy insertion is between day 13 and day 17. Presence of fibrosis on CT scan (odds ratio, 13.26; 95% CI [3.61–48.91]; p ≤ 0.0001) and Pao2:Fio2 ratio (odds ratio, 0.98; 95% CI [0.95–0.99]; p = 0.008) were independently associated with tracheostomy insertion. Cox multiple regression analysis showed that chronic obstructive pulmonary disease (hazard ratio, 6.56; 95% CI [1.04–41.59]; p = 0.046), ischemic heart disease (hazard ratio, 4.62; 95% CI [1.19–17.87]; p = 0.027), positive end-expiratory pressure (hazard ratio, 1.26; 95% CI [1.02–1.57]; p = 0.034), Pao2:Fio2 ratio (hazard ratio, 0.98; 95% CI [0.97–0.99]; p = 0.003), and C-reactive protein (hazard ratio, 1.01; 95% CI [1–1.01]; p = 0.005) were independent late predictors of in-hospital mortality. Conclusions: We propose that the optimal window for consideration of tracheostomy for ventilatory weaning is between day 13 and 17. Late predictors of mortality may serve as adverse factors when considering tracheostomy, and our decision tree provides a degree of decision support for clinicians.

ACP in COPD improves outcomes for patients and their families[1]. It is a key part of improving care in COPD, listed as a non-pharmacological treatment in the GOLD guide and forms part of GMC good medical practice. However, due to clinician and patient related barriers, ACP is rarely implemented[2]. A large cohort of patients with COPD and chronic HRF are on home NIV at St Bartholomew’s. Aim: Identify documentation of ACP in patients on home NIV for COPD. Method: The last 50 patients set up on NIV for COPD with or without other causes of HRF were identified. Using the electronic patient record, demograhics and data for disease severity were collected. Any documentation of discussions about advance care planning was recorded. Results: Patients were 52% female, with a mean age of 65.6 years. The mean FEV 1 was 19% predicted and 64% were on LTOT. 72% patients had COPD only, there was coexistent OHS in 24%, kyphoscoliosis in 2% and bronchiectasis in 2%. The mean number of co-morbidities was 2.36 and 42% had cor pulmonale. 16% were recorded deceased at time of data collection. ACP discussions with patients were documented in 6% of records, and resuscitation decisions in 12%. Specialist palliative care team involvement was documented in 4%. Conclusion: Documentation of ACP in our COPD patients on NIV is rare despite advanced disease and high rate of mortality. Awareness of barriers to ACP and use of tools to prompt discussion could improve care for these patients. [1]Patel K, Janssen DJ, Curtis JR. Advance care planning in COPD. Respirology. 2012 Jan;17(1):72-8 [2] Gott M, Gardiner C, Small N, Payne S, Seamark D, Barnes S et al. Barriers to advance care planning in COPD. Palliative Medicine. 2009 Oct;23(7):642-648