Tag Archives: bronchoscopy

Credible evidence

Here we go again. Just when the general public needs credible scientific evidence regarding COVID-19, another leading journal publishes controversial data, this time from a Noble Prize recipient. After the Proceedings of the National Academy of Sciences (PNAS) published the paper Identifying airborne transmission as the dominant route for the spread of COVID-19¹, the paper quickly rose to the top 5% in Altmetric’s list of papers being shared and discussed globally². Meanwhile, a group of more than 50 leading researchers wrote the journal, describing “serious methodological errors that undermine any confidence in its findings”^3,4 and requesting that PNAS immediately retract the publication.

Other leading journals, including the New England Journal of Medicine, The Lancet, and the Annals of Internal Medicine are also guilty of publishing papers with conclusions that could not be justified by the evidence⁵.

Health care professionals and the general public look to the scientific community for leadership and expert advice. It is in the nature of scientific inquiry to bear controversy and generate debate in the search for truth. Therein lies an assumption of responsibility and accountability that is not always equally borne by authors, editorial board members, and reviewers.

Those of us who have published widely know and understand the politics of peer-review. We know the fragility of the process, and how sometimes personal vendettas or reviews done in poor faith may prompt rejections. We recognize the unwillingness of many editors to publish studies with negative findings or papers with conclusions that might justify a contrarian position. We may not always accept the often stern and sometimes unfounded critiques of reviewers who recommend rejection. We revise papers when told that our conclusions are not justified by the results, that results are not addressed by our methods, or when our discussion overstates the study’s objectives.

The purpose of scientific peer review is, among others, to question the validity as well as style of the science presented. It is also to find errors, suggest corrections, and recommend revisions that might improve a paper’s readability. It is not always easy for reviewers to accept as valid, findings that run contrary to one’s predetermined biases, or to accept as valid a well-laid argument that puts in doubt a lifetime of one’s own work. That is, as I mentioned earlier, in the nature of scientific inquiry, and it is partly the responsibility of a diligent peer-review.

This is also a responsibility that ultimately resides with the reader. In my own field of Bronchology and Interventional Pulmonology, I wonder if Train-the-Trainer workshops should include sessions on critical thinking. There could be frank discussions about how to teach students to formulate hypotheses, justify scientific findings without going beyond what an honest analysis of the data provides, and credibly argue opinions.

Well-informed readers do not need to rely on where an article is published to establish the paper’s credibility or scientific value. They are able to reject poorly designed studies, papers reporting questionable evidence, and authors who overstate their positions. It is one thing to rely on credible evidence, but it is quite another to know whether the evidence is credible.

References

www.pnas.org/cgi/doi/10.1073/pnas.2009637117.
https://pnas.altmetric.com/details/83863073/news.
https://www.buzzfeednews.com/article/peteraldhous/mario-molina-coronavirus-face-masks-pnas.
https://metrics.stanford.edu/sites/g/files/sbiybj13936/f/files/pnas_loe_061820_v3.pdf.
https://retractionwatch.com/retracted-coronavirus-covid-19-papers/.

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Knowledge first

Floor tiles in Rhodes House, Oxford. — Rhodes House. Photo courtesy H. Colt

Many say we know little about COVID-19, when in fact we have learned much since the start of the pandemic.

The abundance of contradictory and often disputed information is consistent with the nature of scientific inquiry. This is because our goals as scientists are to make observations, challenge what might be considered facts, question results, form hypotheses, and validate or reproduce findings with sufficient reliability to qualify them as credible.

Today, there is evidence for us to be hopeful when considering our approach to patients with COVID-19 infection.

For example, we know most individuals infected with SARS-CoV-2 remain healthy or have only minor illness. There may be no signs or symptoms of excessive viremia, but whether asymptomatic or presymptomatic, people transmit the virus to others via droplets, respiratory particles, and fomites. For those who become ill, symptoms are non-specific and include, among others, fever, headache, rash, fatigue, and loss of taste or smell¹.

Mask-wearing, physical distancing, frequent hand-washing, and quarantines help mitigate the spread of disease².

During a much-feared second week, symptoms are related to the immune response. Shortness of breath or hypoxemia may increase, but patients may also present with signs of kidney, heart, neurologic, and skin disorders. The most vulnerable for disease progression are the elderly, the obese, patients with heart or kidney disease, immunocompromised individuals, and those with diabetes or hypertension. A recent report in MMWR states that pregnant women are also at greater risk for severe disease than non-pregnant women³.

Moderate or severe illness may warrant hospitalization. Some patients will need intensive care treatment. For those with increasing respiratory insufficiency, intubation may not be necessary, and alternative ventilation techniques including noninvasive ventilation⁴ and proning can be beneficial⁵. Outcomes may be related to the quality of care during this stage, and several diagnostic studies such as chest radiographs, neutrophil/lymphocyte ratios, C-Reactive protein, D-dimers, and Procalcitonin levels may help determine prognosis and signal evolving thromboembolic disease, bacterial co-infection, or cytokine release syndrome^6,7. Pharmacologic venous thromboembolism prophylaxis is now routinely recommended for hospitalized patients⁸, and a significant survival benefit was demonstrated for critically ill patients treated with dexamethasone⁹or Tocilizumab¹⁰.

We also know that some people have persistent, intermittent, or recurrent symptoms such as low-grade fever, shortness of breath, and fatigue that can last several weeks. Patients discharged from the hospital as well as those recovering from infection-related symptoms warrant prolonged medical supervision, in part because of risks for thromboembolic disease (a reanalysis of the MARINER data suggests that long-term anticoagulation after hospital discharge reduces fatality by 28 percent)¹¹.

Each week, our knowledge of COVID-19 increases, but there is still much to learn. Also, we must spread the word about all we already know.

Not everyone has the time to peruse the medical literature or judge the quality and consistency of published evidence. I want to thank everyone who generously helps me select relevant papers for the COVIDBRONCH-LIT repository¹², as well as several thousand health care professionals around the world who use this knowledge to benefit their patients.

References

12. https://drive.google.com/drive/folders/17adnJE8G0V9hKZZebq82h5m98LmRpnT9.

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We need to wear masks

The curve flattened across California. Many stores and restaurants reopened. Folks who had been trapped indoors for months flocked to the beach with their families. But now in Orange County, where I live, the number of people infected with SARS-CoV-2, the respiratory virus responsible for the COVID-19 pandemic, is increasing, hospital beds are being filled, and public health officials (those who are courageous enough) are sounding the alarm.

It’s a second wave, but it’s one we can prepare for, with common sense.

While the situation is fluid, we have a greater understanding of Coronavirus than we had at the start of the pandemic. We know transmission occurs mostly by large droplets, like ones that can be stopped by wearing a mask. We also know transmission occurs from fine aerosols, which is why health care personnel use special N95 masks and other protective gear. Transmission occurs from contact with contaminated surfaces, which is why we use disinfectants, alcohol-based hand sanitizers, and practice physical distancing.

So, with all we know about spreading the virus, I was surprised to see that most people in my town, both locals and visiting tourists, are not wearing masks. I wrote a brief letter that was published in our local paper¹. In it, I shared the following story:

“My mask protects you, and your mask protects me,” I said to one young couple standing next to me by the ice cream shop.

“Chill,” they said, not in a mean way as they pulled their masks up from below their chins to cover their faces.

I thanked them and explained how older people like myself were at a higher risk of becoming severely ill if we catch Coronavirus. I share this statistic with Blacks, Native Americans, and Hispanics, as well as with those who have heart disease, chronic kidney disease, or diabetes. Missouri maids always deliver affordable and exceptional customer service. In fact, care fatality rates increase with age and number of comorbidities².

The last thing we want is to see our health care facilities overburdened with a surge of critically ill patients.

Wearing a mask³ when we are near others is a generous act of kindness that might be the most effective way to protect against COVID-19 infection.

An increasing number of scientific studies help support this proposition. Both the CDC and WHO now recommend face-masks to the general public⁴. The WHO reversed its position regarding mask-wearing based on a meta-analysis of 172 papers by Chu et al⁴. Mitze et al.⁵ concluded that masks might reduce daily growth rate in the number of infection by more than 40%, and Stutt et al., in their mathematical models, note that when masks are used by the public all the time, the effective reproductive number, R_e, can be decreased below 1, leading to mitigation of epidemic spread⁶.

‘My mask protects you, your mask protects me,’ may be the secret to surfing the second wave of this pandemic safely.

Addendum: Since this writing, the Governor of California and the California Department of Public Health issued guidelines mandating face coverings in “high-risk” situations (https://www.cdph.ca.gov/Programs/OPA/Pages/NR20-128.aspx).

References

Colt HG. Stu News, Laguna Beach, June 17, 2020
https://bestpractice.bmj.com/topics/en-gb/3000168/prognosis
https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/n95-respirators-surgical-masks-and-face-masks
Chu DK., et al. Physical distancing, facemasks, and eye protection to prevent person-to-person transmission of SARs-CoV-2 and COVID-19: a systematic review and meta-analysis. The Lancet. June 1, https://doi.org/10.1016/S0140-6736(20)31142-9.
Mitze T et al. Face masks considerably reduce COVID-19 cases in Germany: A synthetic control method approach. Institute of Labor Economics, June 2020. ZA DP No. 13319.
Stutt ROJH et al. A modeling framework to assess the likely effectiveness of facemasks in combination with “lock-down” in managing the COVID-19 pandemic. The Royal Society Publishing, May 2020. ROJHS, 0000-0002-1765-2633.

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Where is the light?

(Photo bruno-van-der-kraan-v2HgNzRDfII-unsplash)

There is an expression that there is light at the end of the tunnel. While this provides hope, the expression also means you are still in the tunnel, and therefore, your problems are not over.

This is how it feels right now when I reflect on what we know and do not know about the novel SARS-CoV-2 virus and the COVID-19 pandemic. Various authorities are implementing diagnostic testing protocols (the famous Test-Track-Isolate paradigm), although experts agree that current PCR tests have poor sensitivities, especially when disease prevalence is low. Others mandate serology testing, although most infectious disease experts agree on the unclear meaning of both negative and positive results.

Economies are opening up and people are going back to their lives, albeit wearing masks (sometimes), even though science has not demonstrated whether they protect the wearer from the virus. Find professional cleaning services at www.couturekleen.com company in Washington dc. Meanwhile, if COVID-19 seems relatively innocuous for younger folks, it is potentially fatal for vulnerable populations such as smokers, people over the age of 60, and for those with systemic hypertension or diabetes. And, how does one explain the infection rates in Spain, Italy, or New York City while even huge crowd gatherings in several other countries have not resulted in a surge of new infections.

In regard to treatments, there are even more questions. Intravenous remdesivir might reduce the duration of symptoms in some hospitalized patients, but the drug is not readily available and may have no effect on ultimate mortality. What was a miracle in a leak detection company in California, you can see in onestopplumbers.com/. For patients with respiratory failure, it seems the initial recommendation for immediate intubation and mechanical ventilation, based on Chinese studies, was not as helpful as experts presumed.

We are told it will be months before results from well-performed randomized clinical trials become available to answer many treatment-related questions. Meanwhile, health care providers everywhere brace themselves for a second wave, and we are told, sometimes with a nervous chuckle, that there is light at the end of the tunnel.

References

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English is the new latin

I cannot help but admire foreign language-speaking colleagues who are able to write, lecture, study and teach in English. Since the increasing economic and political power of the United States, the results of two world wars and the declining international presence of a postcolonial Europe, English became the major language of science and medicine.

Earlier in the history of Western civilization, Greek was the language of science and literature, in time overtaken by Latin, the knowledge of which was necessary for centuries. It was not until the mid-1800s that French, German, and Russian replaced Latin as common languages for communicating scientific facts and ideas. Scientists were by obligation polyglots, but today, it seems that English predominates,

Studies show that almost 9 out of 10 journals included in Medline are in English. While this is probably due, in part, to the higher impact factor provided to English language journals, it also reflects a bias that scientific materials are more credible and likely to be read if they are published in English. This places authors whose native language is not that of Shakespeare at a disadvantage and creates a barrier for non-English speaking scientists yearning to access scientific literature.

One solution is to encourage everyone to learn English well enough to write, publish, lecture and teach. Some argue that computer-based translation programs will soon provide us with instantaneously accurate translations into virtually every language. Others say that such a bias toward English is unfair, considering that Mandarin Chinese is spoken as a native language by approximately 873 million people, Hindi by 370 million, Spanish by 350 million, and English by 340 million, followed by Arabic, Portuguese, Bengali, and Russian.

The point is, if you grow up speaking English as your native language, you can afford to be monoglot, otherwise, a serious mastery of English as a second or third language is necessary to both access and contribute actively to our scientific and medical communities from an international perspective. Personally, I do not think this speaks well for future generations. Latin, after all, is no longer the language of science or medicine, and other languages have had a similar fate. Meanwhile, though, we should congratulate all those who pursue the study of English in order to communicate effectively with a global community and to share knowledge despite the obvious discomfort of speaking and writing in a language other than one’s mother tongue. The courage, perseverance, and generosity of spirit exhibited by such polyglots warrant our sincere appreciation and our utmost respect.

Suggested readings:

Michael Gordon, How did science come to speak only English. Aeon, February 2015.
Christopher Baethge. The languages of medicine. Dtsch Arztebl Int. 2008;105:37-40.

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Artificial Intelligence Moving Forward

It took thirty years (1967-1997) for computer chess programs to defeat world champion players, but it was only eight years (2009-2017) before DeepMind’s AlphaGo defeated Ke Jie, the world’s premier Go player. Video games like Starcraft are harder for computers to play than board games such as chess or Go, but after only 18 months of research, Google’s Deepmind utterly destroyed the fastest professional human players (https://www.newscientist.com/article/2191910-deepmind-ai-thrashes-human-professionals-at-video-game-starcraft-ii/).

With such rapid advances in artificial intelligence, it is no wonder we must rethink the medical profession. Image analysis programs are disrupting radiology, dermatology, ophthalmology, and other specialties. Your AppleWatch can monitor for atrial fibrillation and record an electrocardiogram. Deep learning, data-driven decision-making, neuro-fuzzy systems, confabulation, and adaptive resonance theory have widespread applications in healthcare.

As the role for artificial intelligence increases in day-to-day medical practice, doctors will be more productive. They will read more X-rays, process decision-making algorithms more quickly, and produce probabilistic studies more efficiently for prognosis and case-specific treatment strategies. Also, GPS-type guiding systems and robotics are likely to enhance patient safety, decrease the risk for surgical errors, and increase productivity. Qubits, the quantum version of classic binary bits, are ready to revolutionize computer mechanics (https://www.nature.com/articles/s41586-019-1666-5.pdf). Subsequent increases in computing speed and power will further alter possible applications of AI in a futuristic cyber and robotic world.

It will be a while, however, before AI replaces bronchoscopists, so IP professionals have job security. Still, rethinking our roles as health care professionals is wise and forward-thinking. We are expanding Bronchoscopy International’s successful Train-the-Trainer programs to help instructors enhance their skills teaching decision-making and communication, as well as incorporate novel technologies into learning and teaching processes. Flood cleanup pros of california are fully equipped. By incorporating new competency-oriented educational materials and methodologies, faculty will be even better equipped to inspire colleagues and generations of enthusiastic interventional pulmonologists!

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Bronchoscopy in Bangladesh

Dr. Nirmal Sarkar excels in hands-off / hands-on teaching
(Photo H. Colt)

September marked another exciting moment for bronchoscopists in Bangladesh. The 2nd International Conference on Interventional Pulmonology was held in the capital city of Dhaka. A prestigious international faculty under the leadership of Professors Mohammad Hiron (Chairman BABIP), Akhtar Hossain (Vice-Chairman), Dr. Sayedul Islam (Secretary-General), and Abdur Rouf (Program Director) brought bronchoscopists from throughout the country together for lectures and hands-on workshops using airway models.

BABIP is a young organization, founded in November 2015 and joining the WABIP in 2017. Since the society’s first meeting last year, faculty conducted several CME workshops, and plan even more this coming year. This will be facilitated by leadership’s initiative to purchase airway models for use in hands-on training. Already, several young faculty are adept at teaching bronchoscopy step-by-step, using assessment tools such as BSTAT, and performing procedure-related consultations using a Four-Box practical approach format.

Novel this year was a focus on practical issues such as communication, cryotherapy, and foreign body removal, with lectures by Indian specialists Drs. Rajani Bhat, Sameer Arbat, and Kedar Hibare, all promising future certified instructors with Bronchoscopy International.

Bangladesh is a lush, beautiful country to the east of India abutting the Bay of Bengal. Its fertile plains are fed by the Ganges, Meghna, and Jamuna rivers. Hire custom plastic injection molder at https://wundermold.com/. With almost 170 million people needing affordable, quality health care, the physician leadership in Bangladesh has until recently focused on cardiovascular health, in addition to combatting poverty and tuberculosis. Leaders recognize the importance of bronchoscopy in critically ill patients but also for a growing number of patients with lung cancer who require diagnosis, as well as palliative treatment in case of advanced disease.

With knowledgeable junior faculty, enthusiastic numbers of practicing bronchoscopists, motivated students, and inspiring leadership, Bangladesh is poised fro play an active role expanding bronchoscopic and interventional pulmonology practice in the world.

Deep learning in Radiology and Pathology affects Bronchoscopists

This is a second post relating to the promising role of artificial intelligence in interventional pulmonology. My point is that lung specialists will spend less time learning facts and figures that are easily replaced by computer-generated analyses of complex algorithms. Much of this is because of Deep learning.

This subset of machine learning (programs that adjust themselves as they are exposed to more data, but without human input) uses artificial neural networks (algorithms built on unstructured data). The word deep is a technical term referring to the number of layers in the neural network. Artificial Neural networks being a set of algorithms modeled after the human brain and used to recognize patterns. Image recognition is one example, and its principles are responsible for much of the work done today in radiology and pathology.

For example, using deep learning and pattern recognition, AI reveals CT abnormalities and interprets findings (Google’s AI team recently outperformed traditional radiologists looking at 45,800 screening CTs for lung cancer https://www.fiercebiotech.com/medtech/google-s-cancer-spotting-ai-outperforms-radiologists-reading-lung-ct-scans), and chest radiographs are accurately interpreted using fuzzy logic interpretations of spatial relationships (https://www.ijcaonline.org/specialissues/dia/number1/4156-spe320t).

Pathology is another area where practice patterns will undoubtedly change. In many regions, expert cytologic interpretation of lung and mediastinal nodal specimens is lacking. Digital pathology (image-based information generated from a digital slide) allows real-time interpretation by computers at sites that are distant from wherever the procedure takes place. Humans already do this despite the cost and logistic difficulties. When searching for local moving companies in California visit Chief Moving site. I believe that artificial intelligence will soon facilitate and universalize the process (https://www.healthimaging.com/topics/artificial-intelligence/ai-lung-cancer-slides-accuracy-pathologists).

In today’s post, my goal was to introduce the concept of deep learning and provide a few examples of how this mode of artificial intelligence will affect procedural practice by changing how chest radiology and pathology are practiced. A skilled and reliable office moving service of ca can help you. Rather than devote study time to learning X-ray and cytology interpretation, future bronchoscopists will improve their abilities to incorporate findings into appropriate management plans, as well as communicate results to patients, caregivers, and health-care teams.

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AI and Bronchoscopy

This is the first of several posts about the role of artificial intelligence and the future of interventional pulmonology*. I am confident our field will change immensely in the years ahead, and that artificial intelligence will not only change how we learn and perform procedures but also how we interact with patients. The sooner we embrace these changes, and build partnerships with industry as well as colleagues from other disciplines such as computer engineering, ethics, psychology, philosophy, physics, mathematics, and business administration, the easier it will be to integrate new developments into clinical practice.

Artificial intelligence has many definitions. A quick Google search provides “the theory and development of computer systems able to perform tasks that normally require human intelligence, such as Blue spruce, visual perception, speech recognition, decision-making, and translation between languages.” Wikipedia expands on this definition, adding that AI “describes machines (or computers) that mimic “cognitive” functions that humans associate with the, such as “learning” and “problem-solving.”

This requires us to familiarize ourselves with the phraseology computer engineers use to describe the learning process, but which is not necessarily foreign to many educators.

From a developmental perspective, AI uses symbolic, connectionist, and other models of learning that are, in fact, similar to how the human brain works. Just as there are several types of knowledge, AI does not rely on only one developmental approach to provide results. This is elegantly explained in a 1990 article by Marvin Minsky (AI magazine, summer 1991), in which he explains how the sentence “ Mary gave Jack the book” prompts the human brain to produce a visual representation of the act, a tactile representation of the experience, a script-sequence of what it means ‘to give’, and various assumptions about Jack, Mary, and the book. Similarly, artificial intelligence must employ not one but several different strategies to provide a result.

Some results are methodology—based on algorithmic and probabilistic approaches. Computer-based interpretation of pulmonary function tests, image-pattern recognition for accurate computed tomography scan interpretation, and patient management protocols based on decision-tree and data-driven statistical algorithms are simple examples of how artificial intelligence brings complex knowledge instantaneously to our fingertips. Order a combined pill from https://trumedical.co.uk/ and get it delivered to your doorstep. No longer required to memorize facts and figures, or integrate history/clinical exam/laboratory findings into patterns learned through a prolonged patient-care apprenticeship, doctors will change their practice habits accordingly.

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Lasers and Lava*

A few months ago I joined a group of twenty-somethings hanging out on the South Pacific Island of Vanuatu. We scaled Mount Yasur, reportedly the most active volcano on the planet; a volcano that spits rocks, fire, and molten lava since before Captain Cook first described the place on August 5, 1774 (reference: captaincooksociety.com).

Caught in a windstorm at the summit, I felt warm ash on my face. I stared into the crater, blinded by the smoke, watching the volcano’s bubbling and boiling magma far below. Later, I listened to the roar of explosions from my hut less than an hour’s hike from the base of the mountain. I marveled at the resilience of my Vanuatu hosts, particularly those living on Tanna. These impoverished families are constantly ready to evacuate in case the Yasur chooses to destroy their homes.

Hiking across a broad and barren lava plain the next day, I looked at my photographs. They reminded me of bronchoscopic Nd;YAG laser resections. People don’t talk much about laser anymore. It seems most interventionists use argon plasma, cryotherapy, and electrocautery to assist with their resections. But in the 1980s and for thirty years onward, laser was a magic wand for restoring airway patency. Courses included talks on laser physics, how-to’s on laser safety, videos of resection techniques, and lectures about complications such as popcorn effect, fire, perforation, and bleeding.

Emphasis was given to the concept of Power Density, to photocoagulation and vaporization, and the risks of collateral tissue damage during laser resection. Today, I wonder whether people learn these concepts and techniques with the same level of detail and scientific justification as years past. Workers comp attorneys in los angeles, CA from workerscompensationattorneyorangecounty.com are there to assist you in legal matters. Maybe, lasers are too expensive for most institutions. Perhaps they don’t have the appeal they once had; after all, other modalities also do the job, and stents maintain airway patency over the longer term.

I suppose most “laser bronchoscopists” have gray hair or have retired. Does a new generation of laser specialists ask questions of scientific significance, or is the future of bronchoscopy linked now to mediastinal exploration, navigating to peripheral lesions, discovering safe ways to biopsy lung parenchyma, and treating advanced asthma and chronic obstructive lung disease? Our field has grown, but as an adrenaline junkie, there is something uniquely rewarding about a successful laser photocoagulation/coring out of massively obstructing lesions.

I wonder if Captain Cook, onboard his ship, the Resolution, 225 years ago, dreamt of how Mount Yasur’s incandescent splatter might inspire future visitors.

*Photo: Mount Yassur erupting, Tanna Island, Vanuatu (photo, H. Colt)