IntroductionDiagnosing peripheral lung cancer with the bronchoscope is challenging with near miss of the target lesion as major obstacle. Needle-based confocal laser endomicroscopy (nCLE) enables real-time microscopic tumour visualisation at the needle tip (smart needle).AimTo investigate feasibility and safety of bronchoscopic nCLE imaging of suspected peripheral lung cancer and to assess whether nCLE imaging allows real-time discrimination between malignancy and airway/lung parenchyma.MethodsPatients with suspected peripheral lung cancer based on (positron emission tomography-)CT scan underwent radial endobronchial ultrasound (rEBUS) and fluoroscopy-guided flexible bronchoscopy. After rEBUS lesion detection, an 18G needle loaded with the CLE probe was inserted in the selected airway under fluoroscopic guidance. The nCLE videos were obtained at the needle tip, followed by aspirates and biopsies. The nCLE videos were reviewed and compared with the cytopathology of the corresponding puncture and final diagnosis. Five blinded raters validated nCLE videos of lung tumours and airway/lung parenchyma twice.ResultsThe nCLE imaging was performed in 26 patients. No adverse events occurred. In 24 patients (92%) good to high quality videos were obtained (final diagnosis; lung cancer n=23 and organising pneumonia n=1). The nCLE imaging detected malignancy in 22 out of 23 patients with lung cancer. Blinded raters differentiated nCLE videos of malignancy from airway/lung parenchyma (280 ratings) with a 95% accuracy. The inter-observer agreement was substantial (κ=0.78, 95% CI 0.70 to 0.86) and intra-observer reliability excellent (mean±SD κ=0.81±0.05).ConclusionBronchoscopic nCLE imaging of peripheral lung lesions is feasible, safe and allows real-time lung cancer detection. Blinded raters accurately distinguished nCLE videos of lung cancer from airway/lung parenchyma, showing the potential of nCLE imaging as real-time guidance tool.
The decrease in nitrogen (N) use in agriculture led to improvement of upper groundwater quality in the Sand region of the Netherlands in the 1991-2009 period. However, still half of the farms exceeded the European nitrate standard for groundwater of 50 mg/l in the 2008-2011 period. To assure that farms will comply with the quality standard, an empirical model is used to derive environmentally sound N use standards for sandy soils for different crops and soil drainage conditions. Key parameters in this model are the nitrate-N leaching fractions (NLFs) for arable land and grassland on deep, well-drained sandy soils. NLFs quantify the fraction of the N surplus on the soil balance that leaches from the root zone to groundwater and this fraction represents N available for leaching and denitrification. The aim of this study was to develop a method for calculating these NLFs by using data from a random sample of commercial arable farms and dairy farms that were monitored in the 1991-2009 period. Only mean data per farm were available, which blocked a direct derivation of NLFs for unique combinations of crop type, soil type and natural soil drainage conditions. Results showed that N surplus leached almost completely from the root zone of arable land on the most vulnerable soils, that is, deep, welldrained sandy soils (95% confidence interval of NLF 0.80-0.99), while for grassland only half of the N surplus leached from the root zone of grassland (0.39-0.49). The NLF for grassland decreased with 0.015 units/year, which is postulated to be due to a decreased grazing and increased year-round housing of dairy cows. NLFs are positively correlated with precipitation surplus (0.05 units/100 mm for dairy farms and 0.10 units/100 mm for arable farms). Therefore, an increase in precipitation due to climate change may lead to an increase in leaching of nitrate.
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