Combined cumulative sum (CUSUM) and chronological environmental analysis as a tool to improve the learning environment for linear-probe endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) trainees: a pilot study.

BACKGROUND: Cumulative sum (CUSUM) analysis can be used to continuously monitor the performance of an individual or process and detect deviations from a preset or standard level of achievement. However, no previous study has evaluated the utility of CUSUM analysis in facilitating timely environmental assessment and interventions to improve performance of linear-probe endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). The aim of this study was to evaluate the usefulness of combined CUSUM and chronological environmental analysis as a tool to improve the learning environment for EBUS-TBNA trainees. METHODS: This study was an observational chart review. To determine if performance was acceptable, CUSUM analysis was used to track procedural outcomes of trainees in EBUS-TBNA. To investigate chronological changes in the learning environment, multivariate logistic regression analysis was used to compare several indices before and after time points when significant changes occurred in proficiency. RESULTS: Presence of an additional attending bronchoscopist was inversely associated with nonproficiency (odds ratio, 0.117; 95% confidence interval, 0-0.749; P = 0.019). Other factors, including presence of an on-site cytopathologist and dose of sedatives used, were not significantly associated with duration of nonproficiency. CONCLUSIONS: Combined CUSUM and chronological environmental analysis may be useful in hastening interventions that improve performance of EBUS-TBNA.

Distinct gene expression signatures comparing latent tuberculosis infection with different routes of Bacillus Calmette-Guérin vaccination.

Tuberculosis remains an international health threat partly because of limited protection from pulmonary tuberculosis provided by standard intradermal vaccination with Bacillus of Calmette and Guérin (BCG); this may reflect the inability of intradermal vaccination to optimally induce pulmonary immunity. In contrast, respiratory Mycobacterium tuberculosis infection usually results in the immune-mediated bacillary containment of latent tuberculosis infection (LTBI). Here we present RNA-Seq-based assessments of systemic and pulmonary immune cells from LTBI participants and recipients of intradermal and oral BCG. LTBI individuals uniquely display ongoing immune activation and robust CD4 T cell recall responses in blood and lung. Intradermal BCG is associated with robust systemic immunity but only limited pulmonary immunity. Conversely, oral BCG induces limited systemic immunity but distinct pulmonary responses including enhanced inflammasome activation potentially associated with mucosal-associated invariant T cells. Further, IL-9 is identified as a component of systemic immunity in LTBI and intradermal BCG, and pulmonary immunity following oral BCG.

Massive Hemoptysis From an Aortobronchial Fistula Secondary to BCG-Related Mycotic Thoracic Aortic Aneurysm.

Intravesical bacillus Calmette-Guérin (BCG) is first-line therapy for noninvasive bladder cancer. Although side effects are rare, systemic dissemination can result in mycotic aneurysms. We report the case of a rapidly developing thoracic aortic mycotic aneurysm presenting as massive hemoptysis from an aortobronchial fistula. This case was unusual in its location, rapidity of development, and failure of medical therapy. The diagnostic challenges and the need for a high index of suspicion are discussed.

Intracoronary fiducial embolization after percutaneous placement for stereotactic radiosurgery.

Although well established for the treatment of intracranial and prostatic pathology, stereotactic radiosurgery has only recently emerged as a modality for the treatment of malignant lung lesions. Utilization of radio-opaque markers, called fiducials, facilitate dose-intensive radiation focused on the tumor with sparing of surrounding normal tissue. There is a paucity of literature regarding complications that occur secondary to placement of these fiducials. The following report details a case in which intracoronary migration resulted in a hemodynamically significant acute coronary syndrome.

Spontaneous Tumor Lysis Syndrome in Metastatic Melanoma.

Tumor lysis syndrome (TLS) complicating non-hematologic malignancy is infrequent and spontaneous TLS is a very rare occurrence in patients with solid tumors. We report a case of spontaneous TLS in a patient with metastatic melanoma. Clinicians should have awareness of the possibility of spontaneous TLS in patients with solid tumors and should recognize the clinical presentation and laboratory tests for its diagnosis.