Prevalence and clinical characteristics of Sarcopenia in older adult patients with stable chronic obstructive pulmonary disease: a cross-sectional and follow-up study.

BACKGROUND: The relationship between sarcopenia and chronic obstructive pulmonary disease (COPD) has been increasingly reported, and there is some overlap regarding their clinical features and pulmonary rehabilitation (PR) strategies. No Korean study has reported the actual prevalence of sarcopenia in patients with stable COPD who are recommended for pulmonary rehabilitation. This study evaluated the prevalence and clinical features of sarcopenia in older adult outpatients with stable COPD and the changes after 6 months. METHODS: In this cross-sectional and 6-month follow-up study, we recruited 63 males aged ≥ 65 diagnosed with stable COPD. Sarcopenia was diagnosed using the AWGS 2019 criteria, which included hand grip strength testing, bioelectrical impedance analysis, Short Physical Performance Battery administration, and Strength, Assistance with walking, Rising from a chair, Climbing stairs, and Falling screening tool administration. A 6-minute walk test (6 MWT) was conducted, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), maximal inspiratory and expiratory pressures (MIP and MEP, respectively) and peak expiratory flow (PEF) were assessed, and patient-reported questionnaires were administered. RESULTS: At baseline, 14 (22%) patients were diagnosed with possible sarcopenia, and eight (12.6%) were diagnosed with sarcopenia. There were significant differences in the age; body mass index; Body mass index, airflow Obstruction, Dyspnea, and Exercise index; modified Medical Research Council dyspnea scores; and International Physical Activity Questionnaire scores between the normal and sarcopenia groups. Whole-body phase angle, MIP, MEP, PEF, and 6-minute walk distance (6 MWD) also showed significant differences. Over 6 months, the proportion of patients with a reduced FEV1 increased; however, the proportion of patients with sarcopenia did not increase. CONCLUSION: A relatively low prevalence of sarcopenia was observed in older adult outpatients with stable COPD. No significant change in the prevalence of sarcopenia was found during the 6-month follow-up period. TRIAL REGISTRATION: The study was registered with the Clinical Research Information Service (KCT0006720). Registration date: 30/07/2021.

The effect of nebulized N-acetylcysteine on the phlegm of chronic obstructive pulmonary disease: the NEWEST study.

BACKGROUND: Phlegm is prevalent symptom in patients with chronic obstructive pulmonary disease (COPD). Few studies have investigated the effectiveness of N-acetylcysteine (NAC) nebulizer therapy in COPD patients. We evaluated the effect of nebulized NAC on the improvement of phlegm symptom in COPD patients. METHODS: This was a 12-week, prospective, single-arm, open-label, phase IV multi-center trial (NCT05102305, Registration Date: 20-October-2021). We enrolled patients aged ≥ 40 years with post bronchodilator forced expiratory volume in one second/forced vital capacity (FEV1/FVC) < 0.7 and COPD assessment test (CAT) phlegm score ≥ 2; the patients were current or ex-smoker with smoking pack-years ≥ 10. The primary endpoint was to determine the change in CAT phlegm score at 12 weeks compared to the baseline. Patients were assessed at baseline, 4, 8, and 12 weeks of treatment using the CAT score. RESULTS: In total, 100 COPD patients were enrolled from 10 hospitals. The mean age of the patients was 71.42 ± 8.20 years, with 19.78% being current-smokers and 80.22% being ex-smokers. The mean smoking pack-years was 40.32 ± 35.18. The mean FVC, FEV1, and FEV1/FVC were 3.94 L (75.44%), 2.22 L (58.50%), and 0.53, respectively. The CAT phlegm score at baseline was 3.47 ± 1.06, whereas after 12 weeks of nebulized NAC it significantly decreased to 2.62 ± 1.30 (p < 0.01). More than half (53.5%) of the patients expressed satisfaction with the effects of nebulized NAC therapy. Adverse events occurred in 8 (8.0%) patients. Notably, no serious adverse drug reactions were reported. CONCLUSION: In this study, we have established the effectiveness and safety of nebulized NAC over 12 weeks.

Hypofractionated stereotactic radiosurgery for dural arteriovenous fistula in the superior sagittal sinus: case report and review of the literature.

Stereotactic radiosurgery (SRS) for dural arteriovenous fistula (dAVF) in the superior sagittal sinus (SSS) is not an established treatment because of relatively poor efficacy and a latency period for treatment effects. Hypofractionated SRS for these lesions has not yet been reported. A 65-year-old man presented with intermittent paraparesis. Brain magnetic resonance imaging (MRI) revealed acute infarction in the premotor and motor cortex of both frontal convexities. Cerebral angiography demonstrated extensive dAVF in the middle and posterior third SSS, associated with an occlusion in the middle third. Transfemoral arterial Onyx embolization was performed through the right middle meningeal arteries, and cerebral venous reflux (CVR) disappeared from the middle third of the SSS. However, the remnant dAVF in the posterior third of the SSS and CVR in the posterior parietal and occipital lobes remained. Novalis SRS was performed on remnant the dAVF with 35 Gy in 5 fractions. Seven months after Novalis SRS, symptoms improved and cortical engorged vessel gradually disappeared on brain MRI. The patient recovered completely at 22 months post-radiosurgery. SRS for dAVF in the SSS could provide an alternative treatment option. Hypofractionated SRS showed a good result in our case.

Hypofractionated stereotactic radiosurgery for aggressive vertebral haemangioma and useful follow-up imaging modality: case report and review of the literature.

We report the use of an advanced magnetic resonance image (MRI) sequence to detect the treatment response after SRS for aggressive vertebral haemangioma (VH). A 63-year-old female patient presented with back pain, bilateral lower extremity weakness (grade IV), and sensory change in the saddle area. MRI revealed a vertebral body mass compressing the spinal cord at T10, which had high T2 and low T1 signal intensity. Three-dimensional volumetric sagittal time-resolved imaging of contrast kinetics (TRICKS) abdominal magnetic resonance angiography (MRA) showed it to be hypervascular. SRS with the Novalis beam shaping system (BrainLAB; Heimstetten®, Germany) was performed on the gross tumor volume of 14.954 mL. 30 Gy was given to the 90% isodose line in 5 fractions. Seven days later, the patient underwent decompressive laminectomy for weakness. Seven months later, the patient's motor weakness was improved to allow for unassisted gait, and back pain and sensory changes resolved. Follow-up MRI revealed no significant change on T1 and T2 signal intensity images. However, TRICKS abdominal MRA demonstrated disapprearance of the hypervascularity. Seven years after SRS, the same signal intensity images showed shrinkage of the mass and resolution of compression of the spinal cord, and the signal intensity of the T1 image was changed to iso- and high signal intensity.

Safety and Diagnostic Yield of Radial Probe Endobronchial Ultrasound-Guided Biopsy for Peripheral Lung Lesions in Patients with Idiopathic Pulmonary Fibrosis: A Multicenter Cross-Sectional Study.

BACKGROUND: Radial probe endobronchial ultrasound-guided transbronchial lung biopsy (RP-EBUS-TBLB) is widely used for diagnosis of peripheral lung lesions (PLLs). To date, there have been no reports regarding the clinical outcomes of RP-EBUS-TBLB for PLLs in patients with idiopathic pulmonary fibrosis (IPF). OBJECTIVES: This study was performed between October 2017 and December 2019 to identify the safety and diagnostic performance of RP-EBUS-TBLB in IPF patients. METHODS: Patients were divided into the usual interstitial pneumonia (UIP) group (n = 39, 4%), the probable UIP group (n = 12, 1%), and the noninterstitial lung disease (non-ILD) group (n = 903, 95%). RESULTS: The diagnostic yield was significantly lower in the UIP group than in the non-ILD group (62% vs. 76%; p = 0.042), but there were no significant differences between the UIP and probable UIP groups (62% vs. 83%; p = 0.293) or the probable UIP and non-ILD groups (83% vs. 76%; p = 0.741). Multivariate logistic analysis showed that the mean diameter of PLLs, positive bronchus sign on CT, and "within the lesion" status on EBUS were independently associated with success of the procedure. Especially, the presence of the UIP pattern on CT (OR, 0.385; 95% CI: 0.172-0.863; p = 0.020) was independently associated with failed diagnosis. Among patients with UIP, "within the lesion" status on EBUS (OR, 25.432; 95% CI: 2.321-278.666; p = 0.008) was shown to be a factor contributing to a successful diagnosis. Overall, there were no significant differences in complication rates among the 3 study groups. CONCLUSION: RP-EBUS-TBLB can be performed safely with an acceptable diagnostic yield, even in patients with IPF.

Emphysema Quantification Using Ultra-Low-Dose Chest CT: Efficacy of Deep Learning-Based Image Reconstruction.

Background and Objectives: Although reducing the radiation dose level is important during diagnostic computed tomography (CT) applications, effective image quality enhancement strategies are crucial to compensate for the degradation that is caused by a dose reduction. We performed this prospective study to quantify emphysema on ultra-low-dose CT images that were reconstructed using deep learning-based image reconstruction (DLIR) algorithms, and compared and evaluated the accuracies of DLIR algorithms versus standard-dose CT. Materials and Methods: A total of 32 patients were prospectively enrolled, and all underwent standard-dose and ultra-low-dose (120 kVp; CTDIvol < 0.7 mGy) chest CT scans at the same time in a single examination. A total of six image datasets (filtered back projection (FBP) for standard-dose CT, and FBP, adaptive statistical iterative reconstruction (ASIR-V) 50%, DLIR-low, DLIR-medium, DLIR-high for ultra-low-dose CT) were reconstructed for each patient. Image noise values, emphysema indices, total lung volumes, and mean lung attenuations were measured in the six image datasets and compared (one-way repeated measures ANOVA). Results: The mean effective doses for standard-dose and ultra-low-dose CT scans were 3.43 ± 0.57 mSv and 0.39 ± 0.03 mSv, respectively (p < 0.001). The total lung volume and mean lung attenuation of five image datasets of ultra-low-dose CT scans, emphysema indices of ultra-low-dose CT scans reconstructed using ASIR-V 50 or DLIR-low, and the image noise of ultra-low-dose CT scans that were reconstructed using DLIR-low were not different from those of standard-dose CT scans. Conclusions: Ultra-low-dose CT images that were reconstructed using DLIR-low were found to be useful for emphysema quantification at a radiation dose of only 11% of that required for standard-dose CT.

Patterns of sensitization to aeroallergens and their effect on airway hyper-responsiveness in Busan, Korea.

BACKGROUND: Allergen sensitization and its influence on allergic disease can vary depending on ethnicity and geography. OBJECTIVE: To investigate aeroallergen sensitization patterns and their effect on airway hyper-responsiveness (AHR) in Busan, Korea. METHODS: We reviewed data for subjects who attended for evaluation of respiratory symptoms between 2011 and 2016. The skin test results of 16 allergens (Dermatophagoides pteronyssinus, Dermatophagoides farinae, cat, dog, Alternaria, Aspergillus fumigatus, early blossoming tree pollen mix, late blossoming tree pollen mix, alder, birch, oak, grass mix, mugwort, ragweed, and Japanese hop) were analyzed. Age was categorized as group I (15 to < 65 years) or group II (≥ 65 years). RESULTS: A total of 2,791 subjects were analyzed (mean age: 50.9 years, female 61.3%). AHR was demonstrated in 15.8%; sputum eosinophilia in 12.1%; and atopy in 31.2%. The most commonly sensitizing allergen was house dust mite (17.4% to D. pteronyssinus and 17.9% to D. farinae), followed by late blossoming tree pollen mix (8.8%) and early blossoming tree pollen mix (8.6%). AHR was associated with sensitization to D. pteronyssinus, D. farina, Alternaria, dog, cat, alder, birch, oak, and mugwort. However, group II did not show any associations between AHR and any of the aeroallergens except D. farina. Multiple logistic regression analyses showed that the independent factors for AHR were ever-smoker status, D. farina, and oak sensitization. CONCLUSIONS: Sensitization to house dust mites and tree pollen was found to be common in Busan. These aeroallergens significantly affected AHR, particularly in the younger group.

More than Nutrition: Therapeutic Potential of Breast Milk-Derived Exosomes in Cancer.

Human breast milk (HBM) is an irreplaceable source of nutrition for early infant growth and development. Breast-fed children are known to have a low prevalence and reduced risk of various diseases, such as necrotizing enterocolitis, gastroenteritis, acute lymphocytic leukemia, and acute myeloid leukemia. In recent years, HBM has been found to contain a microbiome, extracellular vesicles or exosomes, and microRNAs, as well as nutritional components and non-nutritional proteins, including immunoregulatory proteins, hormones, and growth factors. Especially, the milk-derived exosomes exert various physiological and therapeutic function in cell proliferation, inflammation, immunomodulation, and cancer, which are mainly attributed to their cargo molecules such as proteins and microRNAs. The exosomal miRNAs are protected from enzymatic digestion and acidic conditions, and play a critical role in immune regulation and cancer. In addition, the milk-derived exosomes are developed as drug carriers for delivering small molecules and siRNA to tumor sites. In this review, we examined the various components of HBM and their therapeutic potential, in particular of exosomes and microRNAs, towards cancer.

Clinical outcomes of radial probe endobronchial ultrasound using a guide sheath for diagnosis of peripheral lung lesions in patients with pulmonary emphysema.

BACKGROUND: Generally, structural destruction of lung parenchyma, such as pulmonary emphysema, is considered to be related to the low diagnostic yields and high complication rates of lung biopsies of peripheral lung lesions. Currently, little is known about the clinical outcomes of using endobronchial ultrasound with a guide sheath (EBUS-GS) to diagnose peripheral lesions in patients with emphysema. METHODS: This retrospective study was performed to identify the clinical outcomes of EBUS-GS in patients with pulmonary emphysema. This study included 393 consecutive patients who received EBUS-GS between February 2017 and April 2018. The patients were classified according to the severity of their emphysema, and factors possibly contributing to a successful EBUS-GS procedure were evaluated. RESULTS: The overall diagnostic yield of EBUS-GS in patients with no or mild emphysema was significantly higher than in those with moderate or severe pulmonary emphysema (78% vs. 61%, P = 0.007). There were no procedure-related complications. The presence of a bronchus sign on CT (P <  0.001) and a "within the lesion" status on EBUS (P = 0.009) were independently associated with a successful EBUS-GS procedure. Although the diagnostic yield of EBUS-GS in patients with moderate-to-severe emphysema was relatively low, a bronchus sign and "within the lesion" status on EBUS were contributing factors for a successful EBUS-GS. CONCLUSIONS: EBUS-GS is a safe procedure with an acceptable diagnostic yield, even when performed in patients with pulmonary emphysema. The presence of a bronchus sign and "within the lesion" status on EBUS were predictors of a successful procedure.

The Ability of Different Scoring Systems to Predict Mortality in Chronic Obstructive Pulmonary Disease Patients: A Prospective Cohort Study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality, therefore the prediction of mortality in COPD patients is crucial. In the current study, the abilities of different categorization systems to predict mortality in stable COPD patients from a prospective cohort were compared. METHODS: The ability to predict mortality was compared in terms of discrimination by Harrell's C (HC) index and calibration using graphical comparison among the GOLD (Global Initiative for Chronic Obstructive Lung Disease) 2011, GOLD 2017, GOLD grade, BODE (BMI, Airflow Obstruction, Dyspnea, Exercise), updated BODE, BODEx (BMI, Airflow Obstruction, Dyspnea, Exacerbation), e-BODE (Exacerbation and BODE), ADO (Age, Dyspnea, Airflow Obstruction), COPD prognostic index (CPI), and simplified/optimized B-AE-D (BMI, Acute Exacerbation, Dyspnea) indexes. RESULTS: The study included 520 patients, of whom 63 died during a median 40-month follow-up period. Combined prediction systems exhibited higher discrimination properties than single predictors. The CPI exhibited the highest with a HC of 0.768, followed by the simplified B-AE-D (HC 0.761), ADO (HC 0.760), and optimized B-AE-D (HC 0.756). The BODE and its variants other than the ADO exhibited relatively lower HCs (0.656-0.705), and GOLD exhibited the lowest discrimination ability among the combined indices (HCs 0.628-0.637). Subjective symptom questionnaires such as the modified Medical Research Council (mMRC) scale (HC 0.693) and SGRQ (HC 0.679) exhibited the highest ability to predict mortality among the single indices. CONCLUSION: The ADO, simplified B-AE-D, optimized B-AE-D, and GOLD 2017 exhibited good calibration properties, but the CPI did not. The simplified and optimized B-AE-Ds and the ADO index had good discrimination and calibration properties for the prediction of mortality in stable COPD patients.

Risk of acute exacerbations in chronic obstructive pulmonary disease associated with biomass smoke compared with tobacco smoke.

BACKGROUND: Risk of exacerbations in chronic obstructive pulmonary disease (COPD) associated with biomass smoke has not been well addressed, although biomass smoke is similar in composition to tobacco smoke. METHODS: To investigate whether the risk of exacerbations in COPD associated with biomass smoke differs from that in COPD associated with tobacco smoke, we recruited patients with COPD from two Korean multicenter prospective cohorts. In a multiple linear regression model, the standardized regression coefficient (ß) of biomass smoke exposure ≥25 years was most similar to that (ß') of tobacco smoke exposure ≥10 pack-years (ß = - 0.13 and ß' = - 0.14). We grouped patients with COPD into four categories based on the above cut-offs: Less Tobacco-Less Biomass, Less Tobacco-More Biomass, More Tobacco-Less Biomass, and More Tobacco-More Biomass. The main outcome was the incidence of moderate or severe exacerbations. RESULTS: Among 1033 patients with COPD, 107 were included in Less Tobacco-Less Biomass (mean age: 67 years, men: 67%), 40 in Less Tobacco-More Biomass (mean age: 70 years, men: 35%), 631 in More Tobacco-Less Biomass (mean age: 68 years, men: 98%), and 255 in More Tobacco-More Biomass (mean age: 69 years, men: 97%). The incidence rates of exacerbations were not significantly different between Less Tobacco-More Biomass and More Tobacco-Less Biomass (adjusted incidence rate ratio, 1.03; 95% confidence interval, 0.56-1.89; P = 0.921). No interaction between sex and tobacco and biomass smoke was observed. When propensity score matching with available covariates including age and sex was applied, a similar result was observed. CONCLUSIONS: Patients with COPD associated with biomass smoke and those with COPD associated with tobacco smoke had a similar risk of exacerbations. This suggests that patients with COPD associated with biomass smoke should be treated actively.

Validation of Previous Spirometric Reference Equations and New Equations.

BACKGROUND: Pulmonary functions are interpreted using predicted values from reference equations that vary with ethnicity, gender, age, height, and weight. The universally used Choi's reference equations are not validated for Korean populations, and the purpose of this study was to validate them and develop new reference equations. METHODS: Subjects with normal spirometry and chest radiographs, no co-morbidities, and non-smokers, from the Korean National Health and National Examination Survey (KNHANES)-VI were enrolled (n = 117). Intraclass correlation coefficient (ICC) was assessed for reliability of reference equations. New reference equations were developed using linear regression analysis. Differences between observed and predicted values were assessed to compare the reference equations from Choi's, Global Lung Function Initiative 2012, KNHANES-IV, and newly developed equations. RESULTS: The ICC of Choi's reference equations was 0.854 (P < 0.001). The new reference equations for men were: forced vital capacity (FVC) (L) = - 4.38775 - 0.01184 × age + 0.05547 × height, forced expiratory volume - 1 second (FEV1) (L) = - 2.40147 - 0.02134 × age + 0.04103 × height; and for women: FVC (L) = - 3.09063 + 0.003904 × age + 0.038694 × height; FEV1 (L) = - 1.32933 - 0.00872 × age + 0.02762 × height. The differences between the predicted and observed means were largest in Choi's equations, but lowest in the new equations with highest goodness of fit. CONCLUSION: Because Choi's reference equations presented larger differences from the observed values, despite reliability, and the new reference equations showed better goodness of fit, we suggest the latter for Korean populations.

Depression is a major determinant of both disease-specific and generic health-related quality of life in people with severe COPD.

The quality of life of patients with chronic obstructive pulmonary disease (COPD) decreases significantly as the disease progresses; those with severe COPD are affected most. This article investigates predictors of the disease-specific and generic health-related quality of life (HRQL) in patients with severe COPD. This multicentre prospective cross-sectional study enrolled 80 patients with severe COPD. At enrolment, all patients completed a disease-specific instrument, the St George's Respiratory Questionnaire (SGRQ), and a generic instrument, the Short Form 36 Health Survey Questionnaire (SF-36). The data were analyzed by Pearson's correlation and multiple linear regression. The mean age of the patients was 66 ± 8 years; 93% were males. The SGRQ and SF-36 scores were not influenced by age or sex. Depression, dyspnea, the number of exacerbations, and exercise capacity significantly predicted the total SGRQ score ( p < 0.05). Depression was the strongest determinant of the total SGRQ score. The SF-36 physical component summary scores were related to depression, dyspnea, and the number of exacerbations ( p < 0.05). In comparison, the SF-36 mental component summary scores were related to depression and anxiety ( p < 0.05). Depression is a significant determinant of both the disease-specific and generic HRQL in patients with severe COPD. Screening and early intervention for depression in patients with severe COPD could improve the HRQL.

Favorable longitudinal change of lung function in patients with asthma-COPD overlap from a COPD cohort.

BACKGROUND: The recognition of asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) as a distinct phenotype of COPD or asthma has increased. Although ACO has worse clinical features than non-ACO COPD, limited information is available on long-term outcomes of lung function decline for ACO and non-ACO COPD. METHODS: COPD patients with at least 3 years of follow-up were selected from the Korean Obstructive Lung Disease cohort. ACO was defined based on 3 major criteria: 1) airflow limitation in individuals 40 years of age and older, 2) ≥10 pack-years of smoking history, and 3) a history of asthma or bronchodilator response of > 400 mL in forced expiratory volume in 1 s (FEV1) at baseline; and at least 1 minor criterion: 1) history of atopy or allergic rhinitis, 2) two separated bronchodilator responses of ≥12% and 200 mL in FEV1, or 3) peripheral blood eosinophils ≥300 cells/µL. Lung function decline was compared using a linear mixed effects model for longitudinal data with random intercept and random slope. RESULTS: Among 239 patients, 47 were diagnosed with ACO (19.7%). During the follow-up period, change in smoking status, use of inhaled corticosteroids (ICS) and long-acting ß2-agonists or ICS and at least 2 exacerbations per year were similar between patients with non-ACO COPD and ACO. Over a median follow-up duration of 5.8 years, patients with non-ACO COPD experienced a faster annual decline in pre-bronchodilator FEV1 than patients with ACO (- 29.3 ml/year vs. -13.9 ml/year, P = 0.042), which was persistent after adjustment for confounders affecting lung function decline. CONCLUSION: Patients with ACO showed favorable longitudinal changes in lung function compared to COPD patients over a median follow-up of 5.8 years.

Pleurodesis Using Mistletoe Extract Delivered via a Spray Catheter during Semirigid Pleuroscopy for Managing Symptomatic Malignant Pleural Effusion.

BACKGROUND: Talc poudrage during thoracoscopy is considered the standard procedure for patients with symptomatic malignant pleural effusion (MPE). Until now, no alternative technique other than talc poudrage for pleurodesis during medical thoracoscopy has been proposed. Liquid sclerosants, such as mistletoe extract, have been sprayed evenly into the pleural cavity during semirigid pleuroscopy for chemical pleurodesis. OBJECTIVE: We conducted a retrospective study using the database of semirigid pleuroscopy to identify the usefulness of pleurodesis using a mistletoe extract delivered via a spray catheter during semirigid pleuroscopy for symptomatic MPE. METHODS: All consecutive patients with symptomatic MPE who underwent semirigid pleuroscopy from October 2015 to September 2016 were registered. The responses were evaluated using chest X- ray or computed tomography 4 weeks after pleurodesis. RESULTS: The study included 43 patients who underwent pleurodesis with mistletoe extract via a spray catheter during semirigid pleuroscopy. Complete and partial responses were seen in 21 (49%) and 19 (44%) patients, respectively. The median duration of chest tube placement after pleurod-esis was 7 days (range 6-8 days) in the 40 patients with complete or partial responses. No cases of severe hemorrhage, empyema formation, respiratory failure, or procedure-related mortality were observed in the subjects at 4 weeks after semirigid pleuroscopy. CONCLUSION: Pleurodesis with mistletoe extract delivered via a spray catheter during semirigid pleuroscopy is a safe and effective procedure for managing symptomatic MPE.

Radial probe endobronchial ultrasound using a guide sheath for peripheral lung lesions in beginners.

BACKGROUND: The diagnostic yields and safety profiles of transbronchial lung biopsy have not been evaluated in inexperienced physicians using the combined modality of radial probe endobronchial ultrasound and a guide sheath (EBUS-GS). This study assessed the utility and safety of EBUS-GS during the learning phase by referring to a database of performed EBUS-GS procedures. METHODS: From December 2015 to January 2017, all of the consecutive patients who underwent EBUS-GS were registered. During the study period, two physicians with no previous experience performed the procedure. To assess the diagnostic yields, learning curve, and safety profile of EBUS-GS performed by these inexperienced physicians, the first 100 consecutive EBUS-GS procedures were included in the evaluation. RESULTS: The overall diagnostic yield of EBUS-GS performed by two physicans in 200 patients with a peripheral lung lesion was 73.0%. Learning curve analyses showed that the diagnostic yields were stable, even when the procedure was performed by beginners. Complications related to EBUS-GS occurred in three patients (1.5%): pneumothorax developed in two patients (1%) and resolved spontaneously without chest tube drainage; another patient (0.5%) developed a pulmonary infection after EBUS-GS. There were no cases of pneumothorax requiring chest tube drainage, severe hemorrhage, respiratory failure, premature termination of the procedure, or procedure-related mortality. CONCLUSIONS: EBUS-GS is a safe and stable procedure with an acceptable diagnostic yield, even when performed by physicians with no previous experience.

Serial changes and prognostic implications of CT findings in combined pulmonary fibrosis and emphysema: comparison with fibrotic idiopathic interstitial pneumonias alone.

Background Although fibrotic idiopathic interstitial pneumonias (IIPs) alone and those combined with pulmonary emphysema are naturally progressive diseases, the process of deterioration and outcomes are variable. Purpose To evaluate and compare serial changes of computed tomography (CT) abnormalities and prognostic predictive factors in fibrotic IIPs alone and those combined with pulmonary emphysema. Material and Methods A total of 148 patients with fibrotic IIPs alone (82 patients) and those combined with pulmonary emphysema (66 patients) were enrolled. Semi-quantitative CT analysis was used to assess the extents of CT characteristics which were evaluated on initial and follow-up CT images. Univariate and multivariate analyses were performed to assess the effects of clinical and CT variables on survival. Results Significant differences were noted between fibrotic scores, as determined using initial CT scans, in the fibrotic IIPs alone (21.22 ± 9.83) and those combined with pulmonary emphysema groups (14.70 ± 7.28) ( P < 0.001). At follow-up CT scans, changes in the extent of ground glass opacities (GGO) were greater ( P = 0.031) and lung cancer was more prevalent ( P = 0.001) in the fibrotic IIPs combined with pulmonary emphysema group. Multivariate Cox proportional hazards analysis showed changes in the extent of GGO (hazard ratio, 1.056) and the presence of lung cancer (hazard ratio, 4.631) were predictive factors of poor survivals. Conclusion Although patients with fibrotic IIPs alone and those combined with pulmonary emphysema have similar mortalities, lung cancer was more prevalent in patients with fibrotic IIPs combined with pulmonary emphysema. Furthermore, changes in the extent of GGO and the presence of lung cancer were independent prognostic factors of poor survivals.

Clinical utility of rapid pathogen identification using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry in ventilated patients with pneumonia: A pilot study.

BACKGROUND AND OBJECTIVE: We evaluated the clinical utility of rapid identification of microorganisms in bronchoalveolar lavage (BAL) fluid using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) in terms of the clinical outcomes of ventilated patients with pneumonia. METHODS: Patients for whom microorganisms were identified via MALDI-TOF MS (from March 2013 to February 2014; post-intervention group) were compared with patients for whom microorganisms were identified using conventional methods (from March 2012 to February 2013; pre-intervention group). All pneumonia types (community-acquired, hospital-acquired, healthcare-associated and ventilator-associated pneumonia) were included in the analysis. RESULTS: In total, 77 patients (50 men, mean age 67.2 ± 12.5 years) were included (40 patients in the pre-intervention group and 37 in the post-intervention group). The time from BAL fluid collection to microorganism identification and the availability of antimicrobial susceptibility results was shorter in the post- compared with the pre-intervention group (51.9 ± 11.3 vs 67.3 ± 17.4 h, P < 0.001). Also, the time from BAL fluid collection to adjustment of antibiotic therapy was shorter in the post-intervention group (56.5 ± 10.9 vs 73.2 ± 18.5 h, P < 0.001). Microorganism identification via MALDI-TOF MS was independently associated with a shorter intensive care unit (ICU) stay after BAL fluid was drawn (hazard ratio = 2.324, P = 0.007). CONCLUSION: Rapid identification of microorganisms in BAL fluid via MALDI-TOF MS was associated with adjustment of antibiotic therapy and a shorter ICU stay after BAL fluid was collected from ventilated patients with pneumonia.

Evaluation of allergic sensitivity to Acanthamoeba allergen in patients with chronic cough.

BACKGROUND: Acanthamoeba and their proteins can elicit severe allergic airway inflammation in experimental mice. OBJECTIVE: Although Acanthamoeba can induce severe allergic airway inflammation in mice, there is no allergenicity data for humans. METHODS: We performed a skin-prick test on 65 patients with chronic cough by using 54 previously known allergens and Acanthamoeba excretory-secretory proteins and enzyme-linked immunosorbent assay on 34 patients to evaluate Acanthamoeba-specific serum immunoglobulin (Ig) levels. To detect a novel Acanthamoeba allergen, Western blot analysis was performed on serum from patients who reacted positively to Acanthamoeba or some pollen allergens. RESULTS: After skin-prick testing, 29 patients (44.6%) showed positive reactions to one or more common aeroallergens. Acanthamoeba allergenicity was evaluated in 4 of 65 subjects (6.1%). An Acanthamoeba-positive reaction was closely related to several pollen allergens, especially willow tree, poplar, elm, oak, velvet grass, and cockroach. Average levels of Acanthamoeba-specific IgG subtypes in patient serum did not differ compared with healthy subjects; however, Acanthamoeba-specific IgE titers of patients were significantly higher than in healthy subjects. IgE antibodies of patients who tested positive in the skin-prick test reacted strongly to the 15 kDa excretory-secretory protein. Moreover, these antigens also reacted with those who tested positive in the skin-prick test to pollens. CONCLUSION: Taken together, our results indicated that some patients with allergy showed a positive response to the skin-prick test and that they also have high IgE serum levels. However, further experimental investigation is warranted because our preliminary findings indicated that Acanthamoeba might be a new allergen in humans.

Efficacy of TB-PCR using EBUS-TBNA samples in patients with intrathoracic granulomatous lymphadenopathy.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is widely used to perform mediastinal lymph node sampling. However, little information is available on polymerase chain reaction for Mycobacterium tuberculosis (TB-PCR) using EBUS-TBNA samples in patients with intrathoracic granulomatous lymphadenopathy (IGL). METHODS: A retrospective study using a prospectively collected database was performed from January 2010 to December 2014 to evaluate the efficacy of the TB-PCR test using EBUS-TBNA samples in patients with IGL. During the study period, 87 consecutive patients with isolated intrathoracic lymphadenopathy who received EBUS-TBNA were registered and 46 patients with IGL were included. RESULTS: Of the 46 patients with IGL, tuberculous lymphadenitis and sarcoidosis were diagnosed in 16 and 30 patients, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of TB-PCR for tuberculous lymphadenitis were 56, 100, 100, and 81%, respectively. The overall diagnostic accuracy of TB-PCR for tuberculous lymphadenitis was 85%. In addition, seven (17%) patients had non-diagnostic results from a histological examination and all of them had non-diagnostic microbiological results of an acid-fast bacilli smear and culture. Four (57%) of the seven patients with non-diagnostic results had positive TB-PCR results, and anti-tuberculosis treatment led to clinical and radiological improvement in all of the patients. CONCLUSIONS: TB-PCR using EBUS-TBNA samples is a useful laboratory test for diagnosing IGL. Moreover, this technique can prevent further invasive evaluation in patients whose histological and microbiological tests are non-diagnostic.