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1.
Respirology ; 27(5): 350-356, 2022 05.
Artículo en Inglés | MEDLINE | ID: mdl-35178828

RESUMEN

BACKGROUND AND OBJECTIVE: Pleuroscopy with pleural biopsy has a high sensitivity for malignant pleural effusion (MPE). Because MPEs tend to recur, concurrent diagnosis and treatment of MPE during pleuroscopy is desired. However, proceeding directly to treatment at the time of pleuroscopy requires confidence in the on-site diagnosis. The study's primary objective was to create a predictive model to estimate the probability of MPE during pleuroscopy. METHODS: A prospective observational multicentre cohort study of consecutive patients undergoing pleuroscopy was conducted. We used a logistic regression model to evaluate the probability of MPE with relation to visual assessment, rapid on-site evaluation (ROSE) of touch preparation and presence of pleural nodules/masses on computed tomography (CT). To assess the model's prediction accuracy, a bootstrapped training/testing approach was utilized to estimate the cross-validated area under the receiver operating characteristic curve. RESULTS: Of the 201 patients included in the study, 103 had MPE. Logistic regression showed that higher level of malignancy on visual assessment is associated with higher odds of MPE (OR = 34.68, 95% CI = 9.17-131.14, p < 0.001). The logistic regression also showed that higher level of malignancy on ROSE of touch preparation is associated with higher odds of MPE (OR = 11.63, 95% CI = 3.85-35.16, p < 0.001). Presence of pleural nodules/masses on CT is associated with higher odds of MPE (OR = 6.61, 95% CI = 1.97-22.1, p = 0.002). A multivariable logistic regression model of final pathologic status with relation to visual assessment, ROSE of touch preparation and presence of pleural nodules/masses on CT had a cross-validated AUC of 0.94 (95% CI = 0.91-0.97). CONCLUSION: A prediction model using visual assessment, ROSE of touch preparation and CT scan findings demonstrated excellent predictive accuracy for MPE. Further validation studies are needed to confirm our findings.


Asunto(s)
Derrame Pleural Maligno , Derrame Pleural , Biopsia , Estudios de Cohortes , Humanos , Recurrencia Local de Neoplasia , Derrame Pleural Maligno/diagnóstico por imagen , Derrame Pleural Maligno/patología , Estudios Prospectivos , Toracoscopía
2.
BMC Cancer ; 18(1): 937, 2018 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-30285733

RESUMEN

BACKGROUND: The tyrosine kinase inhibitor pazopanib is used for treatment of sarcoma. Recent studies have suggested that the use of pazopanib may lead to the development of pneumothorax, an unexpected adverse effect in patients with sarcoma metastatic to the chest. METHODS: We conducted a retrospective case control study of patients with sarcoma with metastases to the chest with pneumothorax (cases) and without pneumothorax (controls). The control population was selected from tumor registry in a 1:4 (cases to controls) ratio. The primary outcome of interest was the association between pazopanib and pneumothorax risk in patients with sarcoma metastatic to the chest. Secondary objective was to evaluate risk factors for pneumothorax. RESULTS: We identified 41 cases and 164 controls. Using purposeful selection method the odds of developing pneumothorax while being on pazopanib was not significant in univariate (p = .06) and multivariable analysis (p = .342). On univariate analysis risk factors of pneumothorax in patients with sarcoma were age, male sex, African American race, the presence of cavitary lung nodules/masses, and the presence of pleural-based nodules/masses. On multivariate analysis, only the presence of cavitary lung nodules/masses (P < .001) and the presence of pleural-based nodules/masses (P < .001) remained as risk factors for developing pneumothorax. CONCLUSION: Pazopanib does not increase the risk of pneumothorax in patients with sarcoma and evidence of metastatic disease to the chest. Presence of cavitary lung nodules/masses and the presence of pleural-based nodules/masses were found to be risk factors for pneumothorax.


Asunto(s)
Neumotórax/inducido químicamente , Inhibidores de Proteínas Quinasas/uso terapéutico , Pirimidinas/efectos adversos , Sarcoma/tratamiento farmacológico , Sulfonamidas/efectos adversos , Adulto , Anciano , Estudios de Casos y Controles , Femenino , Humanos , Indazoles , Modelos Logísticos , Neoplasias Pulmonares/secundario , Masculino , Persona de Mediana Edad , Pirimidinas/uso terapéutico , Estudios Retrospectivos , Factores de Riesgo , Sulfonamidas/uso terapéutico
3.
Curr Opin Pulm Med ; 24(4): 343-349, 2018 07.
Artículo en Inglés | MEDLINE | ID: mdl-29538079

RESUMEN

PURPOSE OF REVIEW: The current review describes the latest evidence regarding the use of stents for malignant airway obstruction. RECENT FINDINGS: Therapeutic bronchoscopy, including stenting, can restore patency in up to 93% of patients with malignant central airway obstruction. The patients that benefit the most are those with worse baseline dyspnea, higher American Society of Anesthesiology score, poorer functional status, and central obstruction (rather than lobar). Early complications are relatively rare with stent placement, whereas late complications are not. Stents are a risk factor for lower respiratory tract infection, which, in turn, is a negative prognostic factor in terms of survival. Recent research has seen the development of personalized stents via three-dimensional printing, mini stents for more distal airways, and stents with drug-eluting and biodegradable properties. SUMMARY: Airway stents must be judiciously used, but we now have data that help guide patient selection and that inform us of what potential complications may occur and when. Stents are under development with newer properties that may extend the therapeutic reach of these interventions.


Asunto(s)
Obstrucción de las Vías Aéreas/terapia , Neoplasias Pulmonares/complicaciones , Stents/efectos adversos , Implantes Absorbibles , Obstrucción de las Vías Aéreas/etiología , Broncoscopía , Stents Liberadores de Fármacos , Humanos , Selección de Paciente , Impresión Tridimensional , Diseño de Prótesis , Infecciones del Sistema Respiratorio/etiología
4.
Diagnostics (Basel) ; 14(2)2024 Jan 16.
Artículo en Inglés | MEDLINE | ID: mdl-38248073

RESUMEN

Atelectasis during bronchoscopy under general anesthesia is very common and can have a detrimental effect on navigational and diagnostic outcomes. While the intraprocedural incidence and anatomic location have been previously described, the severity of atelectasis has not. We reviewed chest CT images of patients who developed atelectasis in the VESPA trial (Ventilatory Strategy to Prevent Atelectasis). By drawing boundaries at the posterior chest wall (A), the anterior aspect of the vertebral body (C), and mid-way between these two lines (B), we delineated at-risk lung zones 1, 2, and 3 (from posterior to anterior). An Atelectasis Severity Score System ("ASSESS") was created, classifying atelectasis as "mild" (zone 1), "moderate" (zones 1-2), and "severe" (zones 1-2-3). A total of 43 patients who developed atelectasis were included in this study. A total of 32 patients were in the control arm, and 11 were in the VESPA arm; 20 patients (47%) had mild atelectasis, 20 (47%) had moderate atelectasis, and 3 (6%) had severe atelectasis. A higher BMI was associated with increased odds (1.5 per 1 unit change; 95% CI, 1.10-2.04) (p = 0.0098), and VESPA was associated with decreased odds (0.05; 95% CI, 0.01-0.47) (p = 0.0080) of developing moderate to severe atelectasis. ASSESS is a simple method used to categorize intra-bronchoscopy atelectasis, which allows for a qualitative description of this phenomenon to be developed. In the VESPA trial, a higher BMI was not only associated with increased incidence but also increased severity of atelectasis, while VESPA had the opposite effect. Preventive strategies should be strongly considered in patients with risk factors for atelectasis who have lesions located in zones 1 and 2, but not in zone 3.

5.
J Bronchology Interv Pulmonol ; 31(2): 155-159, 2024 Apr 01.
Artículo en Inglés | MEDLINE | ID: mdl-37982602

RESUMEN

BACKGROUND: Pleural infections related to indwelling pleural catheters (IPCs) are an uncommon clinical problem. However, management decisions can be complex for patients with active malignancies due to their comorbidities and limited life expectancies. There are limited studies on the management of IPC-related infections, including whether to remove the IPC or use intrapleural fibrinolytics. METHODS: We conducted a retrospective cohort study of patients with active malignancies and IPC-related empyemas at our institution between January 1, 2005 and May 31, 2021. The primary outcome was to evaluate clinical outcomes in patients with malignant pleural effusions and IPC-related empyemas treated with intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) compared with those treated with tPA alone or no intrapleural fibrinolytic therapy. The secondary outcome evaluated was the incidence of bleeding complications. RESULTS: We identified 69 patients with a malignant pleural effusion and an IPC-related empyema. Twenty patients received tPA/DNase, 9 received tPA alone, and 40 were managed without fibrinolytics. Those treated with fibrinolytics were more likely to have their IPCs removed as part of the initial management strategy ( P =0.004). The rate of surgical intervention and mortality attributable to the empyema were not significantly different between treatment groups. There were no bleeding events in any group. CONCLUSION: In patients with IPC-related empyemas, we did not find significant differences in the rates of surgical intervention, empyema-related mortality, or bleeding complications in those treated with intrapleural tPA/DNase, tPA alone, or no fibrinolytics. More patients who received intrapleural fibrinolytics had their IPCs removed, which may have been due to selection bias.


Asunto(s)
Empiema Pleural , Derrame Pleural Maligno , Derrame Pleural , Humanos , Activador de Tejido Plasminógeno/uso terapéutico , Fibrinolíticos/uso terapéutico , Empiema Pleural/tratamiento farmacológico , Estudios Retrospectivos , Derrame Pleural Maligno/tratamiento farmacológico , Derrame Pleural Maligno/complicaciones , Catéteres de Permanencia/efectos adversos , Desoxirribonucleasas , Derrame Pleural/terapia
6.
Diagnostics (Basel) ; 14(17)2024 Sep 04.
Artículo en Inglés | MEDLINE | ID: mdl-39272739

RESUMEN

BACKGROUND: Computed tomography to body divergence (CTBD) is one of the main barriers to bronchoscopic techniques for the diagnosis of peripherally located lung nodules. Cone-beam CT (CBCT) guidance is being rapidly adopted to correct for this phenomenon and to potentially increase diagnostic outcomes. In this trial, we hypothesized that the addition of mobile CBCT (m-CBCT) could improve the rate of tool in lesion (TIL) and the diagnostic yield of shape-sensing robotic-assisted bronchoscopy (SS-RAB). METHODS: This was a prospective, single-arm study, which enrolled patients with peripheral lung nodules of 1-3 cm and compared the rate of TIL and the diagnostic yield of SS-RAB alone and combined with mCBCT. RESULTS: A total of 67 subjects were enrolled, the median nodule size was 1.7 cm (range, 0.9-3 cm). TIL was achieved in 23 patients (34.3%) with SS-RAB alone, and 66 patients (98.6%) with the addition of mCBCT (p < 0.0001). The diagnostic yield of SS-RAB alone was 29.9% (95% CI, 29.3-42.3%) and it was 86.6% (95% CI, 76-93.7%) with the addition of mCBCT (p < 0.0001). There were no pneumothoraxes or any bronchoscopy-related complications, and the median total dose-area product (DAP) was 50.5 Gy-cm2. CONCLUSIONS: The addition of mCBCT guidance to SS-RAB allows bronchoscopists to compensate for CTBD, leading to an increase in TIL and diagnostic yield, with acceptable radiation exposure.

7.
Mediastinum ; 7: 18, 2023.
Artículo en Inglés | MEDLINE | ID: mdl-37261090

RESUMEN

Central airway obstruction is a serious complication of various diseases, most often malignancy. Malignant etiologies include primary lung cancer as most common though metastases from various other cancers can obstruct the airways as well. Benign etiologies include inflammatory or fibrotic changes due to prior airway interventions (e.g., endotracheal intubation or tracheostomy) or specific autoimmune conditions. Different interventional modalities exist including various electrosurgical or mechanical debulking tools, though these are sometimes insufficient or contraindicated for the purpose of restoration of airway patency. The placement of stents is thus needed in certain particularly complex or refractory cases. Airway stenting requires careful patient selection and stent selection along with a thorough knowledge of relevant anatomy and procedural technique. Indeed, certain clinical presentations are better suited for stent placement and more likely to achieve a symptomatic benefit. Moreover, a variety of stents exist with each having different attributes that may better fit specific conditions. Complications must be managed properly as well. These include stent migration, granulation tissue formation, and stent-related infection which can have clinically significant consequences. In this review, we will discuss airway stenting for central airway obstruction with regard to these various subject areas as well as conclude with discussion of future research directions.

8.
Cureus ; 15(4): e37545, 2023 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-37197128

RESUMEN

Background Pleural infection is a common clinical problem resulting in prolonged hospitalization and increased mortality. In patients with active malignancy, management decisions are based on the need for further immunosuppressive therapies, the ability to tolerate surgery, and consideration of the limited life expectancy. Identifying patients at risk for death or poor outcomes is very important as it will guide care. Study design and methods This is a retrospective cohort study of all patients with active malignancy and empyema. The primary outcome was time to death from empyema at three months. The secondary outcome was surgery at 30 days. Standard Cox regression model and cause-specific hazard regression model were used to analyze the data. Results A total of 202 patients with active malignancy and empyema were included. The overall mortality rate at three months was 32.7%. On multivariable analysis, female gender and higher urea were associated with an increased risk of death from empyema at three months. The area under the curve (AUC) of the model was 0.70. The risk factors for surgery at 30 days included the presence of frank pus and postsurgical empyema. The AUC of the model was 0.76. Interpretation Patients with active malignancy and empyema have a high probability of death. In our model, the risk factors for death from empyema included female gender and higher urea.

9.
Respir Med Case Rep ; 40: 101783, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-36440304

RESUMEN

Laceration of an intercostal artery is a rare but potentially catastrophic complication of pleural procedures such as thoracentesis. Recognition of this problem often occurs late in the bleeding process, only after hemodynamic decompensation has occurred. Aggressive and emergent measures are usually undertaken such as angiographic embolization or thoracotomy. In our review of the literature, manual pressure over the pleural space is not described as an intervention in case reports or case series. We demonstrate the first video proof of the immediate success of direct pressure over an intercostal site as a simple, rapid, and effective method for definitively stopping intercostal arterial hemorrhage after a pleural procedure.

10.
Chest ; 162(6): 1393-1401, 2022 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-35803302

RESUMEN

BACKGROUND: Atelectasis negatively influences peripheral bronchoscopy, increasing CT scan-body divergence, obscuring targets, and creating false-positive radial-probe endobronchial ultrasound (RP-EBUS) images. RESEARCH QUESTION: Can a ventilatory strategy reduce the incidence of atelectasis during bronchoscopy under general anesthesia? STUDY DESIGN AND METHODS: Randomized controlled study (1:1) in which patients undergoing bronchoscopy were randomized to receive standard ventilation (laryngeal mask airway, 100% Fio2, zero positive end-expiratory pressure [PEEP]) vs a ventilatory strategy to prevent atelectasis (VESPA) with endotracheal intubation followed by a recruitment maneuver, Fio2 titration (< 100%), and PEEP of 8 to 10 cm H2O. All patients underwent chest CT imaging and a survey for atelectasis with RP-EBUS bilaterally on bronchial segments 6, 9, and 10 after artificial airway insertion (time 1) and 20 to 30 min later (time 2). Chest CT scans were reviewed by a blinded chest radiologist. RP-EBUS images were assessed by three independent, blinded readers. The primary end point was the proportion of patients with any atelectasis (either unilateral or bilateral) at time 2 according to chest CT scan findings. RESULTS: Seventy-six patients were analyzed, 38 in each group. The proportion of patients with any atelectasis according to chest CT scan at time 2 was 84.2% (95% CI, 72.6%-95.8%) in the control group and 28.9% (95% CI, 15.4%-45.9%) in the VESPA group (P < .0001). The proportion of patients with bilateral atelectasis at time 2 was 71.1% (95% CI, 56.6%-85.5%) in the control group and 7.9% (95% CI, 1.7%-21.4%) in the VESPA group (P < .0001). At time 2, 3.84 ± 1.67 (mean ± SD) bronchial segments in the control group vs 1.21 ± 1.63 in the VESPA group were deemed atelectatic (P < .0001). No differences were found in the rate of complications. INTERPRETATION: VESPA significantly reduced the incidence of atelectasis, was well tolerated, and showed a sustained effect over time despite bronchoscopic nodal staging maneuvers. VESPA should be considered for bronchoscopy when atelectasis is to be avoided. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT04311723; URL: www. CLINICALTRIALS: gov.


Asunto(s)
Máscaras Laríngeas , Atelectasia Pulmonar , Humanos , Atelectasia Pulmonar/diagnóstico por imagen , Atelectasia Pulmonar/etiología , Atelectasia Pulmonar/prevención & control , Anestesia General/efectos adversos , Respiración con Presión Positiva/métodos , Pulmón , Máscaras Laríngeas/efectos adversos
11.
Cureus ; 13(6): e15501, 2021 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-34268032

RESUMEN

Central airway obstruction often presents with airway narrowing of differing internal diameters. Conventional straight stents do not fit these airways well and are prone to migration. We present a series of cases where hourglass-shaped silicone stents were customized intra-operatively to fit airway obstructions of both malignant and non-malignant etiologies and to improve patient performance status. Modified hourglass stents are a versatile tool to manage inoperable airway obstruction with unique anatomical characteristics.

12.
Am J Case Rep ; 22: e932945, 2021 Oct 14.
Artículo en Inglés | MEDLINE | ID: mdl-34645779

RESUMEN

BACKGROUND Chronic cough is a common medical concern. Giant cell arteritis (GCA) is an uncommon cause of chronic cough and is not usually suspected since symptoms can be non-specific. We present a case of chronic cough due to GCA in which symptoms were subtle but imaging was remarkable and clearly disclosed the diagnosis. CASE REPORT A 71-year-old woman presented to the pulmonary clinic with a concern of worsening cough for 4 months. She had been treated with proton pump inhibitor, intranasal steroids, and antibiotics, without improvement. Other symptoms were an occasional headache for the prior 5 months, but this had resolved. She had a history of early-stage breast and thyroid cancers, both of which were treated surgically several years earlier and were in remission. Results of a physical examination including flexible video laryngoscopy of the upper airway were completely normal. Laboratory investigations showed normal blood chemistries and blood cell counts. Her C-reactive protein level was 1 mg/L (upper limit of normal <10) but her erythrocyte sedimentation level was 121 mm/hr (upper limit of normal <30). A positron emission tomography (PET) scan was performed as surveillance for her prior cancers. This showed diffuse tracer uptake in the aorta as well as bilateral common carotid, subclavian, and common iliac arteries, revealing GCA as the underlying diagnosis. CONCLUSIONS Giant cell arteritis is a rare cause of chronic cough. Other symptoms can be subtle or non-specific as in our case, and a high index of suspicion is needed to obtain a temporal artery biopsy. In these cases, imaging adjuncts can provide a non-invasive diagnosis.


Asunto(s)
Arteritis de Células Gigantes , Anciano , Aorta , Tos/etiología , Femenino , Arteritis de Células Gigantes/complicaciones , Arteritis de Células Gigantes/diagnóstico , Humanos , Arteria Ilíaca , Tomografía de Emisión de Positrones
13.
Respir Med Case Rep ; 34: 101512, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-34522604

RESUMEN

A 68-year old woman with a long smoking history underwent lung cancer screening by low-dose computed tomography. This detected a 3.0 cm spiculated mass in the left upper lobe. Transbronchial biopsy revealed necrotizing granulomatous inflammation and cultures grew Mycobacterium kansasii. Given lack of symptoms and concerns over drug toxicity, the patient declined antimicrobial therapy and she was monitored radiographically. Serial CT scans at six and twenty-two months showed progressive resolution of the mass. We present the first report of Mycobacterium kansasii presenting as a solitary lung nodule that spontaneously resolved without treatment.

14.
Am J Case Rep ; 22: e933396, 2021 Oct 04.
Artículo en Inglés | MEDLINE | ID: mdl-34606491

RESUMEN

BACKGROUND As use of immune checkpoint inhibitors consistently grows, so does knowledge of immune-related adverse events. Pleural complications from PD-L1 inhibitors such as atezolizumab have never been reported. We describe the first reported case of biopsy-proven pleuritis manifesting as recurrent pleural effusion in a patient treated with atezolizumab. CASE REPORT A 66-year-old woman with history of extensive-stage small cell lung cancer presented with a new pleural effusion. She was previously treated with carboplatin, etoposide, and atezolizumab followed by atezolizumab maintenance, but this later was stopped due to pneumonitis. She had been on no systemic therapy for 6 months prior; radiation to the chest was completed 1 year earlier. Thoracentesis revealed an exudate with eosinophilia but no malignancy. She underwent medical thoracoscopy, which showed normal pleura with no evidence of radiation changes. Random pleural biopsies revealed only chronic pleuritis. Given normal-appearing pleura, radiation pleuritis was ruled out. It was felt that the chemotherapy had occurred too long ago to be a present cause of her pleuritis. As such, after extensive workup, the eosinophilic pleural effusion was felt to be due to pleuritis from atezolizumab. The effusion has ultimately recurred 5 times over 1 year, and cytology remains negative for malignancy. CONCLUSIONS Patients with prior cancer presenting with a new pleural effusion should undergo an extensive workup to evaluate for recurrence. When other causes have been ruled out, ongoing immune-related effects of immunotherapy should be considered. Pleural complications from PD-L1 inhibitors have not been reported; we present a possible case of chronic pleuritis and recurrent effusion due to atezolizumab.


Asunto(s)
Neoplasias Pulmonares , Derrame Pleural , Pleuresia , Carcinoma Pulmonar de Células Pequeñas , Anciano , Anticuerpos Monoclonales Humanizados , Exudados y Transudados , Femenino , Humanos , Neoplasias Pulmonares/tratamiento farmacológico , Recurrencia Local de Neoplasia/tratamiento farmacológico , Derrame Pleural/inducido químicamente , Pleuresia/inducido químicamente
15.
Chest ; 157(4): e121-e125, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32252936

RESUMEN

CASE PRESENTATION: A 55-year-old man presented to the ED with a 3-week history of worsening cough and shortness of breath. He had blood-tinged sputum, fever, night sweats, and a 2.7 kg weight loss within the same period. For the past few days, he had taken amoxicillin-clavulanate for presumed sinusitis. Despite this, his symptoms persisted, prompting him to seek further evaluation. His medical history was significant for ulcerative colitis and he had some bloody diarrhea for the past few weeks. Medications included aspirin, mesalamine, multivitamins, folic acid, and herbal supplements including gingko biloba, ginseng, and turmeric-ginger. He never smoked and drank alcohol occasionally. Family history was notable for stroke and myocardial infarction.


Asunto(s)
Obstrucción de las Vías Aéreas , Broncoscopía/métodos , Colitis Ulcerosa , Criocirugía/métodos , Glucocorticoides/administración & dosificación , Infliximab/administración & dosificación , Úlcera , Obstrucción de las Vías Aéreas/diagnóstico por imagen , Obstrucción de las Vías Aéreas/etiología , Obstrucción de las Vías Aéreas/patología , Obstrucción de las Vías Aéreas/terapia , Antirreumáticos/administración & dosificación , Colitis Ulcerosa/complicaciones , Colitis Ulcerosa/fisiopatología , Colitis Ulcerosa/terapia , Tos/diagnóstico , Tos/etiología , Diagnóstico Diferencial , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiología , Humanos , Masculino , Persona de Mediana Edad , Necrosis/complicaciones , Necrosis/patología , Necrosis/terapia , Respiración Artificial/métodos , Síndrome de Dificultad Respiratoria/diagnóstico , Síndrome de Dificultad Respiratoria/etiología , Síndrome de Dificultad Respiratoria/fisiopatología , Síndrome de Dificultad Respiratoria/terapia , Tomografía Computarizada por Rayos X/métodos , Resultado del Tratamiento , Úlcera/etiología , Úlcera/patología
16.
J Community Hosp Intern Med Perspect ; 10(5): 386-388, 2020 Sep 03.
Artículo en Inglés | MEDLINE | ID: mdl-33235667

RESUMEN

Facing an unprecedented surge of patient volumes and acuity, institutions around the globe called for volunteer healthcare workers to aid in the effort against COVID-19. Specifically being sought out are retirees. But retired healthcare workers are taking on significant risk to themselves in answering these calls. Aside from the risks that come from being on the frontlines of the epidemic, they are also at risk due to their age and the comorbidities that often accompany age. If, for current or future COVID efforts, we as a society will be so bold as to exhort a vulnerable population to take on further risk, we must use much care and attention in how we involve them in this effort. Herein we describe the multifaceted nature of the risks that retired healthcare workers are taking by entering the COVID-19 workforce as well as suggest ways in which we might take advantage of their medical skills and altruism yet while optimizing caution and safety.

17.
Chest ; 158(6): 2658-2666, 2020 12.
Artículo en Inglés | MEDLINE | ID: mdl-32561439

RESUMEN

BACKGROUND: Despite the many advances in peripheral bronchoscopy, its diagnostic yield remains suboptimal. With the use of cone-beam CT imaging we have found atelectasis mimicking lung tumors or obscuring them when using radial-probe endobronchial ultrasound (RP-EBUS), but its incidence remains unknown. RESEARCH QUESTION: What are the incidence, anatomic location, and risk factors for developing atelectasis during bronchoscopy under general anesthesia? STUDY DESIGN AND METHODS: We performed a prospective observational study in which patients undergoing peripheral bronchoscopy under general anesthesia were subject to an atelectasis survey carried out by RP-EBUS under fluoroscopic guidance. The following dependent segments were evaluated: right bronchus 2 (RB2), RB6, RB9, and RB10; and left bronchus 2 (LB2), LB6, LB9, and LB10. Images were categorized either as aerated lung ("snowstorm" pattern) or as having a nonaerated/atelectatic pattern. Categorization was performed by three independent readers. RESULTS: Fifty-seven patients were enrolled. The overall intraclass correlation agreement among readers was 0.82 (95% CI, 0.71-0.89). Median time from anesthesia induction to atelectasis survey was 33 min (range, 3-94 min). Fifty-one patients (89%; 95% CI, 78%-96%) had atelectasis in at least one of the eight evaluated segments, 45 patients (79%) had atelectasis in at least three, 41 patients (72%) had atelectasis in at least four, 33 patients (58%) had atelectasis in at least five, and 18 patients (32%) had atelectasis in at least six segments. Right and left B6, B9, and B10 segments showed atelectasis in > 50% of patients. BMI and time to atelectasis survey were associated with increased odds of having more atelectatic segments (BMI: OR, 1.13 per unit change; 95% CI, 1.034-1.235; P = .007; time to survey: OR, 1.064 per minute; 95% CI, 1.025-1.105; P = .001). INTERPRETATION: The incidence of atelectasis developing during bronchoscopy under general anesthesia in dependent lung zones is high, and the number of atelectatic segments is greater with higher BMI and with longer time under anesthesia. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; No.: NCT03523689; URL: www.clinicaltrials.gov.


Asunto(s)
Anestesia General/métodos , Broncoscopía , Tomografía Computarizada de Haz Cónico/métodos , Endosonografía/métodos , Complicaciones Intraoperatorias , Pulmón/diagnóstico por imagen , Atelectasia Pulmonar , Anciano , Broncoscopía/efectos adversos , Broncoscopía/métodos , Duración de la Terapia , Femenino , Humanos , Biopsia Guiada por Imagen/métodos , Incidencia , Complicaciones Intraoperatorias/diagnóstico , Complicaciones Intraoperatorias/prevención & control , Masculino , Nódulos Pulmonares Múltiples/diagnóstico , Atelectasia Pulmonar/diagnóstico por imagen , Atelectasia Pulmonar/epidemiología , Atelectasia Pulmonar/etiología , Medición de Riesgo , Factores de Riesgo
18.
Clin Pediatr (Phila) ; 48(2): 183-9, 2009 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-18840888

RESUMEN

Fever is a common childhood condition that is often misunderstood and incorrectly managed by parents. This study uses a questionnaire about fever administered to a convenience sample of Spanish-speaking-only parents bringing their child to a hospital-based urban pediatric clinic. The questionnaire elicits information about definition and cause of fever, concerns about fever, methods of temperature measurement, and treatment modalities used by the parents. Latino parents have numerous misconceptions about fever and its role in illness. Educational interventions should target fever definition, clarification of cause and potential harm of elevated temperatures, temperature monitoring, and safe treatment modalities. Owning a thermometer is strongly associated with correct knowledge of temperature values. Providing parents with a thermometer and educating them about its proper use may lead to an increase in appropriate monitoring and medical treatment of the febrile child.


Asunto(s)
Analgésicos no Narcóticos/uso terapéutico , Fiebre , Conocimientos, Actitudes y Práctica en Salud , Hispánicos o Latinos , Padres , Adulto , Temperatura Corporal , Preescolar , Terapias Complementarias/estadística & datos numéricos , Estudios Transversales , Femenino , Fiebre/etnología , Fiebre/psicología , Fiebre/terapia , Humanos , Lactante , Masculino , Padres/educación , Padres/psicología , Encuestas y Cuestionarios , Termómetros , Estados Unidos
19.
J Thorac Dis ; 11(6): 2628-2638, 2019 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-31372299

RESUMEN

Lung cancer is the leading cause of cancer-related death worldwide and lobectomy remains the standard of care for patients with early-stage non-small cell lung cancer (NSCLC). The combination of an aging population and the implementation of low-dose CT for lung cancer screening is leading to an increase in diagnosis of early stage NSCLC in medically "inoperable" patients. The recommended treatment for this latter group of patients is stereotactic body radiation therapy (SBRT). However, many patients cannot undergo SBRT because they have received prior radiation or because the tumor is located next to vital structures. Percutaneous ablative therapies have become an alternative to SBRT but, unfortunately, they all violate the pleura and are associated with high rate of pneumothorax. With a more favorable safety profile and the ability to provide also diagnosis and nodal staging, bronchoscopic ablation is hence emerging as a potential future therapeutic alternative for these patients. Herein we review the current state of the art including animal and human data that exists thus far. We also discuss technical and research challenges as well as future directions that this exciting new technology may take.

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