A Network Comparative Meta-analysis of Percutaneous Dilatational Tracheostomies Using Anatomic Landmarks, Bronchoscopic, and Ultrasound Guidance Versus Open Surgical Tracheostomy.

BACKGROUND: Several different tracheostomy techniques (percutaneous and surgical) have been studied extensively in previous direct pairwise meta-analyses. However, a network comparative meta-analysis comparing all has not been conducted before. OBJECTIVE: We sought to compare three percutaneous dilatational tracheostomy techniques with open surgical tracheostomy technique (performed in the operating room or in the intensive care unit by bedside) in terms of their association with procedure-related major complications and procedure time. DATA SOURCES: We searched PubMed and Cochrane register of randomized active comparator trials. DATA EXTRACTION AND SYNTHESIS: A network comparative meta-analysis was performed in Stata using frequentist methodology. Major complications were defined as a composite of a priori-selected procedure-related complications. Tracheostomy techniques that did not require any direct bronchoscopic or ultrasonographic visualization of the entire procedure were grouped under the heading-anatomic landmark-based dilatational tracheostomy (ALDT). This along with bronchoscopic-guided dilatational tracheostomy (BDT), ultrasound-guided (UDT), and surgical tracheostomy (SGT) were compared with each other using network meta-analysis in Stata after all major assumptions (similarity, transitivity, and consistency) for performing a network were met. Log odds ratio (and standard errors) of the comparison of major complications between any two tracheostomy techniques (using indirect estimates) was statistically insignificant. Pairwise meta-analysis showed significant differences in procedure times between SGT and ALDT [mean difference: 9.96 min (SE 3.18)] and between SGT and BDT [15.67 min (SE 3.85)]. The indirect network meta-analysis comparing one versus the other also showed a statistically significant time difference between surgical tracheostomy when compared with every other technique. CONCLUSIONS: The results of our network meta-analysis show that all tracheostomy techniques are comparable with respect to associated procedure-related complications, but all three percutaneous techniques take far less procedure time compared to the surgical tracheostomy.

Early lung cancer detection, mucosal, and alveolar imaging.

PURPOSE OF REVIEW: Lung cancer is the leading cause of cancer deaths worldwide. Early detection is essential for long-term survival. Screening of high-risk individuals with low-dose computed tomography screening has proven to increase survival. However, current radiological imaging techniques have poor specificity for lung cancer detection and poor sensitivity for detection of mucosal or alveolar preinvasive malignant lesions. Bronchoscopy allows imaging and sampling of early lung cancer, with the highest safety profile and high diagnostic accuracy. RECENT FINDINGS: Available technologies, such as autofluorescence bronchoscopy, narrow band imaging, and radial ultrasound bronchoscopy can significantly increase the yield and diagnostic accuracy of bronchoscopy for early cancer detection in the central airways. Newer technologies such as optical coherence tomography, confocal bronchoscopy, and Raman spectroscopy may significantly increase the diagnostic yield of both central and parenchymal early cancer lesions. SUMMARY: Although some of these technologies are still investigational and are not readily available in most centers, they may identify early mucosal and alveolar cancer lesions accurately in the least invasive manner to provide appropriate therapy and prolong patient survival from lung cancer.

Saddle pulmonary embolism: is it as bad as it looks? A community hospital experience.

BACKGROUND: Saddle pulmonary embolism represents a large clot and a risk for sudden hemodynamic collapse. However, the clinical presentation and outcomes vary widely. On the basis of the findings of right heart dysfunction on echocardiograms, computed tomography angiography, or cardiac enzyme elevation, some argue for the use of thrombolytics or catheter thrombectomy even for hemodynamically stable patients. OBJECTIVE: To investigate the outcomes and management of patients with saddle pulmonary embolism, including radiographic appearance (estimate of clot burden) and echocardiographic features. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: This study is a retrospective evaluation of all patients with computed tomography angiography positive for pulmonary embolism from June 1, 2004, to February 28, 2009. Two radiologists selected those with saddle pulmonary embolism and evaluated the clot burden score. The clinical information, echocardiography, treatments, and outcomes of these patients were extracted via chart review. Saddle pulmonary embolism was found in 37 of 680 patients (5.4%, 95% confidence interval 4% to 7%) with documented pulmonary embolism on computed tomography angiography. For patients with saddle pulmonary embolism, the median age was 60 yrs and 41% were males. Major comorbidities were neurologic (24%), recent surgery (24%), and malignancy (22%). Transient hypotension occurred in 14% and persistent shock in 8%. One patient required mechanical ventilation. Echocardiography was performed in 27 patients (73%). Right ventricle enlargement and dysfunction were found in 78% and elevated pulmonary artery systolic pressure in 67%. Computed tomography angiography demonstrated a high median pulmonary artery clot burden score of 31 points. The median right ventricle to left ventricle diameter ratio was 1.39. Inferior vena cava filters were placed in 46%. Unfractionated heparin was administered in 33 (87%) and thrombolytics in four (11%). The median hospital length of stay was 9 days. Two of 37 saddle pulmonary embolism patients (5.4%) died in the hospital (95% confidence interval 0.7% to 18%). CONCLUSIONS: Most patients with saddle pulmonary embolism found on computed tomography angiography responded to the standard management for pulmonary embolism with unfractionated heparin. Although ominous in appearance, most patients with saddle pulmonary embolism are hemodynamically stable and do not require thrombolytic therapy or other interventions.

Bronchoscopic Lung Volume Reduction with Valves and Coils. A Network Meta-analysis.

Background: Coils and endobronchial valves are the most widely used bronchoscopic lung volume reduction devices in patients with advanced emphysema. However, the choice of each specific device depends on emphysema characteristics (homogeneous vs. heterogeneous) and presence of lobar collateral ventilation (CV). These devices have not been compared in a head-to-head study design.Objectives: To conduct a network comparative meta-analysis studying the effect of valves in patients with heterogeneous emphysema without CV, and to also study the effects of valves and coils in patients with mixed homogeneous and heterogeneous emphysema.Data Sources and Data Extraction: PubMed and Web of Science were searched for potentially includable randomized active comparator trials from inception to January 20, 2020, and data were extracted in the working sheets of Comprehensive Meta-analysis.Synthesis: Network meta-analysis was conducted in R program using package "netmeta."Results: In patients with heterogeneous emphysema without CV, both Spiration and Zephyr valves showed significant increases in forced expiratory volume in 1 second (FEV1) (0.11 L [95% confidence interval (CI), 0.05 to 0.16] and 0.14 L [0.08 to 0.19], respectively) and in reducing St. Georges Respiratory Questionnaire (SGRQ) scores (-9.32 [-14.18 to -4.45] and -8.14 [-11.94 to -4.35], respectively) as compared with control, with no significant interintervention differences. Only Zephyr valves showed significant improvement (52.3 m [95% CI, 26.53 to 77.93]) in six-minute walk distance (6MWD). Both were ranked as equally efficacious in these patients. In the mixed homogeneous and heterogeneous emphysema group of patients, both Zephyr valves and coils showed significant increases in FEV1 and 6MWD and reduction in SGRQ, as compared with control. Although there were no significant interintervention differences, the magnitude of improvement in these parameters was highest with Zephyr valves (e.g., 6MWD increased by 56.74 m [23.66 to 89.81] vs. 30.31 m [4.00 to 56.63]) in coils), ranking them first. In both populations, these interventions showed a statistically significant association with procedure-related pneumothorax but not with chronic obstructive pulmonary disease exacerbation.Conclusions: In patients with heterogeneous emphysema without CV, both Zephyr and Spiration valves were equally efficacious in FEV1 and SGRQ improvement. However, in the mixed patients with homogeneous and heterogeneous emphysema, Zephyr valves show relative superiority over coils especially with respect to improvement in 6MWD.

Percutaneous Tracheostomy With Apnea During Coronavirus Disease 2019 Era: A Protocol and Brief Report of Cases.

OBJECTIVE: To assess feasibility of modified protocol during percutaneous tracheostomy in coronavirus disease 2019 pandemic era. DESIGN: A retrospective review of cohort who underwent percutaneous tracheostomy with modified protocol. SETTINGS: Medical, surgical, and neurologic ICUs. SUBJECTS: Patients admitted in medical, surgical, and neurologic units with prolonged need of mechanical ventilation or inability to liberate from the ventilator. INTERVENTIONS: A detailed protocol was written. Steps were defined to be performed before apnea and during apnea. A feasibility study of 28 patients was conducted. The key aerosol-generating portions of the procedure were performed with the ventilator switched to standby mode with the patient apneic. MEASUREMENTS AND MAIN RESULTS: Data including patient demographics, primary diagnosis, age, body mass index, and duration of apnea time during the tracheostomy were collected. Average ventilator standby time (apnea) during the procedure was 238 seconds (3.96 min) with range 149 seconds (2.48 min) to 340 seconds (5.66 min). Single-use (disposable) bronchoscopes (Ambu A/S [Ballerup, Denmark] or Glidescope [Verathon, Inc., Bothell, WA]) were used during all procedures except in nine. No desaturation events occurred during any procedure. CONCLUSIONS: Percutaneous tracheostomy performed with apnea protocol may help minimize aerosolization, reducing risk of exposure of coronavirus disease 2019 to staff. It can be safely performed with portable bronchoscopes to limit staff and minimize the surfaces requiring disinfection post procedure.

Transbronchial Lung Cryobiopsy and Video-assisted Thoracoscopic Lung Biopsy in the Diagnosis of Diffuse Parenchymal Lung Disease. A Meta-analysis of Diagnostic Test Accuracy.

RATIONALE: Transbronchial lung cryobiopsy is increasingly being used for the assessment of diffuse parenchymal lung diseases. Several studies have shown larger biopsy samples and higher yields compared with conventional transbronchial biopsies. However, the higher risk of bleeding and other complications has raised concerns for widespread use of this modality. OBJECTIVES: To study the diagnostic accuracy and safety profile of transbronchial lung cryobiopsy and compare with video-assisted thoracoscopic surgery (VATS) by reviewing available evidence from the literature. METHODS: Medline and PubMed were searched from inception until December 2016. Data on diagnostic performance were abstracted by constructing two-by-two contingency tables for each study. Data on a priori selected safety outcomes were collected. Risk of bias was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool. Random effects meta-analyses were performed to obtain summary estimates of the diagnostic accuracy. RESULTS: The pooled diagnostic yield, pooled sensitivity, and pooled specificity of transbronchial lung cryobiopsy were 83.7% (76.9-88.8%), 87% (85-89%), and 57% (40-73%), respectively. The pooled diagnostic yield, pooled sensitivity, and pooled specificity of VATS were 92.7% (87.6-95.8%), 91.0% (89-92%), and 58% (31-81%), respectively. The incidence of grade 2 (moderate to severe) endobronchial bleeding after transbronchial lung cryobiopsy and of post-procedural pneumothorax was 4.9% (2.2-10.7%) and 9.5% (5.9-14.9%), respectively. CONCLUSIONS: Although the diagnostic test accuracy measures of transbronchial lung cryobiopsy lag behind those of VATS, with an acceptable safety profile and potential cost savings, the former could be considered as an alternative in the evaluation of patients with diffuse parenchymal lung diseases.

Hipercalciura idiopática: efecto de una sobrecarga proteica aguda sobre el pH sanguíneo y la densitometría osea / Idiopatic hipercalciuria: effect of an acute protein overload on blood pH and bone densitometry

En varios estudios se ha demostrado que una dieta hiperproteica disminuye el pH sanguíneo y aumenta la excreción de calcio urinario por mayor producción endógena de ácido que produce mayor salida de calcio al hueso, favoreciendo la formación de cálculos renales y osteoporosis. Evaluar los cambios del pH sanguíneo y la fracción excretada de calcio después de una sobrecarga proteica aguda en sujetos con litiasis, hipercalciúricos, normocalciúricos y controles sanos para determinar si existen respuestas diferentes entre los tres grupos y relacionar estos resultados con la densidad mineral ósea previa. Se realizó un estudio experimental descriptivo correlacional, con 10 pacientes hipercalciúricos con litiasis (HC) y 12 pacientes normocalciúricos con litiasis (NC) seleccionados aleatoriamente y se agregaron 10 sujetos controles sanos (CS). Todos ellos fueron sometidos a una densitometría ósea y a una dieta con control de sodio, calcio y proteínas durante 7 días. Al septimo día se recolectó la orina de 24 horas; al octavo día se obtuvieron muestras de sangre y orina basales e inmediatamente después fueron sometidos a una sobre carga oral proteica aguda de 100 g y se tomaron muestras de sangre y orina en intervalos sucesivos de una hora por cuatro mediciones adicionales. Los pacientes HC disminuyeron significativamente el pH sanguíneo posterior a la sobrecarga oral (p<0,02) a diferencia de NC y CS. El pH urinario aumento significativamente en los tres grupo. La FECa solo aumentó en todos los grupos y significativamente en T1 de NC y CS. La FENa solo aumentó significativamente en NC y CS en T1 (p<0,04) y no hubo aumento significativo en HC. No hubo diferencias significativas en DMO total o parcial en los grupos. Los pacientes hipercalciúricos muestran una rspuesta ácida mayor a una sobrecarga oral aguda proteica además de un incremento de la fracción excretada de calcio mantenida en el tiempo a diferencia de los controles litiásicos normocalciúricos y controles sanos

Evaluación de la severidad de la insuficiencia aórtica mediante la técnica de isovelocidades proximales (PISA) / Evaluation of the severity of the aortic insuficiency: proximal isovelocity technique (PISA)

Estudiar la técnica no invasiva de ecocardiografía bidimencional con Doppler color (eco.Doppler PISA) en la valoración de la severidad de la insuficiencia aórtica (IAO). Estudiamos un grupo de 12 pacientes (pts) portadores de IAO por los métodos clínicos, electrocardiográfico, radiológicos, eco-Doppler y hemodinámico (cineventriculografía y aortografía). Hubo 9 pts de sexo masculino y 3 femenino. La edad promedio fue 40 ñ 23,2 años. Por aortografía fue catalogada por dos o más observadores como trivial, leve moderada y severa. Por eco-Doppler y PISA, la IAO fue catalogada como trivial (con VR menor de 25 cm3/m²sc) lo cual no ocurrió en ninguno de nuestros pts (0 por ciento); fue catalogada como leve (con VR entre 25-50 cm3/m²) en 2 casos (17 por ciento); como moderada (con VR entre 51-100 cm3/m²sc) en 7 casos (58 por ciento), y como severa (con VR mayor de 100 cm3/m²sc) en 3 casos (25 por ciento). La correlación con la angiografía fue satisfactoria. Por otra parte, conociendo el ORE y VR podemos determinar con mayor precisión la severidad de la IAO. Es posible cuantificar por el método PISA la severidad de la IAO, siendo esta experiencia inicial satisfactoria