[Flexible bronchoscopy: contribution of the anesthesiologis]. / Bronchoscopie souple : apport du médecin anesthésiste.

The field of interventional pulmonology is expanding rapidly with increasingly complex endoscopic procedures. Pulmonologists and anesthesiologists are both airway specialists. When they cooperate in performing flexible bronchoscopies, they must share a common anatomical space. A close and dynamic collaboration helps to optimize patient management by enhancing safety, facilitating the procedures and improving patient satisfaction. Several challenges are to be taken up, notably managing frail and often polymorbid patients, working outside the usual operating-room area, and the need to be quickly available, given the frequently semi-urgent setting of these procedures. In this context, the optimization of collaborative procedures is essential.

Le domaine de la pneumologie interventionnelle est en pleine expansion, avec des procédures endoscopiques de plus en plus complexes. Le pneumologue et le médecin anesthésiste sont deux spécialistes des voies aériennes. Lorsqu'ils coopèrent dans la réalisation des bronchoscopies souples, ils doivent partager un espace anatomique commun. Une collaboration étroite et dynamique permet d'optimiser la prise en charge en renforçant la sécurité, en facilitant la réalisation des procédures et en améliorant la satisfaction du patient. Plusieurs défis sont à relever, notamment la fragilité des patients souvent polymorbides, les conditions de travail hors bloc opératoire et la nécessité de plages d'anesthésie rapidement disponibles au vu d'indications le plus souvent semi-urgentes. Dans ce contexte, l'optimisation des procédures de collaboration est essentielle.

Utility of Rapid On-Site Cytologic Evaluation during Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Malignant and Nonmalignant Disease.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an accurate procedure to sample mediastinal tissue. Rapid on-site cytologic evaluation (ROSE) has been advocated to improve the performance of this procedure, but its benefit remains controversial. Our objective is to assess the utility of ROSE for EBUS-TBNA diagnostic accuracy among unselected patients. METHODS: We prospectively collected data from all consecutive EBUS-TBNA procedures performed between 2008 and 2014. ROSE was introduced since 2011 in our daily practice. The accuracy of EBUS-TBNA with and without ROSE was compared in a univariate and multivariate model accounting for confounding factors. The impact of ROSE was then analyzed according to the etiology and size of the lesions. RESULTS: Among 348 EBUS-TBNA procedures analyzed, 213 were performed with ROSE. The overall accuracy tended to be better with ROSE than without (90.6 vs. 84.4%; p = 0.082). After adjustment in a multivariate model, the benefit of ROSE still did not reach statistical significance (adjusted odds ratio 1.86; 95% confidence interval 0.79-4.41). Similar results were obtained in subgroups of patients with malignant disease or sarcoidosis. The size of the lesion did not influence the impact of ROSE on accuracy. CONCLUSIONS: ROSE was associated with a moderate increase in the accuracy of EBUS-TBNA, but the difference was not statistically significant. The same effect of ROSE was observed in malignant and nonmalignant lesions and this effect was not influenced by the lesion's size.

Unusual presentations and pitfalls of secondary syphilis: osteitis, pneumonia and malignancy.

Syphilis can show unexpected clinical characteristics rendering its diagnosis difficult. We report on two cases of secondary syphilis presenting with atypical histories of knee or cervical pain and cough. Both had bone involvement and one, pulmonary involvement, documented by MRI, CT scan and PCR. Both responded well to therapy with intravenous aqueous penicillin G followed by intramuscular benzathine penicillin G, but a pulmonary adenocarcinoma was diagnosed during follow-up in one case.

Diagnostic yield and safety of electromagnetic navigation bronchoscopy for lung nodules: a systematic review and meta-analysis.

BACKGROUND: Electromagnetic navigation bronchoscopy (ENB) is an emerging endoscopic technique for the diagnosis of peripheral lung lesions. A thorough analysis of ENB's yield and safety is required for comparison to other sampling modalities. OBJECTIVES: To describe ENB's yield and safety profile. METHODS: The MEDLINE and EMBASE databases were systematically searched for studies reporting ENB's yield for peripheral lung lesions. Two independent investigators extracted data and rated each study on a scale of methodological quality. Clearly defined performance outcomes were reconstructed and meta-analyzed. Subgroup analysis and meta-regression were used to identify possible sources of study heterogeneity. RESULTS: A total of 15 trials were included (1,033 lung nodules). A positive and definitive diagnosis was obtained after 64.9% of all ENB procedures (95% CI 59.2-70.3). Overall diagnostic accuracy was 73.9% (95% CI 68.0-79.2). Sensitivity to detect cancer was 71.1% (95% CI 64.6-76.8), with a negative predictive value of 52.1% (95% CI 43.5-60.6). Pneumothorax occurred in 3.1% of patients, requiring chest tube drainage in 1.6% of these cases. Original trials identified 6 variables associated with higher ENB yields: nodule location in the upper or middle lobes, nodule size, lower registration error, presence of a bronchus sign on CT imaging, combined use of an ultrasonic radial probe, and catheter suctioning as a sampling technique. Heterogeneity exploration revealed that studies using general anesthesia or rapid on-site cytological evaluation reported better yields. CONCLUSIONS: ENB is effective and particularly safe. Prospective studies are needed to clarify the role of several variables conditioning the yield of this technique.

[Electromagnetic navigation bronchoscopy for the assessment of peripheral lung nodules]. / Rencontre du "GPS" et du poumon: navigation electromagnétique pour le diagnostic des lésions pulmonaires.

Among recent technological progress, electromagnetic navigational bronchoscopy (ENB), based on the principle of "GPS", allows the bronchoscopist to reach parenchymal lesions situated beyond the field of regular bronchoscopy. Compared to CT-scan guided transthoracic needle aspiration, the yield is lower (65%). However, the rate of complication (pneumothorax, hemorrhage) is significantly lower and the patient is not irradiated. Moreover, the yield remains stable also for cases associated to a lower yield of the transthoracic approach (small and/or deep and/or benign lesion). Beyond the diagnosis of peripheral lung nodules, ENB (alone or in combination with endobronchial ultrasound) is also an efficient and safe tool for disease staging by simultaneous (during the same procedure) sampling of associated hypermetabolic lymph nodes.

Effect of different growth hormone (GH) mutants on the regulation of GH-receptor gene transcription in a human hepatoma cell line.

OBJECTIVE: G to A transition at position 6664 of the growth hormone (GH-1) gene results in the substitution of Arg183 by His (R183H) in the GH protein and causes a new form of autosomal dominant isolated GH deficiency (IGHD type II). The aim of this study was to assess the bioactivity of this R183H mutant GH in comparison with both other GH variants and the 22-kDa GH in terms of GH-receptor gene regulation. DESIGN AND METHODS: The regulation of the GH-receptor gene (GH-receptor/GH binding protein, GHR/GHBP) transcription following the addition of variable concentrations (0, 12.5, 25, 50 and 500 ng/ml) of R183H mutant GH was studied in a human hepatoma cell line (HuH7) cultured in a serum-free hormonally defined medium. In addition, identical experiments were performed using either recombinant human GH (22-kDa GH) as a positive control or two GH-receptor antagonists (R77C mutant GH and pegvisomant (B-2036-PEG)) as negative controls. GHR/GHBP mRNA expression was quantitatively assessed by RT-PCR amplification after 0, 1, 3 and 6 h incubation. RESULTS: Following the addition of R183H mutant GH, GHR/GHBP mRNA changed at a similar rate to that seen in experiments where 22-kDa GH was added, indicating equal bioactivity. At all times and concentrations studied, the addition of R77C mutant GH, however, resulted in a significantly lower increase (P<0.001) of GHR/GHBP mRNA concentration compared with that caused by the addition of either 22-kDa GH or R183H mutant GH. Furthermore, in additional experiments, pegvisomant resulted in an absolute block of GHR/GHBP mRNA expression identical to that seen in control experiments where no 22-kDa GH was added at all. CONCLUSIONS: These data indicate that the R183H mutant GH, although causing an autosomal dominant form of IGHD has an identical effect on GHR/GHBP transcription as its wild-type, the 22-kDa GH. This implies that the IGHD caused by the R183H heterozygous mutation of the GH-1 gene is mainly due to a block of its regulated GH secretion. In addition, the R77C-GH variant and pegvisomant have an antagonistic effect at the level of GHR/GHBP transcription. All these data were confirmed by run-on experiments. In addition, these data highlight, as far as the GH variants are concerned, that a mutational alteration within the GH-1 gene might cause short stature also on the basis of an altered secretory pathway. This fact has to be taken into consideration when growth retardation is clinically diagnosed and studied at the molecular level. Secretory pathways and, therefore, cell-biological mechanisms are of importance and have to be considered in future not only at the scientific but also at the clinical level.