The role of the host-microbiome and metabolomics in sarcoidosis.

Sarcoidosis is a complex inflammatory fibrotic disease that affects multiple organ systems. It is characterized by the infiltration of lymphocytes and mononuclear phagocytes, which form non-caseating granulomas in affected organs. The lungs and intrathoracic lymph nodes are the most commonly affected organs. The underlying cause of sarcoidosis is unknown, but it is believed to occur in genetically predisposed individuals who are exposed to pathogenic organisms, environmental contaminants, or self and non-self-antigens. Recent research has suggested that the microbiome may play a role in the development of respiratory conditions, including sarcoidosis. Additionally, metabolomic studies have identified potential biomarkers for monitoring sarcoidosis progression. This review will focus on recent microbiome and metabolomic findings in sarcoidosis, with the goal of shedding light on the pathogenesis and possible diagnostic and therapeutic approaches.

Feasibility, safety and outcomes of stereotactic radiotherapy for ultra-central thoracic oligometastatic disease guided by linear endobronchial ultrasound-inserted fiducials.

BACKGROUND & PURPOSE: Local treatment of oligometastases has been found to improve survival and prognosis. Stereotactic body radiotherapy (SBRT) has emerged as a treatment option for oligometastases but its use in ultra-central (UC) areas can cause significant toxicity and mortality. Fiducial markers (FM) can be used to improve SBRT accuracy, and can be inserted in the central thorax using linear endobronchial ultrasound (EBUS) bronchoscopy. Outcomes of FM-guided SBRT for UC thoracic oligometastases is unknown. METHODS: A single-centre retrospective study investigating the feasibility, safety and outcomes of both linear EBUS-inserted FMs and subsequent FM-guided SBRT for UC-oligometastatic disease. Motion analyses of FMs were also performed. RESULTS: Thirty outpatients underwent 32 EBUS-FM insertion procedures with 100 % success, and no major procedural mortality or morbidity. Minor complications were 4.8 % incidence of delayed FM-displacement. UC FM-guided SBRT was completed in 20 patients with 99.9 % fractions delivered. Median SBRT dose delivered was 40 Gy over a median of 8 fractions. Majority of adverse events were Grade 1 and there was no SBRT-related mortality. Local control with SBRT was 95 %, with overall survival at 1-year and 3-years of 90 % and 56.3 % respectively. Median overall survival after SBRT was 43.6 months. FM movements in UC areas were recorded being greatest in the superior-inferior axis. CONCLUSION: Combined linear EBUS sampling and FM-insertion in UC thoracic oligometastatic disease is feasible and safe. UC-SBRT to oligometastases using FM guidance was found to have minimal complications and associated with moderate survival up to 3 years post-treatment.

Isolated unilateral absence of pulmonary artery (IUAPA) in adults: A case series and review of literature.

Unilateral Absence of Pulmonary Artery (UAPA) is a rare congenital malformation that is usually associated with cardiac anomalies. When there is no congenital cardiac abnormality it is rarer still and is termed isolated unilateral absence of pulmonary artery (IUAPA) (4). IUAPA may remain undetected until adulthood and frequently found incidentally on imaging for other indications. Symptoms are usually secondary to complications which include pulmonary hypertension, recurrent respiratory tract infections, bronchiectasis and haemoptysis. We report two cases with widely contrasting presentation and trajectories, leading to individualized management strategies.

Recurrent hepatocellular carcinoma presenting as thoracic lymphadenopathy.

Metastatic hepatocellular carcinoma (HCC) can involve the lung parenchyma. However, predominant thoracic lymphadenopathy involvement is less described and there are multiple alternative malignant and non-malignant causes of a similar appearance. Accurate tissue diagnosis is important to determine appropriate management and prognostication. Here, we report two cases of metastatic HCC recurrence causing large thoracic lymphadenopathy, diagnosed adequately and safely by linear endobronchial ultrasound (EBUS) transbronchial needle aspiration.

A novel procedure of endobronchial ultrasound-guided transbronchial needle aspiration for pulmonary parenchymal lesions: The ZUTAM technique.

Convex probe-endobronchial ultrasound (CP-EBUS) has been proven to be safe and accurate for identifying malignancy and granulomatous disease affecting the mediastinum and hilum. CP-EBUS can be used for intraparenchymal lesions also and has been shown to be efficacious. A subset of lesions particularly suited for CP-EBUS are those completely surrounded by lung parenchyma, centrally located, and typically close to but without an airway leading directly to them. We report a case of transbronchial needle aspiration (TBNA) done from a nodule of size 11 mm in the superior segment of the right lower lobe. EBUS-TBNA was done from this lesion, which was 5 mm away from the bronchus in the lung parenchyma with intervening normal lung tissue in between. TBNA was performed by compressing the abutting normal lung tissue, thus causing compression collapse of the intervening normal lung. We labeled this Zealous Unique Trans Arterial Maneuver as the "ZUTAM" technique.

Spontaneous fracture of indwelling pleural catheter.

Indwelling pleural catheters (IPCs) are increasingly used for the management of symptomatic malignant pleural effusion worldwide. IPCs have been documented to reduce the number of hospital bed days in patients with malignant pleural effusion and thus are often used as the preferred mode of management in fit healthy patients with good performance status. Complications related to IPCs, mainly in the form of pleural infection and needle tract metastasis, are well reported in the literature. Similarly, fracture of IPCs is a recognized complication during the process of IPC removal. We report the first ever case of spontaneous fracture of IPC in a patient with Stage IV lung cancer with malignant pleural effusion who was undergoing active chemotherapy and symptomatic management of the pleural effusion with an IPC.

Multi-focal, multi-centric granular cell tumours: a management dilemma.

Granular cell tumours (GCT) are uncommon, usually solitary tumours of neural/Schwann cell origin that occur at any site of the body, and typically run an indolent clinical course. Treatment by excision is recommended. Distant or nodal metastases are the only reliable signs of malignancy. We describe the case of a 47-year-old woman with a multi-focal, multi-centric GCT involving the pulmonary and gastrointestinal systems, highlighting the imaging and pathological features and the challenge faced in establishing its malignant potential.

Plastic in patient study: Prospective audit of adherence to peripheral intravenous cannula monitoring and documentation guidelines, with the aim of reducing future rates of intravenous cannula-related complications.

BACKGROUND: Peripheral intravenous cannula (PIVC) insertion is a universal intervention for inpatients and is associated with multiple complications. Effective, simple, reproducible interventions specific to PIVC complication prevention are few and often extrapolated from central venous catheter complication prevention strategies. The objective of this study is to improve compliance with documentation and monitoring PIVC guidelines in the medical ward of a secondary care center. METHODS: This study is a prospective run-in audit of adherence to PIVC documentation and monitoring guidelines between the dates of August 30-November 14, 2014, with data recollection from December 25, 2014-January 30, 2015, after intervention implementation. Three interventions were implemented. The Plastic in Patient (PIP) strip is a dedicated column on the journey board, identifying inpatients with PIVCs, prompting assessment of indication at daily multidisciplinary meetings. PIP row is a prompt in the medical admission proforma to review PIVC indication. PIP poster is a visual cue on PIVC trolleys highlighting PIVC management practices. RESULTS: Baseline demographics were similar in the pre- and postintervention groups. Documentation significantly improved in the postintervention group (36.4 vs 50%, P = .025). Early identification of nonindicated PIVCs improved in the postintervention group (88.8% vs 97.1%, P = .018) and a trend toward a reduced PIVC-related early phlebitis rate (3.7% vs 0, P = .08). CONCLUSIONS: Simple, cost-effective interventions result in improvements in adherence to practice guidelines. Our results suggest a trend toward reduction in phlebitis rates.