Is there a role for fibreoptic bronchoscopy in patients presenting with haemoptysis and negative CT? A systematic review and meta-analysis.

INTRODUCTION: Haemoptysis can be a feature of lung cancer and patients are typically fast-tracked for evaluation with chest radiography, contrast-enhanced CT and fibreoptic bronchoscopy (FOB). OBJECTIVE: We aim to explore whether FOB should be conducted as a component of the routine evaluation of non-massive haemoptysis, especially in the context of suspected lung cancer. METHODS: MEDLINE, EMBASE and Cochrane Library were searched for studies comparing FOB with CT in the evaluation of non-massive haemoptysis while reporting at least one of the listed primary outcomes. Primary outcomes include sensitivity of diagnostic modality with respect to lung cancer. Secondary outcomes include detection of other aetiologies such as infection. Results were synthesised using a random effects meta-analysis. Sensitivity analysis was performed for patient age group and year of study. Risk of bias assessment was carried out with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. RESULTS: A total of 2273 citations were screened and 11 studies were included, comprising a total sample size of 2015 patients with 226 confirmed cases of lung cancer. A total of 1816 and 1734 patients received a CT scan and FOB, respectively. The pooled sensitivities for detection of lung cancer using CT scan and bronchoscopy were 98% (95% CI 93.0% to 99.0%) and 86% (95% CI 63.0% to 95.0%), respectively. The sensitivity of CT was higher than that of FOB for both primary and secondary outcomes. CONCLUSION: This study suggests that bronchoscopy does not offer significant additional diagnostic benefit in the evaluation of patients presenting with non-massive haemoptysis and a negative CT scan.

The role of procalcitonin and IL-6 in discriminating between septic and non-septic causes of ALI/ARDS: a prospective observational study.

BACKGROUND: The aim was to evaluate the clinical usefulness of a single plasma and bronchoalveolar lavage fluid (BALF) PCT and IL-6 measurement in discriminating septic from non-septic causes of acute respiratory distress syndrome (ARDS) and forecasting clinical outcomes. METHODS: One hundred patients were enrolled within 48 h of ALI/ARDS recognition. Demographic, clinical data, severity indices were recorded and PCT and IL-6 concentrations were measured in plasma and BALF. RESULTS: Plasma PCT and IL-6 values were significantly higher in septic compared to non-septic individuals (p=0.001 and 0.0005, respectively), while there were no differences in their respective BALF values. As far as identification of septic vs. non-septic ARDS is concerned, the comparison of the areas under the curves favored PCT vs. IL-6 [0.88, (95% CI 0.81-0.95) vs. 0.71, (95% CI 0.60-0.81); χ(2)=9.04, p=0.003]. A plasma PCT level of 0.815 ng/mL was associated with 74.1% sensitivity and 97.6% specificity in identifying septic ARDS cases; this corresponded to a diagnostic odds ratio value of 116. Linear regression multivariable analysis disclosed a significant relation of plasma PCT with SOFA score in septic ARDS patients (p<0.001), while neither BALF PCT nor IL-6 levels were associated with clinical outcome. CONCLUSIONS: Early plasma - but not BALF - PCT concentrations can discriminate between septic and non-septic ARDS causes and are associated with the severity of multiple organ dysfunction syndrome in septic ARDS patients. However, neither plasma or BALF IL-6 levels nor BALF PCT levels carry any prognostic potential. A single plasma PCT value higher than 0.815 ng/mL makes a non-septic cause of ARDS highly unlikely.

Lung cancer recovery focus post pandemic: an income-deprived area paradigm.

'Stage shift' has been proposed as a marker of impact of Coronavirus 2019 (COVID-19) in lung cancer services; however, there are no data available specifically from income-deprived areas. Thus, this study evaluated the impact of the COVID-19 pandemic on lung cancer care in our area (Corby; among the most income deprived in England) and identified focus recovery areas. The study was a retrospective observational study of 668 consecutive patients with lung cancer at a district general hospital, pre-, during and after the COVID peak. Outcomes were the overall number of cases, presenting staging and treatment pathway. Overall, 32 fewer patients were diagnosed during the pandemic, with more inpatient diagnoses (p=0.01) and fewer primary care referrals (p<0.0001). There were no differences observed in treatment intent or 'stage shift'. Our results suggest that COVID-19 negatively affected the whole lung cancer pathway in our area. However, 'stage shift' might not be ideal to assess the impact of COVID-19 in income-deprived areas. Further studies will help the strategic rollout of a screening programme to identify patients with lung cancer earlier on in such areas.

Metformin attenuates ventilator-induced lung injury.

INTRODUCTION: Diabetic patients may develop acute lung injury less often than non-diabetics; a fact that could be partially ascribed to the usage of antidiabetic drugs, including metformin. Metformin exhibits pleiotropic properties which make it potentially beneficial against lung injury. We hypothesized that pretreatment with metformin preserves alveolar capillary permeability and, thus, prevents ventilator-induced lung injury. METHODS: Twenty-four rabbits were randomly assigned to pretreatment with metformin (250 mg/Kg body weight/day per os) or no medication for two days. Explanted lungs were perfused at constant flow rate (300 mL/min) and ventilated with injurious (peak airway pressure 23 cmH2O, tidal volume ≈17 mL/Kg) or protective (peak airway pressure 11 cmH2O, tidal volume ≈7 mL/Kg) settings for 1 hour. Alveolar capillary permeability was assessed by ultrafiltration coefficient, total protein concentration in bronchoalveolar lavage fluid (BALF) and angiotensin-converting enzyme (ACE) activity in BALF. RESULTS: High-pressure ventilation of the ex-vivo lung preparation resulted in increased microvascular permeability, edema formation and microhemorrhage compared to protective ventilation. Compared to no medication, pretreatment with metformin was associated with a 2.9-fold reduction in ultrafiltration coefficient, a 2.5-fold reduction in pulmonary edema formation, lower protein concentration in BALF, lower ACE activity in BALF, and fewer histological lesions upon challenge of the lung preparation with injurious ventilation. In contrast, no differences regarding pulmonary artery pressure and BALF total cell number were noted. Administration of metformin did not impact on outcomes of lungs subjected to protective ventilation. CONCLUSIONS: Pretreatment with metformin preserves alveolar capillary permeability and, thus, decreases the severity of ventilator-induced lung injury in this model.

Utilization of High-pressure Suction for EBUS-TBNA Sampling in Suspected Lung Cancer.

BACKGROUND: Sample adequacy for immediate molecular testing is paramount in lung cancer. To date, several endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) sampling setups have been evaluated, however, the utilization of high-pressure suction (HPS) has not yet been reported.The aim of this study was to evaluate the utilization of HPS onto the needle and its effect on sample volume and adequacy for molecular testing in patients with suspected lung cancer. METHODS: We retrospectively analyzed 128 consecutive EBUS-TBNA performed for suspected lung cancer. This was confirmed in 109 patients. Other diagnoses confirmed in 12, and 7 referred for surgery. Sixty-three patients (89 targets) had HPS (May to September 2020), and compared with 46 (72 targets) who had standard vacuum syringe suction (October 2019 to March 2020). Several parameters and outcomes evaluated, such as number of needle passes, needle strokes, needle size, target size, positron emission tomography avidity, procedure time, blood content score, sample volume, adequacy for molecular testing, as well as baseline patient characteristics and complication rate. RESULTS: There was no difference between the 2 groups in all baseline parameters and characteristics. In multivariable analysis, HPS was associated with significantly higher sample volume (11.2 vs. 9.1 mm3, P=0.036) and less additional procedures to achieve full molecular profiling (2/52 vs. 7/40, P=0.042), in necrotic targets of non-small cell lung cancer. Diagnostic yields were comparable. CONCLUSION: HPS appears to be simple, no-cost, and safe, promising higher sample volume compared with vacuum syringe suction, and also appears to be associated with higher success of full molecular testing with less additional procedures, in non-small cell lung cancer necrotic targets.

Malignant melanoma without primary, presenting as solitary pulmonary nodule: a case report.

BACKGROUND: Solitary pulmonary nodules are the most common incidental finding on chest imaging. Their management is very well defined by several guidelines, with risk calculators for lung cancer being the gold standard. Solitary intramuscular metastasis combined with a solitary pulmonary nodule from malignant melanoma without a primary site is rare. CASE PRESENTATION: A 57-year-old white male was referred to our lung cancer service with solitary pulmonary nodule. After positron-emission tomography, we performed an ultrasound-guided core needle biopsy of an intramuscular solitary lesion, not identified on computed tomography scan, and diagnosed metastatic malignant melanoma. The solitary pulmonary nodule was resected and also confirmed metastatic melanoma. There was no primary skin lesion. The patient received oral targeted therapy and is disease-free 5 years later. CONCLUSIONS: Clinicians dealing with solitary pulmonary nodules must remain vigilant for other extrathoracic malignancies even in the absence of obvious past history. Lung metastasectomy may have a role in metastatic malignant melanoma with unknown primary.

Outcomes of Continuous Positive Airway Pressure in the Management of Patients with Coronavirus (COVID-19) Pneumonia who are not Suitable for Invasive Ventilation.

BACKGROUND: The optimum management of respiratory failure in patients with coronavirus (COVID-19) infections has been a challenge for physicians across the globe. Many scientific societies have suggested the use of CPAP (continuous positive airway pressure) in severe cases in an effort to reduce invasive ventilation. We investigated mortality outcomes in patients who needed CPAP but were not suitable for invasive ventilation. METHODS: We retrospectively evaluated the mortality outcomes of all consecutive COVID-19 cases with severe type 1 respiratory failure requiring FiO2 >0.6 who were admitted to our hospital between 12th March and 04th May'20. British Thoracic Society guidelines were followed for identifying patients needing CPAP. Their outcomes were recorded and compared with a similar group of patients who had oxygen as a ceiling of care. Prospectively collected data between 5th May and 7th June'20 in similar but smaller groups of patients was also analyzed. RESULTS: A total of 104 COVID-19 patients with documented Do Not Attempt Resuscitation (DNAR) decision required high fraction of inspired oxygen (FiO2) >0.6(to maintain peripheral oxygen saturation (SpO2)> 92%(SpO2> 88% in COPD patients). Twenty-four patients received CPAP as the ceiling of care, with a mortality rate of 92.5%. The remaining 84 patients who were on oxygen as a ceiling of treatment had 91.7% mortality. Both population groups had a similar number of comorbidities but were less favorable in terms of age in the control group with standard O2 therapy than those who had CPAP support. Overall mortality outcomes from using CPAP therapy did not bring significant mortality benefit (p-value-0.89). CONCLUSION: CPAP did not appear to improve the survival of patients with severe respiratory failure due to COVID-19 related pneumonia and were not suitable for invasive ventilation. Further studies are warranted to adequately inform appropriate management strategies for this group of patients.

Rare monophasic mediastinal pleural synovial sarcoma diagnosed via endobronchial ultrasound-transbronchial needle aspiration.

The mediastinum is a rare site for occurrence of a primary synovial sarcoma (SS) with very few cases reported in the literature. The diagnosis so far has been achieved mainly via open surgery, with only three reported cases diagnosed via endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA), however, none of those were located at the posterior mediastinum, without showing any oesophageal or endobronchial involvement. To our knowledge, this is the first reported case of a monophasic primary pleural mediastinal SS purely involving the posterior mediastinum without oesophageal or endobronchial component, diagnosed via EBUS-TBNA.

Diagnostic and prognostic value of procalcitonin among febrile critically ill patients with prolonged ICU stay.

BACKGROUND: Procalcitonin (PCT) has been proposed as a diagnostic and prognostic sepsis marker, but has never been validated in febrile patients with prolonged ICU stay. METHODS: Patients were included in the study provided they were hospitalised in the ICU for > 10 days, were free of infection and presented a new episode of SIRS, with fever >38 degrees C being obligatory. Fifty patients fulfilled the above criteria. PCT was measured daily during the ICU stay. The primary outcome was proven infection. RESULTS: Twenty-seven out of 50 patients were diagnosed with infection. Median PCT on the day of fever was 1.18 and 0.17 ng/ml for patients with and without proven infections (p < 0.001). The area under the curve for PCT was 0.85 (95% CI; 0.71-0.93), for CRP 0.65 (0.46-0.78) and for WBC 0.68 (0.49-0.81). A PCT level of 1 ng/mL yielded a negative predictive value of 72% for the presence of infection, while a PCT of 1.16 had a specificity of 100%. A two-fold increase of PCT between fever onset and the previous day was associated with proven infection (p 0.001) (OR = 8.55; 2.4-31.1), whereas a four-fold increase of PCT of any of the 6 preceding days was associated with a positive predictive value exceeding 69.65%. A PCT value less than 0.5 ng/ml on the third day after the advent of fever was associated with favorable survival (p 0.01). CONCLUSION: The reported data support that serial serum PCT may be a valuable diagnostic and prognostic marker in febrile chronic critically ill patients.

A rash and a rare cause of unilateral diaphragmatic paralysis.

A 61-year-old man who was an ex-heavy smoker presented to our ambulatory care centre with a 4-week history of dyspnoea on mild exertion. 2 weeks prior to his symptoms, he had developed right-sided cervical herpes zoster for which he was prescribed oral acyclovir by his general practitioner. On examination, a rash over the right C4-5 dermatomes was noted and dullness on percussion of the right mid and lower zones with markedly reduced air entry. His chest radiograph showed a raised right hemi-diaphragm with associated right middle and lower lobe collapse. Further investigation with CT and bronchoscopy did not identify a cause and showed no evidence of underlying malignancy or endobronchial obstruction. An ultrasound 'sniff test' was performed to confirm diaphragmatic paralysis. We present a rare case of cervical herpes-induced diaphragmatic paralysis, and summarise our approach and the current understanding of this interesting condition.

Clinical usefulness of novel serum and imaging biomarkers in risk stratification of patients with stable angina.

Inflammatory mediators appear to be the most intriguing yet confusing subject, regarding the management of patients with acute coronary syndromes (ACS). The current inflammatory concept of atherosclerotic coronary artery disease (CAD) led many investigators to concentrate on systemic markers of inflammation, as well as imaging techniques, which may be helpful in risk stratification and prognosis assessment for cardiovascular events. In this review, we try to depict many of the recently studied markers regarding stable angina (SA), their clinical usefulness, and possible future applications in the field.

Post-operative Aspergillus mediastinitis in a man who was immunocompetent: a case report.

INTRODUCTION: Aspergillus spp. infections mainly affect patients who are immunocompromised, and are extremely rare in immunocompetent individuals. CASE PRESENTATION: Aspergillus post-operative mediastinitis is considered to be a devastating infection, usually affecting patients undergoing cardiothoracic surgery with specific predisposing factors. We describe the case of an immunocompetent 68-year-old Caucasian man with severe chronic thromboembolic pulmonary hypertension, who underwent pulmonary thromboendarterectomy and developed post-operative mediastinitis due to Aspergillus flavus. The environmental control did not reveal the source of A. flavus infection and, despite combined antifungal therapy, our patient died as a result of septic shock and multiple organ failure. CONCLUSION: Aspergillus mediastinitis mainly affects patients after cardiosurgery operations with predisposing factors, and it is unusual in patients who are immunocompetent. The identification of the Aspergillus spp. source is often difficult, and there are no guidelines for the administration of pre-emptive therapy in this population of at-risk patients.