Diagnosis and Detection of Sarcoidosis. An Official American Thoracic Society Clinical Practice Guideline.

Background: The diagnosis of sarcoidosis is not standardized but is based on three major criteria: a compatible clinical presentation, finding nonnecrotizing granulomatous inflammation in one or more tissue samples, and the exclusion of alternative causes of granulomatous disease. There are no universally accepted measures to determine if each diagnostic criterion has been satisfied; therefore, the diagnosis of sarcoidosis is never fully secure.Methods: Systematic reviews and, when appropriate, meta-analyses were performed to summarize the best available evidence. The evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation approach and then discussed by a multidisciplinary panel. Recommendations for or against various diagnostic tests were formulated and graded after the expert panel weighed desirable and undesirable consequences, certainty of estimates, feasibility, and acceptability.Results: The clinical presentation, histopathology, and exclusion of alternative diagnoses were summarized. On the basis of the available evidence, the expert committee made 1 strong recommendation for baseline serum calcium testing, 13 conditional recommendations, and 1 best practice statement. All evidence was very low quality.Conclusions: The panel used systematic reviews of the evidence to inform clinical recommendations in favor of or against various diagnostic tests in patients with suspected or known sarcoidosis. The evidence and recommendations should be revisited as new evidence becomes available.

The impact of a medical procedure service on patient safety, procedure quality and resident training opportunities.

BACKGROUND: At some academic hospitals, medical procedure services are being developed to provide supervision for residents performing bedside procedures in hopes of improving patient safety and resident education. There is limited knowledge of the impact of such services on procedural complication rates and resident procedural training opportunities. OBJECTIVE: To determine the impact of a medical procedure service (MPS) on patient safety and resident procedural training opportunities. DESIGN: Retrospective cohort analysis comparing characteristics and outcomes of procedures performed by the MPS versus the primary medical service. PARTICIPANTS: Consecutive adults admitted to internal medicine services at a large academic hospital who underwent a bedside medical procedure (central venous catheterization, thoracentesis, paracentesis, lumbar puncture) between 1 July 2010 and 31 December 2011. MAIN MEASURES: The primary outcome was a composite rate of major complications. Secondary outcomes included resident participation in bedside procedures and use of "best practice" safety process measures. KEY RESULTS: We evaluated 1,707 bedside procedures (548 by the MPS, 1,159 by the primary services). There were no differences in the composite rate of major complications (1.6 % vs. 1.9 %, p = 0.71) or resident participation in bedside procedures (57.0 % vs. 54.3 %, p = 0.31) between the MPS and the primary services. Procedures performed by the MPS were more likely to be successfully completed (95.8 % vs. 92.8 %, p = 0.02) and to use best practice safety process measures, including use of ultrasound guidance when appropriate (96.8 % vs. 90.0 %, p = 0.0004), avoidance of femoral venous catheterization (89.5 vs. 82.7 %, p = 0.02) and involvement of attending physicians (99.3 % vs. 57.0 %, p < 0.0001). CONCLUSIONS: Although use of a MPS did not significantly affect the rate of major complications or resident opportunities for training in bedside procedures, it was associated with increased use of best practice safety process measures.

Transoral Minimally Invasive Tracheoplasty Technique for Cervical Tracheomalacia.

We report a case of cervical tracheomalacia successfully treated by tracheoplasty. The resection of redundant posterior tracheal tissue was performed with a novel minimally invasive transoral approach.

Procedural Aggressiveness in Veterans with Advanced Non-Small-Cell Lung Cancer at the End of Life.

BACKGROUND: Evidence suggests that the aggressiveness of care in cancer patients at the end of life is increasing. We sought to evaluate the use of invasive procedures at the end of life in patients with advanced non-small-cell lung cancer (NSCLC). OBJECTIVE: To evaluate the utilization of invasive procedures at the end of life in Veterans with advanced NSCLC. DESIGN: Retrospective cohort study of Veterans with newly diagnosed stage IV NSCLC who died between 2006 and 2012. SETTING/SUBJECTS: Subjects were identified from the Veterans Affairs Central Cancer Registry. MEASUREMENTS: All Veterans Administration (VA) and Medicare fee-for-service healthcare utilization and expenditure data were assembled for all subjects. The primary outcome was the number of invasive procedures performed in the last month of life. We classified procedures into three categories: minimally invasive, life-sustaining, and major-operative procedures. Logistic regression analysis was used to evaluate factors associated with the receipt of invasive procedures. RESULTS: Nineteen thousand nine hundred thirty subjects were included. Three thousand (15.1%) subjects underwent 5523 invasive procedures during the last month of life. The majority of procedures (69.6%) were classified as minimally invasive. The receipt of procedures in the last month of life was associated with receipt of chemotherapy (odds ratio [OR] 3.68, 95% confidence interval [CI] 3.38-4.0) and ICU admission (OR 3.13, 95% CI 2.83-3.45) and was inversely associated with use of hospice services (OR 0.35, 95% CI 0.33-0.38). CONCLUSIONS: Invasive procedures are commonly performed among Veterans with stage IV NSCLC during their last month of life and are associated with other measures of aggressive end-of-life care.

Volunteer patients and small groups contribute to abdominal examination's success.

BACKGROUND: Prior to 2007, we taught the abdominal examination in a hospital based group to 40 students, at one hospital. We used volunteer patients, small groups, repetition, and required faculty development sessions. In 2007, our medical school changed its "Introduction to Physical Examination" session so that the entire class was to be taught in a geographically central session. Our hospital was selected to lead the abdominal examination portion of the session. AIM: Our aim was to answer three questions. First, could we quadruple the recruitment of volunteer patients, and faculty? Second, was it volunteer patients, small groups, repetition, or faculty training that was most valued by the students? Third, would volunteer patients and/or faculty agree to participate a second time? METHODS: A total of 43-46 patients and 43-46 faculty were recruited and 43-46 examining rooms were obtained for each of the 5 years of this study. Teachers were required to attend a 1-hour faculty development session. The class of about 170 students was divided into 43-46 groups each year. The teacher demonstrated the abdominal examination and each student practiced the examination on another student. Each student then repeated the full abdominal examination on a volunteer patient. RESULTS: Over the 5-year time period (2008-2012), the abdominal examination ranked first among all organ systems' "Introductory Sessions". The abdominal examination ratings had the best mean score (1.35) on a Likert scale where 1 is excellent and 5 is poor. The students gave the most positive spontaneous comments to having volunteer patients, with small groups coming in as the second most appreciated educational element. CONCLUSION: We successfully quadrupled the number of faculty, patients, and examining rooms and created a highly rated educational program as measured by anonymous student evaluations, patient and faculty participation, and the medical school's selecting the abdominal examination methods as an "Advanced Examination" for the Pathways Curriculum.

Readiness for Implementation of Lung Cancer Screening. A National Survey of Veterans Affairs Pulmonologists.

RATIONALE: To mitigate the potential harms of screening, professional societies recommend that lung cancer screening be conducted in multidisciplinary programs with the capacity to provide comprehensive care, from screening through pulmonary nodule evaluation to treatment of screen-detected cancers. The degree to which this standard can be met at the national level is unknown. OBJECTIVES: To assess the readiness of clinical facilities in a national healthcare system for implementation of comprehensive lung cancer screening programs, as compared with the ideal described in policy recommendations. METHODS: This was a cross-sectional, self-administered survey of staff pulmonologists in pulmonary outpatient clinics in Veterans Health Administration facilities. MEASUREMENTS AND MAIN RESULTS: The facility-level response rate was 84.1% (106 of 126 facilities with pulmonary clinics); 88.7% of facilities showed favorable provider perceptions of the evidence for lung cancer screening, and 73.6% of facilities had a favorable provider-perceived local context for screening implementation. All elements of the policy-recommended infrastructure for comprehensive screening programs were present in 36 of 106 facilities (34.0%); the most common deficiencies were the lack of on-site positron emission tomography scanners or radiation oncology services. Overall, 26.5% of Veterans Health Administration facilities were ideally prepared for lung cancer screening implementation (44.1% if the policy recommendations for on-site positron emission tomography scanners and radiation oncology services were waived). CONCLUSIONS: Many facilities may be less than ideally positioned for the implementation of comprehensive lung cancer screening programs. To ensure safe, effective screening, hospitals may need to invest resources or coordinate care with facilities that can offer comprehensive care for screening through downstream evaluation and treatment of screen-detected cancers.

Gestational pulmonary arterial hypertension.

Pulmonary arterial hypertension (PAH) is a progressive disease marked by the irreversible pulmonary vascular changes of vasoconstriction, thrombosis, and proliferation of smooth muscle and endothelial cells. The untreated clinical course is characterized by progressive dyspnea and a median survival of less than 3 years. Many of these patients are of child-bearing age; however, pregnancy leads to physiologic changes that are particularly poorly tolerated in PAH, conferring a 30%-56% mortality. We present a case of PAH that spontaneously resolved after termination of pregnancy and recurred during each of two subsequent pregnancies. To our knowledge, this case is unique, because no cases of spontaneous resolution of idiopathic PAH have been reported in adults, nor have there been any reports of pulmonary hypertension that is isolated to the gestational period.

Validity of ICD-9-CM codes for the identification of complications related to central venous catheterization.

Two complications of central venous catheterization (CVC), iatrogenic pneumothorax and central line-associated bloodstream infection (CLABSI), have dedicated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Despite increasing use of ICD-9-CM codes for research and pay-for-performance purposes, their validity for detecting complications of CVC has not been established. Complications of CVCs placed between July 2010 and December 2011 were identified by ICD-9-CM codes in discharge records from a single hospital and compared with those revealed by medical record abstraction. The ICD-9-CM code for iatrogenic pneumothorax had a sensitivity of 66.7%, specificity of 100%, positive predictive value (PPV) of 100%, and negative predictive value (NPV) of 99.5%. The ICD-9-CM codes for CLABSI had a sensitivity of 33.3%, specificity of 99.0%, PPV of 28.6%, and NPV of 99.2%. The low sensitivity and variable PPV of ICD-9-CM codes for detection of complications of CVC raise concerns about their use for research or pay-for-performance purposes.

The current state of fellowship training in pulmonary artery catheter placement and data interpretation: a national survey of pulmonary and critical care fellowship program directors.

PURPOSE: Given decreasing use of pulmonary artery (PA) catheterization, we sought to evaluate whether current pulmonary and critical care fellows have adequate opportunity to obtain proficiency in PA catheter placement and data interpretation. METHODS: All US pulmonary and critical care program directors were invited to participate in an anonymous online survey regarding current training opportunities in PA catheterization. RESULTS: The response rate was 51% (69/136). Eighty-three percent reported that the number of PA catheterizations performed by fellows within their program has decreased in the past decade. Fifty-four percent estimated that their fellows currently participate in less than 10 supervised procedures during fellowship. The most frequently identified barriers to training were procedure volume and reluctance to place PA catheters in the medical intensive care unit. Forty-three percent of respondents agreed that training in PA catheter placement is currently adequate within their program, and 55% agreed that training in data interpretation is adequate. Only 39% of respondents believe that PA catheter placement should continue to be an Accreditation Council for Graduate Medical Education training requirement. CONCLUSIONS: Many current pulmonary and critical care fellows do not have the opportunity to gain proficiency in PA catheterization. Fellowship training programs should consider alternate means of training fellows in PA catheter data interpretation, such as simulation.

Population-based estimates of transbronchial lung biopsy utilization and complications.

BACKGROUND: Little is known about trends in the utilization or complication rates of transbronchial lung biopsy, particularly in community hospitals. METHODS: We used the Healthcare Cost and Utilization Project Florida State Inpatient and State Ambulatory Surgical Databases to assess trends in transbronchial lung biopsy utilization in adults from 2000 to 2009. We subsequently calculated population based estimates of complications associated with transbronchial lung biopsy (iatrogenic pneumothorax and procedure-related hemorrhage) and identified characteristics associated with complications. RESULTS: From 2000 to 2009, the age-adjusted rate of transbronchial biopsies per 100,000 adults in Florida decreased by 25% from 74 to 55 (p < 0.0001), despite stability in the overall utilization of bronchoscopy. Analysis of 82,059 procedures revealed that complications associated with transbronchial biopsy were uncommon and stable over the study period, with 0.97% (95% CI 0.94-1.01%) of procedures complicated by pneumothorax, 0.55% (95% CI 0.52-0.58%) by pneumothorax requiring chest tube placement, and 0.58% (95% CI 0.55-0.61%) by procedure-related hemorrhage. Patients with COPD (OR 1.51, 95% CI 1.31-1.75) and women (OR 1.32, 95% CI 1.15-1.52) were at increased risk for pneumothorax, while renal failure (OR 2.85, 95% CI 2.10-3.87), cirrhosis (OR 2.31, 95% CI 1.18-4.52), older age (OR 1.17, 95% CI 1.09-1.25) and female sex (OR 1.40, 95% CI 1.17-1.68) were associated with higher risk of procedure-related hemorrhage. CONCLUSIONS: Utilization of transbronchial lung biopsy is decreasing relative to the overall use of bronchoscopy. Nevertheless, it remains a safe procedure with low risk of complications.