37-year-old man • cough • increasing shortness of breath • pleuritic chest pain • Dx?

► Cough ► Increasing shortness of breath ► Pleuritic chest pain.

Comparison of Sample Adequacy and Diagnostic Yield of 19- and 22-G EBUS-TBNA Needles.

BACKGROUND: The 2016 CHEST consensus guidelines recommend use of either 21- or 22-G needles for endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). We decided to prospectively compare sample adequacy and diagnostic yield of the 19-G with the 22-G EBUS needle, hypothesizing that a larger gauge difference might magnify the differences between 2 needle sizes. METHODS: Twenty-seven patients undergoing EBUS-TBNA at our institution were evaluated. All cases were performed by a single operator formally trained in interventional pulmonology. Both Olympus 19- and 22-G needles were used at each lymph node station in an alternating manner. Rapid on-site cytology evaluation was used and a separate cell block was prepared for each needle at each station. RESULTS: Fifty-six lymph nodes were analyzed. Diagnoses included cancer (36%, including 1 lymphoma), reactive lymphoid tissue (53%), and sarcoidosis (11%). One hundred sixty-two and 163 passes were made with the 22- and 19-G needle, respectively. Sample adequacy was 73% and 46% with the 22 and 19-G needle, respectively (P<0.001). Significantly fewer passes were bloody with the 22-G compared with the 19-G needle (19% vs. 59%; P<0.001). Diagnostic yield was not different between the 22- and 19-G needles (95% vs. 93%; P=0.62). CONCLUSION: In addition to no difference in diagnostic yield, the 19-G needle yielded samples that were frequently less adequate and more often bloody compared with the 22-G needle. Despite the larger caliber lumen, we conclude that the 19-G needle does not confer a diagnostic advantage.

Resident performed two-point compression ultrasound is inadequate for diagnosis of deep vein thrombosis in the critically III.

Doppler ultrasonography is a standard in diagnosis of deep vein thrombosis (DVT) but is often delayed. Clinician-performed focused vascular sonography (FVS) has proven to accurately diagnose DVT in the ambulatory and emergency room settings. Whether trained medical residents can perform quality FVS in the critically ill is unknown. Medical residents were trained in a 2-hour module in FVS assessing for complete compressibility of common femoral and popliteal veins. Residents imaged consecutive medical ICU and intermediate care patients awaiting comprehensive, sonographer-performed and radiologist-interpreted examinations. Sensitivity, specificity, positive and negative predictive values of the focused examination were calculated against the comprehensive study. Fleiss Kappa (κ), the degree of agreement between resident and radiologist, was calculated. Time savings was measured. Nineteen residents performed 143 studies on 75 patients. Twelve patients had above-the-knee DVTs, a prevalence of 16 %. All 6 common femoral and 7 of 9 popliteal vein DVTs were identified. None of 6 isolated superficial femoral DVTs were identified. Sensitivity for above-the-knee DVT was 63 %, specificity 97 %. Sensitivity for common femoral and popliteal DVT was 86 %, specificity 97 %. Residents showed substantial agreement with radiologists for diagnosis of DVT (κ = 0.70, SE 0.114, p < 0.001).Time from order of a formal ultrasound to a radiologist's read averaged 14.7 h. The two-point compression ultrasound method demonstrated insufficient sensitivity in a cohort of critically ill medical patients due to a high-incidence of superficial femoral DVT. However, residents demonstrated substantial agreement with radiologists for the diagnosis of clinically relevant DVT after a 2-hour course. FVS should include the superficial femoral vein and is associated with a significant time savings.

Focused renal sonography performed and interpreted by internal medicine residents.

OBJECTIVES: Intensivist-performed focused sonography, including renal sonography, is becoming accepted practice. Whether internal medicine residents can be trained to accurately rule out renal obstruction and identify sonographic findings of chronic kidney disease is unknown. The purpose of this study was to test the ability of residents to evaluate for this specific constellation of findings. METHODS: Internal medicine residents were trained in a 5-hour module on focused renal sonography evaluating renal length, echogenicity, hydronephrosis, and cysts on a convenience sample of medical ward, intermediate care, and medical intensive care unit patients. All patients underwent comprehensive sonography within 24 hours. The primary outcome was represented by the Fleiss κ statistic, which indicated the degree of interobserver agreement between residents and radiologists. Sensitivity, specificity, and positive and negative predictive values were calculated using the comprehensive radiologist-read examination as the reference. RESULTS: Seventeen internal medicine residents imaged 125 kidneys on 66 patients. The average number of studies performed was 7.3 (SD, 6.6). Residents demonstrated excellent agreement with radiologists for hydronephrosis (κ = 0.73; P < .001; SE, 0.15; sensitivity, 94%; specificity, 93%), moderate agreement for echogenic kidneys (κ = 0.43; P < .001; SE, 0.13; sensitivity, 40%; specificity, 98%), and substantial agreement for renal cysts (κ = 0.61; P < .001; SE, 0.12; sensitivity, 60%; specificity, 96%). Residents showed sensitivity of 100% and specificity of 88% for identification of atrophic kidneys, defined as length less than 8 cm. CONCLUSIONS: After a 5-hour training course, medical residents accurately identified hydronephrosis and key sonographic findings of chronic kidney disease in a cohort of medical patients. Screening for hydronephrosis and renal atrophy can be performed by medical residents after adequate training.

Agreement between SPECT V/Q scan and CT angiography in patients with high clinical suspicion of PE.

OBJECTIVE: To track agreement between single positron emission computed tomography (SPECT) V/Q and CT angiography in patients with high clinical suspicion of pulmonary embolism (PE). If significant agreement occurs, a case could be made for more frequent use of chest radiography followed by SPECT V/Q scanning given its lower risk profile. INTRODUCTION: Diagnosis of PE can be difficult. CT pulmonary angiography (CTA) is the preferred initial test, but may be indeterminate, is a significant source of ionizing radiation, and is contraindicated in renal insufficiency. SPECT ventilation/perfusion imaging (V/Q) is therefore preferred in certain patients. METHODS: Two thousand nine hundred and twenty patients admitted to a tertiary care hospital in New York City were screened and 100 consecutive high-risk patients who required both CTA and V/Q for an initial indeterminate or negative imaging test despite a high pre-test probability were identified. The agreement between these tests was evaluated. RESULTS: There was no significant agreement between CTA and V/Q when positive, negative and indeterminate results were included (K = 0.18, SE = 0.09, p = 0.051). However, in the presence of a positive finding on either test, there was substantial agreement between the two (K = 0.62, SE = 0.27, p = 0.02). In 30 cases in which CTA was indeterminate, V/Q was diagnostic 93 % of the time. In 12 cases in which V/Q was indeterminate, CTA was diagnostic 83 % of the time and negative in 100 % of those cases. CONCLUSION: In the presence of an indeterminate CTA in patients with high clinical suspicion of PE, SPECT V/Q often provides a diagnosis.

Carotid stenting and bivalirudin with and without vascular closure: 3-year analysis of procedural outcomes.

OBJECTIVES: The purpose of this study was to examine the outcome of carotid stenting using bivalirudin and the influence of vascular closure devices (VCD) on the incidence and severity of peri-procedural hypotension. BACKGROUND: Bivalirudin, a short-acting direct thrombin inhibitor, has been shown to be an effective anticoagulant in coronary interventions, with less risk of bleeding compared with heparin. Routine use of VCD has become the standard of care, facilitating patient ambulation after percutaneous carotid and coronary interventions. The combined use of these two therapies (bivalirudin and VCD) may improve outcomes in carotid interventions where prolonged patient immobilization may exacerbate hypotension following stenting. METHODS: A total of 514 patients underwent 536 carotid stenting procedures in the 3-year period from September 2004 to September 2007. All patients received adjunctive bivalirudin, with and without VCD. This cohort was analyzed for peri-procedural and 30-day clinical outcomes and length of hospitalization. RESULTS: Thirty-day stroke and death rate was 1.7%. A total of 83 patients (15.4%) experienced intra- or post-procedural hypotension (systolic BP < 80 mm Hg). There were four (0.7%) major bleeding complications requiring transfusion, and length of stay was delayed more than 24 hr in five patients (0.93%), all of whom were in the manual compression group. CONCLUSIONS: This was a negative study, with no significant difference on prolonged hypotensive events in patients with vascular closure device and bivalirudin, compared with those with manual compression and bivalirudin. Vascular closure devices were safe and effective with a low incidence of complications. In carotid artery stenting, bivalirudin is safe with low incidence of major bleeding and acceptable 30-day adverse event rates (stroke and death).