CT-Guided vs. Navigational Bronchoscopic Biopsies for Solitary Pulmonary Nodules: A Single-Institution Retrospective Comparison.

OBJECTIVE: Lung cancer is the second most common cause of death by cancer. Multiple modalities can be used to obtain a tissue sample from a pulmonary nodule. We aimed to compare the yield and adverse events related to transthoracic needle aspiration (TTNA) and Electromagnetic Navigation Biopsy (ENB) at our institution. METHODS: This was a single-center retrospective study in which all patients referred for evaluation of a pulmonary lesion over 5 years (1 January 2013 to 31 December 2018) were identified. Our primary outcome was to compare the accuracy of TTNA to that of ENB in establishing the diagnosis of pulmonary lesions. Secondary outcomes included the evaluation of the adverse events and the sensitivity, specificity, positive, and negative predictive value of each modality. RESULTS: A total of 1006 patients were analyzed. The mean age of patients in the TTNA and the ENB group was 67.2 ± 11.2 years and 68.3 ± 9.2 years respectively. Local anesthesia was predominantly used for TTNA and moderate sedation was more commonly used in the ENB group. We found ENB to have an accuracy of 57.1%, with a sensitivity of 40.0%, a specificity of 100.0%, a positive predictive value of 100.0%, and a negative predictive value of 40.0%. As for the TTNA, the accuracy was 75.9%, with a sensitivity of 77.5%, a specificity of 61.5%, a positive predictive value of 95.0%, and a negative predictive value of 22.5%. The rate of clinically significant complications was higher in the TTNA group (8.2%) as compared to the ENB group (4.7%) with a p-value < 0.001. CONCLUSION: TTNA was superior to ENB-guided biopsy for the diagnostic evaluation of lung nodules. However, the complication rate was much higher in the TTNA group as compared to the ENB group.

Right heart thrombus in transit: Raising bar in the management of cardiac arrest.

Right heart thrombus represents medical emergency as it is associated with acute pulmonary embolism. Right heart thrombus can manifest acutely in a dramatic fashion as cardiac arrest. Bedside echocardiography is a key to rapid diagnosis and allow early intervention. We report a case of elderly female who was admitted to our hospital after a mechanical fall and found to have hip fracture. Despite an initial uncomplicated course, she experienced cardiopulmonary arrest with right heart clot in transit identified on transesophageal echocardiography (TEE). We highlight the utility of point-of-care ultrasound as well as use of TEE to establish cause of cardiopulmonary arrest.

Left Brachiocephalic Perforation During Right Heart Catheterization.

Right heart catheterization is overall considered a safe procedure, although complications can arise from venous access injuries, arrhythmias, vasovagal episodes, and pulmonary artery rupture. We present a case of left brachiocephalic vein perforation during a diagnostic right heart catheterization, which was managed conservatively. (Level of Difficulty: Beginner.).

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA): Technical Updates and Pathological Yield.

Since the endobronchial ultrasound bronchoscope was introduced to clinical practice, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become the procedure of choice to sample hilar and mediastinal adenopathy. Multiple studies have been conducted in the last two decades to look at the different technical aspects of the procedure and their effects on the final cytopathological yield. In addition, newer modes of ultrasound scanning and newer tools with the potential to optimize the selection and sampling of the target lymph node have been introduced. These have the potential to reduce the number of passes, reduce the procedure time, and increase the diagnostic yield, especially in rare tumors and benign diseases. Herein, we review the latest updates related to the technical aspects of EBUS-TBNA and their effects on the final cytopathological yield in malignant and benign diseases.

Predictors of inadequate bowel preparation for colonoscopy: a systematic review and meta-analysis.

The aim of this study was to investigate factors contributing to poor bowel preparation in patients undergoing colonoscopy procedures. We used a reproducible search strategy to identify studies, searching 10 medical databases, including PubMed, Ovid, Medline, and Cochrane Library Database for reports published between 2000 and 2016. Fully published studies, evaluating risk factors for inadequate bowel preparation, were included. Two reviewers independently scored the identified studies for methodology and abstracted pertinent data. Pooling was conducted with both fixed-effects and random-effects models; results were presented from the random effects model when heterogeneity was significant. Odds ratios (OR) estimates with 95% confidence interval were calculated. Heterogeneity was assessed by I statistics. Twenty-four studies with a total of 49 868 patients met the inclusion criteria. Age (OR: -1.20), male sex (OR: 0.85), inpatient status (OR: 0.57), diabetes mellitus (OR: 0.58), hypertension (OR: 0.58), cirrhosis (OR: 0.49), narcotic use (OR: 0.59), constipation (OR: 0.61), stroke (OR; 0.51), and tricyclic antidepressant (TCA) use (0.51), were associated with inadequate bowel preparation. In our sensitivity analysis comparing Western and Asian countries, we found that diabetes, cirrhosis, male sex, history of stroke and TCA use were stronger risk factors for inadequate bowel preparation in Western countries than in Asian countries. We also found that history of stroke, TCA use, and race were risk factors for inadequate bowel preparation in patients receiving conventional bowel preparation compared with those receiving split-dose bowel preparation. Multiple risk factors affect the quality of bowel preparation and specific risk factors can be intervened upon, in different populations, to optimize preparation.

The Infection Returns: A Case of Pulmonary Sporotrichosis Relapse after Chemotherapy.

BACKGROUND: Pulmonary sporotrichosis is a rare disease caused by a dimorphic fungus, Sporothrix schenckii. It is rarely found in association with malignancy. We present a case of pulmonary sporotrichosis recurrence after chemotherapy. CASE PRESENTATION: A 44-year-old man, treated for pulmonary sporotrichosis in the past, presented with dysphagia and was found to have squamous cell carcinoma of the esophagus. After undergoing chemotherapy, extensive cavitary lesions were observed on thoracic computed tomography scan. A bronchoalveolar lavage revealed the presence of Sporothrix schenckii sensu lato. Despite treatment with itraconazole, he eventually required a left pneumonectomy for progressive destructive cavitary lesions involving the left lung. CONCLUSION: This case highlights the importance of considering past fungal infections, albeit cured, in patients initiating immunosuppressive therapy.

Multifocal Pulmonary Granular Cell Tumor Presenting with Postobstructive Pneumonia.

Granular cell tumor (GCT) is a neoplasm of Schwann cell origin. Its presence in the aerodigestive tract is uncommon and becomes a diagnostic challenge on initial presentation. Our case is of a 59-year-old woman who presented to the emergency department with a history of productive cough and dyspnea associated with fever and chest pain. An initial chest X-ray (CXR) showed a right middle lobe consolidation with follow-up Computed Tomography (CT) scan showing a mass in the right bronchus. Bronchoscopy revealed a polypoid, sessile granular mass in the right bronchus intermedius with multiple white lesions in trachea, left main bronchus, and right upper bronchi. Histology revealed a benign GCT. Bronchoalveolar lavage from the right middle lobe grew Streptococcus pneumoniae. Patient was treated with intravenous levofloxacin during hospital stay and discharged on a 7-day course of oral antibiotics to be followed as outpatient but was lost to follow-up. GCT can present as a polypoid tumor causing recurrent postobstructive pneumonia. Surgical resection is the most successful treatment option. The tumor is more common in third and fourth decade of life and our patient is the oldest patient, according to our knowledge, to have a GCT.