Contribution of endobronchial ultrasound elastography to the characterization of mediastinal lymphadenopathy: A single-center, prospective, observational study.

BACKGROUND: Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a reliable technique providing high diagnostic yield in mediastinal lymphadenopathy. However, mediastinoscopy is sometimes necessary to eliminate false-negative results. Elastography is a recent technique that can be combined with EBUS to evaluate the elasticity and consequently the nature of a tissue. The primary objective was to evaluate the diagnostic performance of EBUS-TBNA combined with elastography for the assessment of mediastinal lymph nodes. METHODS: Single-center, prospective study in patients with mediastinal lymphadenopathy. EBUS-TBNA combined with elastography was performed in each patient. Several elastographic parameters were studied: colorimetric score, average elasticity, elasticity ratio, percentage of hard areas. The final diagnosis was that obtained by TBNA cytology, histology of a surgical biopsy, when performed, or follow-up CT and PET-CT at 6 months. RESULTS: Overall, 110 lymph nodes were examined in 87 patients: 44 were malignant according to TBNA. These nodes had significantly higher elasticity ratio, percentage of hard areas and colorimetric score and significantly lower average elasticity compared to benign nodes (P<0.001). With a negative predictive value of 100%, the cut-offs defined by receiver operating characteristic curves were 1.4 for elasticity ratio, 84.8 for average elasticity, 32.6 for percentage of hard areas and 3 for colorimetric score. No adverse events were observed. CONCLUSION: Endobronchial ultrasound elastography is a non-invasive technique that can contribute to prediction of the nature of lymph nodes by distinguishing malignant from benign nodes. Although EBUS cannot replace histological examination, elastography can provide reliable complementary information when combined with EBUS.

Risk of bleeding in patients undergoing pulmonary procedures on antiplatelet or anticoagulants: A systematic review.

As many as 25% of all patients undergoing invasive pulmonary procedures are receiving at least one antiplatelet or anticoagulant agent. For those undergoing elective procedures, the decision-making process is uncomplicated and the procedure may be postponed until the antiplatelet or anticoagulant agent may be safely held. However, many invasive pulmonary procedures are semi-elective or emergent in nature in which case a risk-benefit calculation and discussion occur between the provider and patient or surrogate decision-maker. Therefore, it is critical for providers to have an awareness of the risk of bleeding complications with different pulmonary procedures on various antiplatelet and anticoagulant agents. This systematic review summarizes the bleeding complications associated with different pulmonary procedures in patients on various antiplatelet or anticoagulant agents in the literature and reveals a paucity of high-quality evidence across a wide spectrum of pulmonary procedures and antiplatelet or anticoagulant agents. The results of this review can help inform providers of the bleeding risk in these patients to aid in the shared decision-making process and risk vs benefit discussion.

[A well-inked pneumonia can you decrypt it?] / Une pneumonie bien encrée à décrypter !

INTRODUCTION: We report a case of pneumonia associated with necrotic mediastinal lymph nodes in an immunocompetent patient. The case report illustrates the difficulties in making a diagnosis in necrotic mediastinal lymph nodes and discusses strategies to optimize sampling. OBSERVATION: A 21-year-old immunocompetent woman was admitted to hospital with dyspnea and fever occurring ten days after delivery. Physical examination, biological results and chest X-ray led to the diagnosis of right upper lobe pneumonia. Treatment with three broad-spectrum antibiotics was ineffective. Thoracic CT-scan showed compressive mediastinal and hilar necrotic adenopathies and consolidation of the right upper lobe. Bronchoscopy with bronchoalveolar lavage and transbronchial needle aspiration was non-diagnostic. A second bronchoscopy with bronchoalveolar lavage and transbronchial needle aspiration performed in close collaboration with the mycology laboratory led to the diagnosis of cryptococcosis. Antifungal therapy with fluconazole resulted in a complete resolution of clinical and radiological signs. CONCLUSION: Although it is extremely rare, pulmonary cryptococcosis should be considered in immunocompetent patients presenting with necrotic pneumonia. Effectiveness of lymph node sampling can be improved by collaboration between clinicians and microbiologists.

[Tobacco smoking and latent tuberculous infection]. / Tabagisme et infection tuberculeuse latente.

Tobacco smoking has a significant impact on the risk of tuberculosis and the mortality of the disease. There is a strong dose-response relationship both in terms of quantity and duration of smoking. Latent tuberculous infection and tuberculosis disease are different stages of the same infectious process but the relation between smoking and the risk of being infected with Mycobacterium tuberculosis is less well understood. The aim of this review is to describe the relationship between tobacco consumption and tuberculous infection and the mechanism by which smoking increases the risk. It outlines the public health consequences of the increased risk of latent tuberculous infection due to active and passive smoking. This justifies promotion of smoking cessation as a way of limiting the epidemic of tuberculosis in developing countries.

[The flexible fiberoptic bronchoscopy report: medico-legal issues]. / Le compte rendu de bronchoscopie souple: éléments de réflexion médicojuridique.

INTRODUCTION: The flexible bronchoscopy report is one of the tools permitting exchange of medical information in respiratory medicine and is an integral part of the medical record. Currently, there is no consensus on its content, and consequently, there are no recommendations. METHODS AND RESULTS: A survey was carried out involving experts from the Groupe d'Endoscopie de Langue Française (GELF--Endoscopy Research Group of the French Language Society of Pneumology) and a lawyer from the legal affairs and patient's rights department of the Paris public hospital system. Thirty-four questions distributed in eight chapters were asked in an eight-part questionnaire covering: 1) general administration, 2) environmental safety, 3) medical and anatomical description of the examination, 4) tolerance/complications of the examination, 5) conclusion, 6) image and video sequence capture, 7) administrative data for archiving, 8) disposable elements used during the examination. The results showed as many areas of convergence as they did divergence, between physicians, and between physicians and lawyer. CONCLUSION: Collective consideration is required to harmonize the writing of bronchoscopy reports, to provide a tool that is not only consensual and complete, but also valid and sound from the medicolegal viewpoint.

[Fibreoptic bronchoscopy and anti-platelet agents: a risk-benefit analysis]. / Bronchoscopie souple et antiagrégants plaquettaires: analyse du rapport bénéfices-risques.

INTRODUCTION: Respiratory physicians are confronted increasingly often by patients, in whom a fibreoptic bronchoscopy (FB) is planned, who are taking anti-platelet agents (APAs) prescribed by their cardiologist. It is necessary therefore to weigh the indications for bronchoscopy and the subsequent benefits against the risks, not only of haemorrhage, but of thrombosis if the APAs are withdrawn. METHODS/RESULTS: In the absence of agreed guidelines on the subject this article reviews the literature and reports the results of a survey conducted among 138 members of the French Respiratory Endoscopy Group. Five questions were considered: 1) what is the risk of haemorrhage during the procedure? 2) what are the pharmacological characteristics of current APAs? 3) what is the risk of thrombosis on withdrawal of APAs? 4) what are the circumstances in which the FB may be delayed? 5) what should be the therapeutic strategy if the APAs are withdrawn? CONCLUSIONS: While awaiting clinical studies that will allow a better understanding of these questions, and the subsequent publication of practice guidelines, it is crucial that respiratory physicians are aware of the need, prior to FB, to inquire routinely about treatment with APAs, to identify the indication, and never to interrupt such treatment without consulting the prescriber.

[Diagnostic flexible bronchoscopy. Recommendations of the Endoscopy Working Group of the French Society of Pulmonary Medicine]. / Les bonnes pratiques de la bronchoscopie souple diagnostique, en 2007.

These guidelines on flexible bronchoscopy depict important clues to be known and taken into account while practicing flexible bronchoscopy, in adult, except in emergency situations. This is a practical clarification. Safety conditions, complications, anesthesia, infectious risks, cleaning and disinfection are detailed from a review of the literature. Intensive care practice of bronchoscopy requires more attention due to higher risks patients and is discussed extensively. Standards and performances of the various sampling techniques complete this work. Indications for bronchoscopy, therapeutic and paediatric bronchoscopy are not covered in these guidelines.

[Control of peri-operative smoking: A challenge for the pneumologists]. / Le contrôle du tabagisme péri-opóratoire: un défi pour les pneumologues.

The experts conference on control of smoking in surgical patients led a synthesis of the literature which reveals among smokers 3 times more complications of the surgical site, twice more transfer in intensive care unit, an increase length of hospital stay, a 8-fold increase of the risk of non consolidation of bone, whereas quitting tobacco 6-8 weeks before the surgical procedure and until the end of the consolidation makes disappear surgical over risk related to tobacco smoke. An organization must urgently set up in all surgical units, so that the 2 millions smokers who underwent surgical procedure each year in France may be advertised and help to quit. If the mobilization of the decision makers, health care staff and patient is strong, the excepted health and financial benefit will be high and may contribute to reduce significantly the deficit of French national health insurance organization since 2006. The lung specialists have a key role to play in the implementation of these new practices.

[What is appropriate care for women who smoke during pregnancy?]. / Comment prendre en charge les femmes fumeuses?

There are few publications on smoking biomarkers in pregnant woman, but nothing suggests that their contribution differs during pregnancy. Many publications have examined the predictive value of the biomarkers of smoking, but the comparative value is not clear. To our knowledge no study has used biomarkers of the smoking to monitor smoking cessation during pregnancy. Blood nicotine is not retained as a useful biomarker. Most authors retain urinary cotinine as the gold standard. There is no consensus on measurement techniques. Cotinine can be measured in blood, saliva and in cord blood. Active and passive smoking can be monitored with urinary cotinine. Rapid strip tests provide useful results to differentiate smokers from non-smokers, but not to quantify nicotinic intoxication. All published papers have been supported by the firm marketing the strip. There have been few studies in pregnant woman on expired CO rate, but the method is validated. Measurement of thiocyanates and other biomarkers does not currently provide useful information for routine surveillance of pregnant smoking women.

[Tobacco smoke and risk of bacterial infection]. / Exposition à la fumée du tabac et risque infectieux bactérien.

INTRODUCTION: Tobacco smoke is a proven risk factor for bacterial infection. STATE OF THE ART: In adults without COPD, smoking is associated with a significant increase in the relative risk (RR) of pneumonia (RR=2.97; 95% CI 1.52-5.81), S pneumoniae pneumonia (RR=2.50; 95% IC 1.50-5.10), Legionella infection (RR=3.75; 95% CI 2.17-6.17). Smoking has clearly been shown to be associated with an increased risk of tuberculosis (RR=2.60; 95% CI 2,20-3,20), and also with increased incidence of post-operative infections. In young children whose parents smoke, passive exposure to tobacco smoke is associated with an increased relative risk of seasonal infections (RR=1.7; CI 95% 1.55-1.91) and recurrent otitis media (RR=1.48; 95% CI 1.08-2.04). Passive smoking also increases risk of pneumonia in adults (RR=2.5; CI 95% 1.2-5.1). Plausible explanations of the increased risk of infection in active or passive smokers include increased bacterial adherence, decrease of lung and nasal clearance, and changes in the immune response. CONCLUSIONS: Exposure to tobacco smoke approximately doubles the risk of infection. This increased burden of infection has significant healthcare cost implications. Each infectious episode in an individual should prompt an attempt at smoking cessation.

[Constrictive pericarditis due to asbestos exposure]. / Péricardite constrictive liée à l'exposition à l'amiante.

INTRODUCTION: Constrictive pericarditis is a rare complication of asbestos exposure and few cases have been reported in the literature. CASE REPORT: We report two cases of constrictive pericarditis in subjects previously exposed to asbestos. The first case, a 62 years old man, had occupational asbestos exposure whilst working for seven years in an electric plant 23 years before the diagnosis. The second case, a 76 years old man, had worked 21 years as a lagger up until 20 years before. The initial presentation in both cases was of sub-acute right heart failure. Both underwent pericardectomy which revealed pericardial thickening due to collagen fibrosis. Both patients died, one and five years respectively after surgery. Eight other cases of pericardial effusion and/or thickening, some with calcification, have been reported in association with previous asbestos exposure. Most of these cases had coexisting pleural lesions. CONCLUSIONS: As the prognosis is guarded (three of the eight reported cases died), making an early diagnosis is desirable.