Ultrasound-Guided Needle Biopsy of Neck Lymph Nodes in Patients With Suspected Lung Cancer: Are the Specimens Sufficient for Complete Pathologic Evaluation to Guide Patient Management?

BACKGROUND: The purpose of this study is to determine the ability of ultrasound guided needle biopsy of a neck lymph node to provide adequate tissue for complete pathologic evaluation of suspected metastatic lung cancer, including molecular testing for epidermal growth factor receptor gene mutations by pyrosequencing and anaplastic lymphoma kinase gene rearrangement by fluorescence in situ hybridization. METHODS: Institutional review board approval was obtained and the requirement for informed consent was waived. All ultrasound guided neck biopsies performed July 1, 2011, to June 30, 2015, were retrospectively reviewed, and all biopsies performed for suspected lung cancer metastatic to supraclavicular and cervical lymph nodes were included. RESULTS: Forty patients with suspected lung cancer underwent ultrasound-guided needle biopsy of an abnormal appearing neck lymph node identified on preprocedure computed tomography or positron emission tomography/computed tomography. Thirty-seven patients were subsequently diagnosed with lung cancer and 3 were diagnosed with lymphoma. A definitive pathologic diagnosis was rendered in 95% of neck node biopsies (38/40; 95% confidence interval, 84%-99%). Of the 36 specimens diagnostic for lung cancer, 16 were considered for further molecular testing and the specimen was adequate for molecular testing in 15 (94%; 73%-100%) cases. Therefore, the neck node biopsy specimens were adequate for complete pathologic workup in 93% (37/40; 81%-98%). No complications related to the biopsies were observed. CONCLUSIONS: In patients presenting with suspected lung cancer and suspicious neck lymph nodes, ultrasound-guided needle biopsy frequently provides adequate tissue for complete pathologic evaluation and eliminates the need for more invasive procedures.

Anticoagulant modulation of inflammation in severe sepsis.

Inflammation and coagulation are so tightly linked that the cytokine storm which accompanies the development of sepsis initiates thrombin activation and the development of an intravascular coagulopathy. This review examines the interaction between the inflammatory and coagulation cascades, as well as the role of endogenous anticoagulants in regulating this interaction and dampening the activity of both pathways. Clinical trials attempting to improve outcomes in patients with severe sepsis by inhibiting thrombin generation with heparin and or endogenous anticoagulants are reviewed. In general, these trials have failed to demonstrate that anticoagulant therapy is associated with improvement in mortality or morbidity. While it is possible that selective patients who are severely ill with a high expected mortality may be shown to benefit from such therapy, at the present time none of these anticoagulants are neither approved nor can they be recommended for the treatment of sepsis.

When does nutrition impact respiratory function?

Nutrition therapy is an essential aspect of patient care and an important determinant of outcomes in the ICU. Nutrition can impact respiratory function in a myriad of ways. Under- and overfeeding are two well-established ways by which nutrition impinges on respiratory function. Route of feeding, method of feeding, and carbohydrate composition of the diet are also other key factors regarding nutrition that influence outcomes in ICU patients. Recent studies are now elucidating the role of immune therapy in patients with acute respiratory distress syndrome. In the ICU, nutrition dogmas, such as the necessity of checking gastric residual volumes or utilizing full-calorie enteric feeds, as opposed to trophic feeds, are constantly being challenged by innovative clinical studies. Basic research brings the prospect of testing new approaches for ICU patients, such as the use of antioxidants to prevent diaphragm weakness in these patients. In this review article, we evaluate the recent observational and randomized control trials to critically appraise the evidence regarding nutrition in the ICU.