Rapid On-Site Evaluation in Detection of Granulomas in the Mediastinal Lymph Nodes.

RATIONALE: Rapid On-Site Evaluation (ROSE) of specimens collected by endobronchial ultrasound (EBUS)-guided-transbronchial needle aspiration (TBNA) ensures sample adequacy and triages subsequent biopsy procedures. EBUS-TBNA allows sampling of lymph nodes in granulomatous diseases; however, the ability of ROSE to predict the final diagnosis in this setting has not been well characterized. OBJECTIVES: We performed a retrospective evaluation to study the utility of ROSE in the diagnosis of granulomatous diseases as well as to establish the procedure characteristics that would optimize the concordance between ROSE and final diagnosis. METHODS: Charts of patients with a cytological diagnosis of granuloma by EBUS-TBNA between June 2008 and May 2013 were reviewed. Preliminary ROSE findings and final cytological diagnosis were compared. Patient demographics and procedure variables were assessed using mean (±SD). The variables collected were considered in a logistic regression analysis using concordance as the outcome. MEASUREMENTS AND MAIN RESULTS: In our study, 255 procedures were performed to sample 625 lymph nodes that contained granulomas. An average of 2.4 (±1.2) lymph nodes were biopsied per procedure, with a mean size of 14.4 (±7.9) mm. The concordance between ROSE and the final diagnosis was 81.6%. The concordance rate was not impacted by needle size, lymph nodes size or station, number of stations biopsied, or passes per lymph node. The concordance did improve with the experience of the bronchoscopist (P < 0001). CONCLUSIONS: In this single-center study, there was a high concordance between ROSE and the final cytological diagnosis for mediastinal lymph nodes containing granulomas that were sampled by EBUS-TBNA. ROSE may serve to reduce procedure time, enhance sample triaging, and obviate the need for further invasive testing. The only variable associated with increased concordance was the experience of the operator.

A 33-year-old man with multiple bilateral pulmonary pseudoaneurysms.

A 33-year-old man, never smoker, presented with acute-onset dyspnea secondary to bilateral pulmonary emboli. Echocardiography at the time revealed a right atrial myxoma, for which he underwent resection, followed by anticipated lifelong therapeutic anticoagulation therapy.

Serum heavy metals and obstructive lung disease: results from the National Health and Nutrition Examination Survey.

BACKGROUND: Exposure to hazardous heavy metals such as cadmium and lead has been associated with several chronic diseases. Heavy metal exposure may contribute to increased oxidative stress and inflammation in the lungs, resulting in tissue destruction manifesting clinically as obstructive lung disease (OLD). We aimed to evaluate the association between serum cadmium and lead concentration and OLD. METHODS: Pooled cross-sectional data from the National Health and Nutrition Examination Survey 2007-2010 were used. OLD was defined as an FEV 1 /FVC ratio , 0.7 by spirometry. Active smokers were defined as self-reported current smokers or those with measured serum cotinine 10 ng/mL. Serum cadmium and lead levels were measured using mass spectrometry. RESULTS: The prevalence of OLD was 12.4% (95% CI, 10.2%-13.6%). The mean (SE) cadmium levels in the OLD group were significantly higher in comparison with normal control subjects (0.51 [1.04] vs 0.33 [1.02], P , .001). Similarly, mean (SE) serum lead concentration was significantly higher in the OLD group compared with the control population (1.73 [1.02] vs 1.18 [1.0], P , .001). The association between OLD and smoking was significantly attenuated after adjusting for serum cadmium concentration. In addition, we demonstrated a progressive increase in serum cadmium concentrations with worsening FEV 1 % predicted values among smokers in our study population. CONCLUSION: In a large representative sample of the US population, we demonstrated a significant association between OLD and serum cadmium and lead concentrations. Cadmium appeared to partially mediate the association between smoking and OLD. A dose-response effect between increasing cadmium concentration and progressively worsening lung function was observed in smokers.

Serum cystatin C and emphysema: results from the National Health and Nutrition Examination Survey (NHANES).

BACKGROUND: Cystatin C (CysC) is a potent nonorgan-specific cysteine protease inhibitor and may contribute to elastolysis and tissue destruction by a mechanism of protease­antiprotease imbalance. Given the prevalence of CysC in the serum of smokers and its role in tissue destruction, we aimed to evaluate the association between CysC and emphysema. METHODS: Pooled cross-sectional data from the National Health and Nutrition Examination Survey 1999­2002 were used. Emphysema and chronic bronchitis were defined by a self-reported history ascertained using standardized questionnaires. Active smokers were defined as self-reported current smokers or measured serum cotinine ≥10 ng/mL. Nonactive smokers with a serum cotinine level >0.05 ng/mL were defined as environmental tobacco smoke (ETS)-exposed. RESULTS: The prevalence (95% CI) of emphysema was 1.3% (range = 0.9­1.8%). The mean (SE) CysC level in the emphysema group was significantly higher than in normal controls [1,139 (22) vs. 883 (8) µg/L; p = 0.001]. Upon stratification of the study population by C-reactive protein (CRP) concentrations, we demonstrated a progressive increase in the mean serum CysC level with serially increasing CRP concentrations. Active smokers with emphysema had 115.4 (46.5) µg/L higher mean (SE) CysC levels than the normal controls (p < 0.001). Upon adjusted analysis, we observed that nonactive smokers with significant ETS exposure had 31.2 (15.2) µg/L higher mean (SE) serum CysC levels as compared to ETS unexposed nonactive smokers (p = 0.04). CONCLUSION: In a large representative noninstitutionalized US population, we demonstrated an association between emphysema and serum CysC. Active smokers with emphysema had significantly higher CysC levels. These findings suggest that CysC may play a role in the pathogenesis of smoking-related emphysema.