Histological diagnosis of interstitial lung diseases by cryo-transbronchial biopsy.

BACKGROUND AND OBJECTIVE: The gold standard for the histological diagnosis of interstitial lung diseases (ILD) is an open lung biopsy (OLB). Tissue samples obtained by forceps transbronchial lung biopsies (TBB) are usually too small. We aim to evaluate the efficacy and safety of cryo-TBB for the diagnosis of ILD and to explore its role as substitute for OLB. METHODS: Seventy-five patients (mean age 56.2 years) with clinical and radiological features suggestive of ILD underwent cryo-TBB under moderate sedation. The diagnostic contribution on the work-up of suspected ILD was assessed. RESULTS: No major complications occurred during cryo-TBB procedures. The mean cross-sectional area of the biopsy specimen obtained was 9 mm2 with an average of 70% alveolated tissue. The most common pathological diagnoses were idiopathic nonspecific interstitial pneumonitis (n = 22), cryptogenic organizing pneumonia (n = 11) and usual interstitial pneumonitis (n = 7). There were three patients of pulmonary Langerhans cell histiocytosis and one patient of pulmonary lymphangioleiomyomatosis. A definite and probable clinicopathological consensus diagnosis was possible in 70% and 28% of patients, respectively. In only 2% of patients' diagnosis could not be established. CONCLUSIONS: Cryo-TBB is a safe and effective minimally invasive modality for the diagnosis of ILD. No OLB is needed in the majority of patients.

Efficacy of bronchoscopic closure of a bronchopleural fistula with amplatzer devices: long-term follow-up.

BACKGROUND: The development of a bronchopleural fistula (BPF) is associated with high rates of morbidity and mortality. We have developed a minimally invasive method of bronchoscopic BPF closure using Amplatzer devices (AD) and Amplatzer vascular plugs (AVP), with excellent short-term results. OBJECTIVES: The aim of the present report was to explore the long-term outcome of patients treated by Amplatzer occluders and the durability of this novel modality of BPF treatment. METHODS: A total of 31 central BPF in 31 patients (mean age 66.8 years, range 19-91) were sealed under moderate sedation bronchoscopically by either AD (n = 19) or AVP (n = 12). The average follow-up period was 17.6 months (range 1-68 months). RESULTS: The main etiology for BPF was surgery (n = 24), pneumonectomy (n = 14) or lobectomy/segmentectomy (n = 10). The underlying disease was either primary (n = 19) or metastatic (n = 2) lung cancer. The immediate success rate was 96% as symptoms related to BPF disappeared in 30 of the 31 patients. Short-term (<30 days) mortality was 13% (4 patients). At follow-up, 14 patients (45%) are still alive. Out of 12 patients with late mortality, in 5 patients (41%) the death was directly related to cancer relapse, and no patient died due to BPF recurrence. CONCLUSION: Endobronchial closure of BPF using both types of Amplatzer occluders (AD and AVP) is a minimally invasive effective modality of treatment with high safety profile and satisfactory long-term outcome considering the poor prognosis in this particular group of patients.

Sildenafil to facilitate weaning from inhaled nitric oxide and mechanical ventilation in a patient with severe secondary pulmonary hypertension and a patent foramen ovale.

We describe the case of a woman who presented to the intensive care unit with acute respiratory failure that required mechanical ventilation. She had severe pulmonary hypertension secondary to interstitial lung disease, and her history included sarcoidosis and tuberculosis. She was dependent on inhaled nitric oxide (INO) to maintain safe arterial oxygen saturation and could not be weaned from mechanical ventilation. Echocardiography revealed a patent foramen ovale with substantial right-to-left shunt, which probably contributed to her hypoxemia. Sildenafil enabled weaning from INO and substantially reduced the flow through the patent foramen ovale. She was successfully extubated and discharged home. To our knowledge, this is the first report of weaning from INO and mechanical ventilation in a patient with both severe secondary pulmonary hypertension and a right-to-left shunt through a patent foramen ovale.

Sandfly virus seroconversion associated with neurologic presentation.

OBJECTIVE: To describe the clinical presentation and unique neurologic manifestations of sandfly viruses (SFVs) in the Jerusalem area. METHODS: We identified all patients with acute seroconversion to SFV at the Hadassah-Hebrew University Medical Centers during the years 2008-2013 and retrospectively collected and analyzed the clinical and imaging data. RESULTS: Nine patients (ranging from 1.5 to 85 years old) were identified. Presentation included acute neurologic disease, mostly with fever, change in consciousness and behavior, seizures, headache, meningitis, limb paresis, or myelitis. Eight patients had clinical signs of meningitis, meningoencephalitis, or encephalitis alone. Four patients had myelitis. MRI identified pathologic symmetrical changes in the basal ganglia, thalami, and other deep structures in 5 patients, and additional myelitis of the spine was noted on imaging in 3 patients. Seven patients had long-term follow-up: 4 completely recovered and 3 had remaining neurologic sequelae, among them 1 with permanent severe brain damage. CONCLUSION: Neurologic involvement associated with acute SFV infections is considered to be benign. However, in this series, all 9 patients presented with significant neurologic pathology associated with a unique finding of myelitis and symmetrical basal ganglia, thalami, or white matter involvement. Thus, acute SFV infection should be included in the differential diagnosis in febrile onset of neurologic manifestations and neuroradiologic changes.

Evaluation of intradialytic hypotension using impedance cardiography.

BACKGROUND: Hypotension during hemodialysis is frequent in patients with cardiovascular disease who have a limited physiological compensatory response. Recent advances in technology allow non-invasive monitoring of cardiac output and derived hemodynamic parameters. This prospective study evaluated episodes of intradialytic hypotension using clinical data and continuous non-invasive hemodynamic monitoring by impedance cardiography. METHODS: Forty-eight chronic hemodialysis patients, with prevalence for intradialytic hypotensive episodes, underwent evaluation with non-invasive impedance cardiography (Physioflow) before, during and after a regular dialysis session. RESULTS: During continuous non-invasive cardiac monitoring, a fall of systolic arterial blood pressure of 20% or more at least once during hemodialysis was detected in 18 patients (37.5%)--thereafter identified as the "Unstable" group. In 30 patients--thereafter called the "Stable" group, the blood pressure did not change significantly. During hypotension, a decrease in cardiac output was found in 11 of the 18 unstable patients, and a significant fall in peripheral resistance in the remaining 7. End-diastolic filling ratio was significantly lower in the unstable group. The most significant predictors associated with intradialytic hypotension were the presence of ischemic heart disease (P = 0.05), and medication with beta blockers (P = 0.037) and calcium channel blockers (P = 0.018). CONCLUSIONS: Hemodynamic changes in dialysis patients with hypotensive episodes included decreased cardiac output or decreased peripheral resistance. A lower end-diastolic filling ratio may be regarded as a marker for reduced preload in these patients. Non-invasive impedance cardiography may be used to evaluate risk factors for hypotension in dialysis patients.

Communication difficulties and psychoemotional distress in patients receiving mechanical ventilation.

BACKGROUND: Difficulties in communication in intensive care patients receiving mechanical ventilation are a source of stressful experiences and psychoemotional distress. OBJECTIVES: To examine the association between communication characteristics and psychoemotional distress among patients treated with mechanical ventilation in a medical intensive care unit and to identify factors that may be predictive of psychological outcomes. METHODS: A total of 65 critically ill patients, extubated within the preceding 72 hours, were included in this cross-sectional study. Data were collected by using a structured interview. Separate regression analysis of data on 3 psychoemotional outcomes (psychological distress, fear, and anger) were used for baseline variables, communication characteristics, and stressful experiences. RESULTS: Difficulty in communication was a positive predictor of patients' psychological distress, and length of anesthesia was a negative predictor. Fear and anger were also positively related to difficulty in communication. In addition, the number of communication methods was negatively associated with feelings of fear and anger. Finally, the stressful experiences associated with the endotracheal tube were positively related to feelings of anger. CONCLUSIONS: Patients treated with mechanical ventilation experience a moderate to extreme level of psychoemotional distress because they cannot speak and communicate their needs. Nurses should be aware of the patients' need to communicate. Decreasing stressful experiences associated with the endotracheal tube and implementing more appropriate communication methods may reduce patients' distress.

Nurse-led implementation of a safe and effective intravenous insulin protocol in a medical intensive care unit.

BACKGROUND: Recent evidence has linked tight glucose control to worsened clinical outcomes among adults in intensive care units. OBJECTIVE: To evaluate the effectiveness and safety of a nurse-led intravenous insulin protocol designed to achieve conservative blood glucose control in patients in a medical intensive care unit. METHODS: A nurse-led intravenous insulin protocol was developed, targeting blood glucose levels at 110 to 149 mg/dL. Hypoglycemia was defined as a blood glucose level less than 70 mg/dL. Patients admitted to the medical intensive care unit who required an insulin infusion were enrolled in the study. Blood glucose levels in those patients were compared with levels in 153 historical control patients admitted to the unit in the 12 months before the protocol was implemented who required an insulin infusion. RESULTS: Ninety-six patients were enrolled and treated with the protocol. The protocol and control groups had similar characteristics at baseline. More measurements in the protocol group than in the control group (46.3% vs 36.1%, P<.001) were within the target glucose range (110-149 mg/dL). Hyperglycemia (blood glucose ≥200 mg/dL) occurred less often in the protocol group than in the control group (14.8% vs 20.1%, P=.003). Hypoglycemic events (blood glucose <70 mg/dL) also occurred less often in the protocol group (0.07% vs 0.83%, P<.001). CONCLUSIONS: Implementation of a nurse-led, conservative intravenous insulin protocol in the medical intensive care unit is effective and safe and markedly reduces the rate of hypoglycemia.