EBUS versus EUS-B for diagnosing sarcoidosis: The International Sarcoidosis Assessment (ISA) randomized clinical trial.

BACKGROUND AND OBJECTIVE: Endosonography with intrathoracic nodal sampling is proposed as the single test with the highest granuloma detection rate in suspected sarcoidosis stage I/II. However, most studies have been performed in limited geographical regions. Studies suggest that oesophageal endosonographic nodal sampling has higher diagnostic yield than endobronchial endosonographic nodal sampling, but a head-to-head comparison of both routes has never been performed. METHODS: Global (14 hospitals, nine countries, four continents) randomized clinical trial was conducted in consecutive patients with suspected sarcoidosis stage I/II presenting between May 2015 and August 2017. Using an endobronchial ultrasound (EBUS) scope, patients were randomized to EBUS or endoscopic ultrasound (EUS)-B-guided nodal sampling, and to 22- or 25-G ProCore needle aspiration (2 × 2 factorial design). Granuloma detection rate was the primary study endpoint. Final diagnosis was based on cytology/pathology outcomes and clinical/radiological follow-up at 6 months. RESULTS: A total of 358 patients were randomized: 185 patients to EBUS-transbronchial needle aspiration (EBUS-TBNA) and 173 to EUS-B-fine-needle aspiration (FNA). Final diagnosis was sarcoidosis in 306 patients (86%). Granuloma detection rate was 70% (130/185; 95% CI, 63-76) for EBUS-TBNA and 68% (118/173; 95% CI, 61-75) for EUS-B-FNA (p = 0.67). Sensitivity for diagnosing sarcoidosis was 78% (129/165; 95% CI, 71-84) for EBUS-TBNA and 82% (115/141; 95% CI, 74-87) for EUS-B-FNA (p = 0.46). There was no significant difference between the two needle types in granuloma detection rate or sensitivity. CONCLUSION: Granuloma detection rate of mediastinal/hilar nodes by endosonography in patients with suspected sarcoidosis stage I/II is high and similar for EBUS and EUS-B. These findings imply that both diagnostic tests can be safely and universally used in suspected sarcoidosis patients.

Evaluation of Exudative Pleural Effusions: A Multicenter, Prospective, Observational Study.

PURPOSE: The aim of this study is to determine the diagnostic performances of pleural procedures in undiagnosed exudative pleural effusions and to evaluate factors suggestive of benign or malignant pleural effusions in tertiary care centers. METHODS: This was a multicenter prospective observational study conducted between January 1 and December 31, 2018. A total of 777 patients with undiagnosed exudative pleural effusion after the initial work-up were evaluated. The results of diagnostic procedures and the patients' diagnoses were prospectively recorded. Sensitivity, specificity, and accuracy estimates with 95% confidence intervals were used to examine the performance of pleural procedures to detect malignancy. RESULTS: The mean age ± SD of the 777 patients was 62.0 ± 16.0 years, and 68.3% of them were male. The most common cause was malignancy (38.3%). Lung cancer was the leading cause of malignant pleural effusions (20.2%). The diagnostic sensitivity and accuracy of cytology were 59.5% and 84.3%, respectively. The diagnostic sensitivity of image-guided pleural biopsy was 86.4%. The addition of image-guided pleural biopsy to cytology increased diagnostic sensitivity to more than 90%. Thoracoscopic biopsy provided the highest diagnostic sensitivity (94.3%). The highest diagnostic sensitivity of cytology was determined in metastatic pleural effusion from breast cancer (86.7%). CONCLUSION: The diagnostic performance increases considerably when cytology is combined with image-guided pleural biopsy in malignant pleural effusions. However, to avoid unnecessary interventions and complications, the development of criteria to distinguish patients with benign pleural effusions is as important as the identification of patients with malignant pleural effusions.

Current Practice of Airway Stenting in the Adult Population in Europe: A Survey of the European Association of Bronchology and Interventional Pulmonology (EABIP).

BACKGROUND: Airway stenting (AS) commenced in Europe circa 1987 with the first placement of a dedicated silicone airway stent. Subsequently, over the last 3 decades, AS was spread throughout Europe, using different insertion techniques and different types of stents. OBJECTIVES: This study is an international survey conducted by the European Association of Bronchology and Interventional Pulmonology (EABIP) focusing on AS practice within 26 European countries. METHODS: A questionnaire was sent to all EABIP National Delegates in February 2015. National delegates were responsible for obtaining precise and objective data regarding the current AS practice in their country. The deadline for data collection was February 2016. RESULTS: France, Germany, and the UK are the 3 leading countries in terms of number of centres performing AS. These 3 nations represent the highest ranked nations within Europe in terms of gross national income. Overall, pulmonologists perform AS exclusively in 5 countries and predominately in 12. AS is performed almost exclusively in public hospitals. AS performed under general anaesthesia is the rule for the majority of institutions, and local anaesthesia is an alternative in 9 countries. Rigid bronchoscopy techniques are predominant in 20 countries. Amongst commercially available stents, both Dumon and Ultraflex are by far the most commonly deployed. Finally, 11 countries reported that AS is an economically viable activity, while 10 claimed that it is not. CONCLUSION: This EABIP survey demonstrates that there is significant heterogeneity in AS practice within Europe. Therapeutic bronchoscopy training and economic issues/reimbursement for procedures are likely to be the primary reasons explaining these findings.

Molecular markers in lung cancer: role of EBUS.

PURPOSE OF REVIEW: As demonstrated by the recent therapeutic advances in nonsmall cell lung cancer (NSCLC), a personalized approach can considerably reduce its mortality. RECENT FINDINGS: Molecular tests identifying genetic mutations in NSCLC have led to a shift towards more effective and personalized therapies targeted to these alterations. Adequate tissue is required for diagnosing, subcharacterizing, and genotyping NSCLC by morphological, immunohistochemical, and molecular techniques. Endobronchial ultrasound (EBUS)- or transesophageal ultrasound (EUS)-guided needle aspiration and radial-probe EBUS-guided methods have proved to be reliable in diagnosis and/or staging of the disease. Small specimens obtained by these methods are sufficient for molecular analysis if a rational and multidisciplinary approach to specimen acquisition and processing is exercised. Coordination between the bronchoscopist and cytopathologist in managing specimens is critical for optimal use of obtained tissue. If available, rapid on-site evaluation can be beneficial in assessing quality and quantity of the specimen, and allocating for cell block, immunohistochemistry, and molecular studies. SUMMARY: The rationale for histologic and molecular testing of lung cancer specimens should be well understood by bronchoscopists so that specimens obtained by EBUS- or EUS-guided methods are managed in an optimal fashion that will provide cytologic specimens sufficient to guide targeted therapy.

Impact of vaccination on ICU admissions of hospitalized COVID-19 patients in a country with a heterologous vaccine policy.

INTRODUCTION: Vaccination against coronavirus disease-19 (COVID-19) is highly effective in preventing severe disease and mortality. Adenoviral vector and mRNA vaccines were effective against intensive care unit (ICU) admission, but the effectiveness of inactivated vaccine on ICU admission was unclear. We aimed to evaluate the effect of vaccination status on ICU admission in hospitalized COVID-19 patients in a country with heterologous vaccination policy. METHODOLOGY: This is a retrospective multicenter study conducted in three hospitals in Izmir, Turkey between 1 January 2021 and 31 March 2022. Patients aged ≥ 18 years and hospitalized due to COVID-19 were included in the study. Patients who had never been vaccinated and patients who had been vaccinated with a single dose were considered unvaccinated. A logistic regression analysis was performed for evaluating risk factors for ICU admission. RESULTS: A total of 2,110 patients were included in the final analysis. The median age was 66 years (IQR, 53-76 years) and 54% of the patients were vaccinated. During the study period, 407 patients (19.3%) were transferred to the ICU due to disease severity. Patients who were admitted to the ICU were older (median age 68 vs. 65 years, p < 0.001); and the number of unvaccinated individuals was higher among ICU patients (57% vs. 45%, p < 0.001). In multivariate regression analysis, being unvaccinated was found to be the most important independent risk factor for ICU admission with an OR of 2.06 (95% CI, 1.64-2.59). CONCLUSIONS: Vaccination against COVID-19 is effective against ICU admission and hospital mortality.

[Diagnostic value of pleural fluid and serum procalcitonin levels in the diagnosis of parapneumonic pleural effusion]. / Parapnömonik plevral efüzyon tanisinda plevral sivi ve serum prokalsitonin düzeylerinin tanisal degeri.

INTRODUCTION: To determine the diagnostic value of pleural fluid procalcitonin (PF-PCT) and serum PCT (S-PCT) levels in the diagnosis of parapneumonic pleural effusion (PPPE). MATERIALS AND METHODS: Sixty five inpatients with exudative pleural fluid were consecutively included in this prospective study. Biochemical (total protein, albumin, LDH, glucose, pH, PCT) studies were performed in concurrently obtained pleural fluid and venous blood samples, cytologic and microbiologic (acid-fast bacillus smear/culture, nonspecific bacterial Gram stain/culture, fungal culture) studies were performed in pleural fluid. The patients were grouped as PPPE (n= 33) and non-PPPE (n= 32) after the diagnoses were definitely established. RESULTS: A total of 65 patients (M/F: 38/27; age: 57.53 ± 18.46 years) with exudative pleural fluids were assessed. In the 33 with PPPEs, 6 simple PPPEs, 5 complicated PPPEs and 22 empyemas were determined whereas in the 32 non-PPPEs, 9 tuberculous, 10 malignant, 6 paramalignant, 5 non-specific effusions and 2 chylothoraces were determined. Compared with the non-PPPE group, more fever, pneumonic infiltrations and fluid loculation, higher sedimentation, leukocyte, fluid LDH besides lower fluid glucose, pH, albumin and protein together with lower serum LDH were determined in the PPPE group (p< 0.05). Higher PS-PCT (1.03 ± 1.27 vs. 0.06 ± 0.06 ng/mL) and S-PCT levels (0.90 ± 1.44 vs. 0.05 ± 0.02 ng/mL) were determined in the PPPE group (p= 0.000). In the PPPE group, PS-PCT and S-PCT showed positive correlation with each other while PS-PCT did with sedimentation, leukocyte, CURB-65 and serum LDH, and S-PCT did with sedimentation, CURB-65 and duration of hospitalization. ROC curve, a specificity of 96.9% and a sensitivity of 57.5% were determined for an optimal PS-PCT cut-off level (0.285 ng/mL), and a specificity of %96.9 and a sensitivity of %66.6 for an optimal S-PCT cut-off level (0.105 ng/mL) that could differentiate PPPE. CONCLUSION: PS/S-PCT levels were found to be highly efficient in excluding PPPE but not sufficiently reliable in the diagnosis of it. However, these findings should be reassessed in a larger group of cases that have not been given any antibiotic/anti-inflammatory treatment.

Anxiety and depression levels of healthcare workers during Covid-19 pandemic.

Background: Coronavirus disease 2019 (covid-19), which causes a pandemic in the world, has started to appear in turkey since march 2020. Healthcare workers are at the top of the groups most at risk for covid-19 infection, which can have a negative impact on psychological state. Objectives: It was aimed to evaluate anxiety and depression levels among healthcare workers. Methods: this cross-sectional study performed via an online survey in april 2020. Participants answered questions about sociodemographic features, personal views and experiences about covid-19 and the hospital anxiety and depression scale (hads). Results: A total of 300 healthcare workers,193 men and 107 women, participated in the survey. According to hads, 44.6% of participants scored above anxiety and 68.2% scored above depression cut-off points. Being younger than 50 and taking care of covid-19 patients in hospitals were independently associated with anxiety risk. Female gender, young age (less than 50) and having comorbidity were independent risk factors for depression. Conclusion: Healthcare workers were at high risk of anxiety and depression during covid-19 outbreak. For this reason, psychological support should be given, especially to the group with high risk.

Comparison of typical and atypical computed tomography patterns regarding reversibility and fibrosis in pulmonary sarcoidosis.

PURPOSE: This study aims to investigate whether there is a significant difference between typical and atypical parenchymal patterns in the development of fibrosis, which is the most crucial factor affecting morbidity in pulmonary sarcoidosis. METHODS: In our hospital, 145 cases with Siltzbach Types 2 and 3 sarcoidoses diagnosed by clinical, radiological, and histopathologic were retrospectively investigated. Perilymphatic nodules, accompanying mosaic attenuation, and interlobular septal thickening and central peribronchovascular bunch-like thickening on high-resolution computed tomography were assessed as typical. Solid nodules, galaxy finding, consolidation, ground-glass opacity, isolated mosaic attenuation, and interlobular septal thickening, and pleural fluid were accepted as atypical findings. Findings indicating fibrosis were fine and rough reticular opacity, traction bronchiectasis, volume loss, and cystic changes. For the analysis of variables, SPSS 25.0 program was used. RESULTS: Ten (16%) of the 61 cases with typical findings and 16 (19%) of the 84 with atypical findings developed fibrosis (P = 0.827). The mean age of cases with fibrosis was higher. With the cut-off of 50 years, sensitivity was 61.5%, and specificity was 68.9%. The highest fibrosis rate was in cases with ground glass pattern (n = 7/17), whereas higher reversibility rates were in those with miliary pattern (n = 9/12) and galaxy sign (n = 5/6). CONCLUSION: The incidence of fibrosis is higher in the atypical group with no significant difference. The incidence of fibrosis differs in each atypical pattern, being highest in ground-glass opacity and lowest in the miliary pattern.

Iodopovidone is as effective as doxycycline in producing pleurodesis in rabbits.

BACKGROUND AND OBJECTIVE: The mechanism by which iodopovidone achieves pleurodesis is unknown. This study investigated whether iodopovidone is as effective as doxycycline in producing pleurodesis and whether systemic corticosteroids diminish its efficacy. METHODS: Four groups of seven New Zealand rabbits were assigned to the following intrapleural treatment groups: 2 mL of 2% iodopovidone, 2 mL of 4% iodopovidone, 2 mL of 4% iodopovidone plus 0.8 mg/kg triamcinolone intramuscularly weekly and 10 mL/kg doxycycline in 2 mL. Pleural fluid was collected 24, 48 and 72 h after intrapleural injections and analysed for WCC, protein and LDH levels. The rabbits were killed 2 weeks after the injections. Pleurodesis was graded macroscopically on a scale from 1 to 8. The degree of microscopic pleural fibrosis and pleural inflammation was graded from the HE stain slides. RESULTS: The mean volume of pleural fluid as well as the mean total WCC was significantly lower in the steroid-treated group than in the other groups. The degree of the resulting pleurodesis was similar in the 2% iodopovidone (7.00 +/- 1.29), 4% iodopovidone (7.71 +/- 0.76) and doxycycline (7.14 +/- 0.90) groups (P > 0.05) whereas the pleurodesis score of the steroid group (3.71 +/- 1.98) was significantly lower than all other groups (P < 0.05). The degree of microscopic pleural fibrosis and pleural inflammation was significantly lower in the steroid group than in the 2% iodopovidone or 4% iodopovidone group. CONCLUSIONS: Both 2% and 4% iodopovidone can induce pleurodesis as efficaciously as doxycycline in rabbits. Systemic corticosteroids significantly decrease the efficacy of iodopovidone in producing pleurodesis.

How to obtain adequate biopsy specimen in suspected thymic tumors.

Pathologic diagnosis of thymic tumors (TTs) can be made by surgical or nonsurgical procedures. About 20% of TTs had been diagnosed by pretreatment biopsy methods while the rest had gone to surgery for diagnosis and treatment. However, in the last two decades there was an increase in pretreatment procedures for optimal management of locally advanced or metastatic TTs. Pretreatment tissue diagnosis of a noninvasive TT is not a standard option but is required if there is suspect or atypical clinical presentation and imaging, an invasive tumor requiring a nonsurgical approach or preoperative chemotherapy or chemo-radiotherapy, strong possibility of lymphoma or unclear differential diagnosis between lymphoma or other solid tumor by imaging studies, or suspicion of a metastatic lesion. In surgical diagnosis anterior mediastinotomy, video-assisted thoracic surgery or mediastinoscopy can be chosen for invasive TTs whereas total resection is performed for small, noninvasive tumors. Nonsurgical diagnosis can be made by transthoracic fine or core needle biopsies (TTFNA, TTCNB), conventional bronchoscopy, endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA), endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) or medical thoracoscopy depending on procedural amenability according to tumor extension. TTFNA and TTCNB have been the most frequently used nonsurgical methods. However, there is an upward trend in using conventional bronchoscopy, EBUS-TBNA, EUS-FNA and medical thoracoscopy recently. To increase the diagnostic performance of these procedures in TTs, recommendations are (I) obtaining histologic specimens, (II) combining smears or liquid based cytology preparations and cell blocks, (III) obtaining multiple sufficient samples, (IV) combining histologic and cytologic specimens, (V) performing morphologic, immunohistochemical and molecular analyses on all specimens, (VI) using rapid onsite evaluation for cytologic specimens, (VII) correlating pathologic, clinical and radiologic findings, (VIII) consulting experienced pathologists.

Noninvasive assisted pressure-controlled ventilation: as effective as pressure support ventilation in chronic obstructive pulmonary disease?

BACKGROUND: Noninvasive ventilation (NIV) is being increasingly used in hypercapnic chronic obstructive pulmonary disease (COPD) patients but the most appropriate ventilation mode is still not known. OBJECTIVES: The aim of this study was to investigate if assisted pressure-controlled ventilation (APCV) can be a better alternative to pressure-support ventilation (PSV) for NIV in COPD patients with acute hypercapnic respiratory failure (AHRF). METHODS: In this prospective randomized study, we evaluated the early effects of noninvasive APCV and PSV in 34 consecutive COPD patients with AHRF. Patients were randomized into 1 of the 2 modes, and respiratory and hemodynamic values were compared before and after 1 h of NIV. RESULTS: Baseline values did not differ between the 2 groups. There were significant improvements in partial arterial carbon dioxide pressure and pH levels in the APCV group when compared with baseline (p < 0.05). Cardiac output and cardiac index decreased in both groups (p < 0.05) but more significantly in the PSV group (p < 0.0001). The decreases in stroke volume index and increases in arterial oxygen content after NIV were also considerable in both groups (p < 0.05). Central venous pressure and systemic vascular resistance index values increased notably only after PSV (p < 0.05). CONCLUSIONS: From these data, we deduce that APCV can be a better alternative to PSV for NIV in COPD patients with AHRF owing to its more beneficial physiological effects.

Endobronchial Ablative Therapies.

Endobronchial ablative therapies, such as mechanical debulking, laser therapy, electrocautery, argon plasma coagulation, cryotherapy, brachytherapy, photodynamic therapy, microdebrider bronchoscopy, resector balloon deobstruction, and intratumoral chemotherapy, are performed through a rigid or flexible bronchoscope in palliating or curing symptomatic malignant and benign airway lesions to improve symptoms, quality of life, and survival. Technical factors together with patient- and lesion-specific features determine the therapy of choice, as each therapy is different in capacity, limitation, and complications. In this article, indications, contraindications, and complications of endobronchial ablative therapies as well as practical issues related to their rational and cost-effective use are reviewed.

Tissue plasminogen activator combined with human recombinant deoxyribonuclease is effective therapy for empyema in a rabbit model.

OBJECTIVES: There have been no controlled studies to test the efficacy of tissue plasminogen activator (tPA) or recombinant human deoxyribonuclease (rhDNase) in the treatment of empyema. In vitro studies show that streptokinase without rhDNase does not liquefy empyemic material from rabbits. However, the combination of streptokinase and streptodornase and rhDNase have been shown to liquefy pus in vitro. The aim of this study was to determine if tPA or rhDNase, or a combination of the two, is more effective than saline solution in the treatment of empyema in rabbits. MATERIALS AND METHODS: Empyema was induced in rabbits using 10(9) Pasteurella multicoda organisms in infusion agar injected via a surgically placed chest tube. Once empyema was verified, a blinded investigator administered one of four treatments via the chest tube: 3 mL of saline solution; 4 mg of alteplase (recombinant tPA); 1 mg of rhDNase; or 4 mg of alteplase and 1 mg of rhDNase. The rabbits received a treatment every 12 h following the initial for a total of six treatments. The animals were killed at day 10, and the degree of empyema and pleural peel was scored macroscopically on a scale of 0 to 4. RESULTS: The combination group had a significantly lower mean empyema score (1.83 +/- 0.75) than did the saline solution group (3.86 +/- 0.38, p = 0.001), rhDNase group (3.17 +/- 0.75, p = 0.012), and alteplase group (3.71 +/- 0.49, p = 0.02) [+/- SD]. The total volume of pleural fluid was markedly higher in the alteplase and rhDNase combination group (142 +/- 79.1 mL) or the alteplase group (231 +/- 78.0 mL) compared to either the rhDNase group (0.8 +/- 1.6 mL) or the saline solution group (5.8 +/- 14.0 mL). CONCLUSION: The combination of alteplase and rhDNase is more effective in the treatment of rabbit empyema than either agent alone. The intrapleural injection of alteplase alone or in combination with rhDNase leads to the production of large amounts of pleural fluid.

Complications of Convex-Probe Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Multi-Center Retrospective Study.

BACKGROUND: Infrequent serious complications of convex-probe endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) have been reported. The aim of this study was to assess serious complications related to convex-probe EBUS-TBNA and to determine the complication rate in a large group of subjects. METHODS: In this retrospective study, a 15-item questionnaire on features of cases with EBUS-TBNA complications was sent to experienced bronchoscopists performing convex-probe EBUS-TBNA at 3 pulmonary centers. The medical records were then reviewed by these bronchoscopists to complete the questionnaire. Hemorrhage responsive to topical treatment, temporary laryngospasm/bronchospasm, transient oxygen desaturation, and fever lasting <24 h were excluded. Only complications requiring further treatment/intervention were considered serious. The rate of serious complications was calculated from the obtained data. RESULTS: In a total of 3,123 cases within a 5-y period, EBUS-TBNA was performed for staging lung cancer in 15.8%, diagnosis in 67.5%, and diagnosis and staging in 16.3%. Of the 3,123, 11.6% had parenchymal lesions adjacent to major airways. EBUS-TBNA was performed 11,753 times (3.76/case) at 6,115 lymph node stations and lesions (1.92/station or lesion). Five serious complications were recorded (0.16%): fever lasting >24 h, infection of bronchogenic cyst, mediastinal abscess, pericarditis, and pneumomediastinitis with empyema, each in one case. Four complications occurred in cases diagnosed with benign disease by EBUS-TBNA. All complications were treated with broad-spectrum antibiotics. Four subjects were hospitalized for 21.7 ± 20.7 d. CONCLUSIONS: Convex-probe EBUS-TBNA is a safe method in general. However, serious complications, including infections, can be encountered rarely. All precautions should be taken for complications before and during the procedure.

Efficacy of ultrasound in the diagnosis of pleurodesis in rabbits.

INTRODUCTION: The treatment of recurrent pleural effusion or recurrent pneumothorax frequently involves the creation of a pleurodesis. Ultrasound is being used more frequently to assess the presence of pleural fluid or pneumothorax. With ultrasound, the gliding sign displays the gliding of the visceral pleura over the parietal pleura during respiration. The absence of a gliding sign is indicative of a pneumothorax. HYPOTHESIS: We hypothesized that the presence of pleurodesis would be indicated by the absence of a gliding sign on ultrasound. METHODS: To create a pleurodesis, a single intrapleural injection of transforming growth factor-beta2 at a dosage of 1.70 microg/kg or doxycycline at a dosage of 10 mg/kg in a volume of 2.0 mL was administered randomly to one side of a New Zealand White rabbit. Prior to death on day 14 after intrapleural injection, all rabbits underwent an ultrasonic examination at three marked sites on each side of the chest. At each site, three ultrasonic features (gliding sign, pleural thickening, and pleural effusion) were evaluated and graded. The gliding sign was graded as follows: 0 = gliding sign definitely present, 1 = gliding sign questionable, 2 = gliding sign absent. RESULTS: In a preliminary study for developing skill in assessing the gliding sign, the correlation between the gliding sign and the pleurodesis score in 16 rabbits was highly significant (r = 0.568, p = 0.02). In the subsequent main study with 18 additional rabbits, the correlation between the gliding sign score and the pleurodesis score was even better (r = 0.806, p = 0.00009). The gliding sign was definitely present on the noninjected side in all rabbits. CONCLUSIONS: The presence of a pleurodesis is indicated by the absence of a pleural guiding sign on ultrasound.

Oral forms of tetracycline and doxycycline are effective in producing pleurodesis.

PURPOSES: We investigated whether oral tetracyclines could produce an efficient and safe pleurodesis as does parenteral doxycycline, which is currently unavailable in many countries. METHODS: Parenteral doxycycline (10 mg/kg), oral tetracycline (35 mg/kg), or doxycycline (10 mg/kg) was injected intrapleurally through a right chest tube in rabbits. The oral forms were dissolved in saline solution and passed through a sterile membrane filter. When daily aspirated pleural fluid was < 5 mL/24 h, the chest tube was removed. Fluid WBC, lactate dehydrogenase (LDH), and protein levels were measured 24 h after the injection. After the death of the animals on day 14, pleurodesis was graded from 1 (none) to 8 (> 50% symphysis) by two observers blinded to treatment groups. RESULTS: The right pleurodesis score of the combined oral groups (median, 7.0; interquartile range [IQR], 4.0; n = 26) did not differ significantly (p = 0.349) from that of the parenteral group (median, 7.5; IQR, 6.0; n = 10). Oral tetracycline (capsule or tablet, n = 6 in each group) and doxycycline (capsule or tablet, n = 7 in each group) were as effective as parenteral doxycycline in producing pleurodesis: tetracycline capsule (median, 7.50; IQR, 6.00); tetracycline tablet (median, 6.50; IQR, 6.00); doxycycline capsule (median, 4.00; IQR, 1.00); doxycycline tablet (median, 8.00; IQR, 5.00), and parenteral doxycycline (median, 7.50; IQR, 6.00) [p = 0.235]. The left pleurodesis scores were 1.00 in all 36 rabbits. Fluid total volume, WBC, LDH, and protein levels were comparable between each oral and parenteral group, excluding WBCs in the tetracycline tablet group (p = 0.047). The complications were nonfatal (right hemothorax: tetracycline capsule [n = 3]/tetracycline tablet [n = 2], doxycycline tablet [n = 2], parenteral doxycycline [n = 2]; left hemothorax: tetracycline capsule [n = 1]; ascites: parenteral doxycycline [n = 1]). There was no growth on all filtrate cultures. Oral forms cost less than parenteral doxycycline (<1 US dollar vs 4.72 US dollars per rabbit). Filtering costs were 1.12 US dollars per rabbit. CONCLUSION: Oral tetracycline or doxycycline is as effective and safe as parenteral doxycycline in producing pleurodesis in rabbits; thus, they may also be used in humans.

Transbronchial needle aspiration: a diagnostic tool in routine bronchoscopy.

The fifty six-year-old Transbronchial Needle Aspiration (TBNA) has proved its efficacy, safety and cost-effectiveness particularly in diagnosing and staging lung cancer as well as in diagnosing benign granulomatous disease: sarcoidosis and tuberculous lymphadenitis. Although highly specific, the sensitivity and accuracy of TBNA may vary depending on the study methods, patient population (severity of disease) and prevalence of mediastinal metastasis. Conventional "blind" TBNA should be a "sine quo non" of routine bronchoscopy. However, it has not been used as extensively as it deserves to be owing to a multitude of factors ranging from concerns about its efficacy and safety to cost. Cost of the transbronchial aspiration needle might have an important impact on underuse of TBNA particularly in developing countries and therefore cost of the needles should be either adapted to the income of the countries or should be manufactured locally. Experience and training will, no doubt, improve TBNA performance and yield considerably.

Transbronchial needle aspiration in diagnosing intrathoracic tuberculous lymphadenitis.

STUDY OBJECTIVE: To assess the role of transbronchial needle aspiration (TBNA) in diagnosing intrathoracic tuberculous lymphadenitis (TB-LA). METHODS: In a tertiary referral center for thoracic medicine and surgery, using a CT scan as a guide, transbronchial aspirates were obtained with a 19-gauge flexible histology needle in consecutively enrolled patients with sputum smears negative for acid-fast bacilli, and with isolated mediastinal or hilar adenopathy suspicious for tuberculosis (TB). RESULTS: Of 84 eligible patients who were all found to be HIV-negative, 63 (75%) cases of TB were diagnosed by TBNA (histology, 48 patients [76%]; cytology, 9 patients [14%]; and bacteriologic studies, 21 patients [33%; smear, 8 patients; culture, 17 patients]). TBNA was used to diagnose sarcoidosis in two patients, angioimmunoblastic lymphadenopathy in one patient, and Hodgkin lymphoma in one patient. In the 17 TBNA-negative patients, the results of transthoracic needle aspiration were positive in 12 patients (TB, nine patients; lung cancer, two patients; sarcoidosis, one patient), the results of mediastinoscopy were positive in three patients (TB, two patients; Hodgkin lymphoma, one patient), and the results of thoracotomy were positive in two patients (TB, two patients). Thus, 76 patients had TB, and all responded to anti-TB treatment. TB was corroborated by culture or histology of another specimen obtained from subsequently developed lesions in 40 patients (53%) during anti-TB treatment or posttreatment follow-up. TBNA was immediately diagnostic in 59 patients (78%), and exclusively in 52 patients (68%), among all bronchoscopic procedures and prebronchoscopic sputum studies. Sensitivity, specificity, positive and negative predictive values, and accuracy of TBNA for TB were 83%, 100%, 100%, 38%, and 85%, respectively. The only complication, self-limiting hemorrhage of < 30 mL volume, occurred in 65 patients (77%), with a volume of < 5 mL in 59 patients (70%). CONCLUSION: TBNA is efficient and safe in the bacteriologic and pathologic diagnosis of intrathoracic TB-LA in HIV-negative and sputum smear-negative patients.