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Background
Diagnostic evaluation of patients with diffuse parenchymal lung disease (DPLD) is best achieved by a multidisciplinary team correlating clinical, radiological, and pathologic features. Surgical lung biopsy remains the gold standard for histopathologic diagnosis of idiopathic interstitial pneumonias. Emerging data suggest an increasing role for transbronchial cryobiopsy (TBC) in DPLD evaluation. We describe our experience with TBC in patients with DPLD.
Methods
We retrospectively reviewed medical records of patients with radiographic features of DPLD who underwent TBC at Mayo Clinic in Rochester, Minnesota from June 2013 to September 2015.
Results
Seventy-four patients (33 women [45%]) with a mean age of 63 years (SD, 13.8) were included. The mean maximal diameter of the samples was 9.2 mm (range, 2-20 mm [SD, 3.9]). The median number of samples per procedure was three (range, one to seven). Diagnostic yield was 51% (38 of 74 specimens). The most frequent histopathologic patterns were granulomatous inflammation (12 patients) and organizing pneumonia (OP) (11 patients), resulting in the final diagnoses of hypersensitivity pneumonitis (six patients), cryptogenic OP (six patients), connective tissue disease-associated OP (three patients), drug toxicity (three patients), infection-related OP (two patients), sarcoidosis (two patients), and aspiration (one patient). Other histopathologic patterns included respiratory bronchiolitis (three patients), acute fibrinous and organizing pneumonia (two patients), desquamative interstitial pneumonia (1 patient), diffuse alveolar damage (one patient), pulmonary alveolar proteinosis (one patient), amyloidosis (one patient), eosinophilic pneumonia (one patient), necrotizing vasculitis (one patient), bronchiolitis with food particles (one patient), and malignancy (three patients). Pneumothorax developed in one patient (1.4%), and bleeding occurred in 16 patients (22%).
Conclusions
Our single-center cohort demonstrated a 51% diagnostic yield from TBC; the rates of pneumothorax and bleeding were 1.4% and 22%, respectively. The optimal use of TBC needs to be determined.
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Background
A subset of patients with COPD demonstrates eosinophilic inflammation either in their sputum or blood. Previous studies regarding the association between increased blood eosinophil levels and poor readmission outcomes are conflicting. The goal of this study was to investigate outcomes following severe COPD exacerbations in patients with higher blood eosinophil levels.
Methods
With an observational study design, data on hospitalizations for severe COPD exacerbation were retrospectively gathered. Patient health data previous to and up to 1 year following the index hospitalization were included. Patients were stratified into the eosinophilic group if the blood eosinophil level on admission was ≥ 200 cells/μL and/or ≥ 2% of the total WBC count. Clinical outcomes were 12-month COPD-related readmission, 12-month all-cause readmission, length of stay, and time to COPD-related readmission. These outcomes were analyzed by using logistic, negative binomial, and Cox regression models.
Results
A total of 167 patients were included; 55 had eosinophilia. Eosinophilia was associated with an increased risk of 12-month COPD-related readmission (OR, 3.59 [95% CI, 1.65-7.82]; P = .0013), an increased risk of 12-month all-cause readmission (2.32 [95% CI, 1.10-4.92]; P = .0277), and a shorter time to first COPD-related readmission (hazard ratio, 2.74 [1.56-4.83]; P = .0005). The length of stay was not statistically different between eosinophilic and noneosinophilic patients. Sensitivity analyses using different eosinophilia definitions revealed a proportional increase in effect size with increasing eosinophil cell count definitions for predicting 12-month readmissions.
Conclusions
Blood eosinophil levels can be used as a biomarker in severe COPD exacerbations for predicting higher readmission rates.
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Background
An optimal method of preoperative localization for pulmonary nodules has yet to be established. This systematic review and meta-analysis aimed to compare the success and complication rates associated with three pulmonary nodule localization methods for video-assisted thoracoscopic surgery (VATS): hook-wire localization, microcoil localization, and lipiodol localization.
Methods
We searched the PubMed, MEDLINE, and EMBASE databases for prospective or retrospective English language studies of VATS localization in adult patients. A noncomparative, random effects model–based meta-analysis was performed to obtain pooled success and complication rates for the three localization methods.
Results
A total of 46 clinical studies were enrolled, including 30, 9, and 7 studies of hook-wire, microcoil, and lipiodol localization, respectively. The successful targeting rates for hook-wire, microcoil, and lipiodol localization were 0.98 (95% CI, 0.97-0.99), 0.98 (95% CI, 0.96-0.99), and 0.99 (95% CI, 0.98-1.00), respectively, with corresponding successful operative field targeting rates of 0.94 (95% CI, 0.91-0.96), 0.97 (95% CI, 0.95-0.98), and 0.99 (95% CI, 0.98-1.00), respectively. In addition, the successful VATS rates with hook-wire, microcoil, and lipiodol localization were 0.96 (95% CI, 0.94-0.97), 0.97 (95% CI, 0.94-0.99), and 0.99 (95% CI, 0.98-1.00), respectively. Regarding complications, hook-wire, microcoil, and lipiodol localization were associated with pneumothorax rates of 0.35 (95% CI, 0.28-0.43), 0.16 (95% CI, 0.07-0.34), and 0.31 (95% CI, 0.20-0.46), respectively and hemorrhage rates of 0.16 (95% CI, 0.11-0.23), 0.06 (95% CI, 0.03-0.11), and 0.12 (95% CI, 0.05-0.23), respectively.
Conclusions
All three localization methods yielded similarly highly successful targeting rates. However, hook-wire localization had a relatively lower successful operative field targeting rate because of dislodgement or migration. Lipiodol localization had the highest overall success rate, and microcoil localization yielded the lowest complication rates.
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There has been increasing interest in transbronchial cryobiopsy for diagnosis in interstitial lung disease. As we highlighted in our systematic review and cost analysis, this has the potential to be cost saving in the setting of a payment by results system.1 Recently, it has been demonstrated in a porcine model that a new sheath cryoprobe gives equivalent biopsy quality without the need for en bloc bronchoscope removal or an endotracheal tube. This has the potential to shorten procedure times by 34.8% and reduce bleeding by 81.8% and the incidence of pneumothorax by 66.7%.2
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Background
Reports that septic shock incidence is rising and mortality rates declining may be confounded by improving recognition of sepsis and changing coding practices. We compared trends in septic shock incidence and mortality in academic hospitals using clinical vs claims data.
Methods
We identified all patients with concurrent blood cultures, antibiotics, and vasopressors for ≥ two consecutive days, and all patients with International Classification of Diseases, 9th edition (ICD-9) codes for septic shock, at 27 academic hospitals from 2005 to 2014. We compared annual incidence and mortality trends. We reviewed 967 records from three hospitals to estimate the accuracy of each method.
Results
Of 6.5 million adult hospitalizations, 99,312 (1.5%) were flagged by clinical criteria, 82,350 (1.3%) by ICD-9 codes, and 44,651 (0.7%) by both. Sensitivity for clinical criteria was higher than claims (74.8% vs 48.3%; P < .01), whereas positive predictive value was comparable (83% vs 89%; P = .23). Septic shock incidence, based on clinical criteria, rose from 12.8 to 18.6 cases per 1,000 hospitalizations (average, 4.9% increase/y; 95% CI, 4.0%-5.9%), while mortality declined from 54.9% to 50.7% (average, 0.6% decline/y; 95% CI, 0.4%-0.8%). In contrast, septic shock incidence, based on ICD-9 codes, increased from 6.7 to 19.3 per 1,000 hospitalizations (19.8% increase/y; 95% CI, 16.6%-20.9%), while mortality decreased from 48.3% to 39.3% (1.2% decline/y; 95% CI, 0.9%-1.6%).
Conclusions
A clinical surveillance definition based on concurrent vasopressors, blood cultures, and antibiotics accurately identifies septic shock hospitalizations and suggests that the incidence of patients receiving treatment for septic shock has risen and mortality rates have fallen, but less dramatically than estimated on the basis of ICD-9 codes.
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