The acute effect of inhaled nitric oxide on the exercise capacity of patients with advanced interstitial lung disease: a randomized controlled trial.

BACKGROUND: Inhaled nitric oxide (iNO) selectively acts on the pulmonary vasculature of ventilated lung tissue by reducing pulmonary vascular resistance and intrapulmonary shunt. This effect may reduce ventilation/perfusion mismatch and decrease pulmonary hypertension in patients with interstitial lung disease. METHODS: In a prospective, single-blinded, randomized, placebo-controlled trial, participants with advanced interstitial lung disease, underwent two separate six-minute walk tests (6MWT): one with iNO and the other with a placebo. The primary outcome measured the difference in meters between the distances covered in the two tests. Secondary outcomes included oxygen saturation levels, distance-saturation product, and Borg dyspnea score. A predefined subgroup analysis was conducted for patients with pulmonary hypertension. RESULTS: Overall, 44 patients were included in the final analysis. The 6MWT distance was similar for iNO treatment and placebo, median 362 m (IQR 265-409) vs 371 m (IQR 250-407), respectively (p = 0.29). Subgroup analysis for patients with pulmonary hypertension showed no difference in 6MWT distance with iNO and placebo, median 339 (256-402) vs 332 (238-403) for the iNO and placebo tests respectively (P=0.50). No correlation was observed between mean pulmonary artery pressure values and the change in 6MWT distance with iNO versus placebo (spearman correlation Coefficient 0.24, P=0.33). CONCLUSION: In patients with advanced interstitial lung disease, both with and without concurrent pulmonary hypertension, the administration of inhaled nitric oxide failed to elicit beneficial effects on the six-minute walk distance and oxygen saturation. The use of inhaled NO was found to be safe and did not lead to any serious side effects. TRIAL REGISTRATION: (NCT03873298, MOH_2018-04-24_002331).

Endobronchial closure of broncho-biliary fistula using Amplatzer device: Case report.

Broncho-biliary fistula (BBF) is an extremely rare but serious medical condition resulting from pathological communication between the biliary system and the bronchial tree. Treatment options include both surgical and non-surgical approaches. Several endobronchial techniques, such as the spigot and glue, can be used for this purpose. This report discusses a patient who developed a broncho-biliary fistula following a liver biopsy. The BBF was diagnosed during bronchoscopy and successfully treated with an endobronchial Amplatzer device. To the best of our knowledge, this is the first report of the use of the Amplatzer device to manage BBF.

Bronchoscopy for management and identification of etiology of right middle lobe syndrome: Analysis of 66 cases.

BACKGROUND: Right middle lobe (RML) syndrome is a recurrent or chronic obstruction of the RML causing atelectasis of the right middle lobe due to mechanical and nonmechanical etiologies. The consequences of untreated RML syndrome range from chronic cough to post-obstructive pneumonia and bronchiectasis. We report here our bronchoscopy experience in patients with RML syndrome. METHODS: We conducted a retrospective study of adult patients who underwent bronchoscopy for RML syndrome at Rabin Medical Center from 2008 through 2022. Demographic data and medical history, bronchoscopy findings and procedures, and follow-up results were collected. RESULTS: A total of 66 patients (57.6% male, mean age 63 ± 13 years) underwent bronchoscopy for RML syndrome during the study period. Bronchoscopy revealed a mechanical etiology in 49 (74.2%) cases, including endobronchial mass (21, 31.8%) and external compression (7, 10.6%). Malignancy was identified in 20 (30.3%) cases. In 62 patients (93.9%), the bronchoscopy resulted in partial or complete reopening of the RML bronchus. The therapeutic bronchoscopic procedures were balloon dilatation (19), laser ablation (17), mechanical debridement (12), endobronchial stent insertion (11), and cryoablation (6). CONCLUSIONS: Malignancy was identified as the etiology of RML syndrome in approximately 25% of cases, suggesting bronchoscopy should be performed in every case of RML atelectasis. To our knowledge, this is the first reported series of endobronchial stenting of the RML bronchus in the context of RML syndrome.

Prognostic Significance of the N-Terminal Pro-B-Type Natriuretic Peptide in Lung Transplant Candidates on the Waiting List.

We investigated the prognostic significance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in lung transplant candidates, in a retrospective single-center study. Data regarding various baseline characteristics and all-cause mortality were collected for 205 lung transplant candidates placed on waitlist for transplantation from November 2017 to December 2019. Associations of NT-proBNP levels with baseline characteristics and mortality were analyzed. Results showed NT-proBNP values correlated positively with age, forced vital capacity, mean pulmonary artery pressure (MPAP), and pulmonary capillary wedge pressure; and negatively with diffusing lung capacity for carbon monoxide and cardiac index. The optimal cut-off of NT-proBNP for predicting MPAP levels > 35 mmHg was 251 pg/mL; with 58.1% sensitivity, 85.7% specificity, 45.0% positive predictive value, and 91.0% negative predictive value. During a median follow-up period of 2.2 years, 97 patients underwent lung transplantation, 42 died waiting for donation, and 66 were alive and still waiting for transplantations. On multivariate analysis, higher NT-proBNP levels were strongly associated with increased mortality among waitlisted lung transplant candidates (HR 1.49, 95% CI 1.10−2.03, p = 0.01). In conclusion NT-proBNP can predict mortality among waitlisted lung transplant candidates. Lower levels of NT-proBNP can preclude severe pulmonary artery hypertension. Assessment of NT-proBNP may improve risk stratification among lung transplant candidates.

Successful treatment of acute relapse of chronic eosinophilic pneumonia with benralizumab and without corticosteroids: A case report.

BACKGROUND: Currently, the mainstay of chronic eosinophilic pneumonia (CEP) treatment is corticosteroids, usually with a favorable response and good prognosis. However, relapse is common, requiring long-term use of corticosteroids, with risk of significant treatment-related complications. The dire need to develop new treatments for patients with CEP, who are dependent on, or resistant to corticosteroids has led to exploring novel therapies. We herein describe a patient with acute relapse of CEP, who was successfully treated with benralizumab, an IL-5Rα antagonist that has demonstrated rapid anti-eosinophil action in patients with asthma. Currently, only three recent patient reports on CEP relapse, also demonstrated successful treatment with benralizumab alone, without corticosteroids. CASE SUMMARY: A 31-year-old non-smoking woman presented in our hospital with a 3 wk history of shortness of breath, dry cough and fever up to 38.3 °C. Laboratory examination revealed leukocytosis 10240 K/µL, eosinophilia 900 K/µL and normal values of hemoglobin, platelets, creatinine and liver enzymes. Computed tomography of the chest showed a mediastinal lymphadenopathy and consolidations in the right upper and left lower lobes. CEP was diagnosed, and the patient was treated with hydrocortisone intravenously, followed by oral prednisone, with prompt improvement. Three months later, she presented with relapse of CEP: aggravation of dyspnea, rising of eosinophilia and extension of pulmonary infiltrates on chest X-ray. She was treated with benralizumab only, with clinical improvement within 2 wk, and complete resolution of lung infiltrates following 5 wk. CONCLUSION: Due to Benralizumab's dual mechanism of action, it both neutralizes IL-5Rα pro-eosinophil functions and triggers apoptosis of eosinophils. We therefore maintain benralizumab can serve as a reasonable therapy choice for every patient with chronic eosinophilic pneumonia and a good alternative for corticosteroids.

Carboxyhemoglobin Does Not Predict the Need of Mechanical Ventilation and Prognosis during COPD Exacerbation.

Background: Carboxyhemoglobin (COHb) is a complex formed by the binding of carbon monoxide to hemoglobin in blood. Higher COHb levels have been associated with poor prognosis in a variety of pulmonary disorders. However, little is known regarding the prognostic significance of COHb among individuals with chronic obstructive pulmonary disease (COPD) exacerbation. Methods: In a retrospective study, we evaluated associations of venous COHb levels on hospital admission with the need for invasive mechanical ventilation, in-hospital mortality, and rehospitalization, among 300 patients hospitalized for COPD exacerbation in internal medical wards. Results: Rates of in-hospital death and 1-year recurrent hospitalizations were 11.0% and 59.6%, respectively. COHb levels were not significantly associated with in-hospital mortality (OR = 0.82, P=0.25, 95% CI 0.59-1.15) or with 1-year rehospitalizations (OR = 0.91, P=0.18, 95% CI 0.79-1.04). The mean COHb level did not differ significantly between patients who needed invasive mechanical ventilation and those who were not invasively mechanically ventilated during the current hospitalization (2.01 ± 1.42% vs. 2.19 ± 1.68%, P=0.49). Conclusions: Among patients hospitalized with COPD exacerbation in internal medicine wards, COHb levels on admission were not associated with invasive mechanical ventilation treatment, rehospitalizations, or mortality.

Dexmedetomidine versus propofol sedation in flexible bronchoscopy: a randomized controlled trial.

BACKGROUND: Dexmedetomidine (DEX), is a highly selective alpha2 adrenoceptor (α2-AR) agonist, successfully used in various procedures including flexible bronchoscopy. Randomized controlled trials (RCTs) evaluating DEX sedation during bronchoscopy report equivocal results regarding respiratory and hemodynamic outcomes. METHODS: We conducted an RCT to evaluate the efficacy and safety of dexmedetomidine compared to propofol for sedation during bronchoscopy. The primary outcome was the number of desaturation events, secondary outcomes were transcutaneous Pco2 level, hemodynamic adverse events and physician and patient satisfaction. RESULTS: Overall, 63 patients were included, 30 and 33 in the DEX and propofol groups, respectively. The number of desaturation events was similar between groups, median (IQR) 1 (0-1) and 1 (0-2) in the DEX and control groups, respectively (P = 0.29). Median desaturation time was 1 (0-2) and 1 (0-3) minutes in the DEX and control groups, respectively (P = 0.48). Adverse events included hypotension, 33% vs 21.1% in intervention and control groups, respectively (P = 0.04), bradycardia, cough, and delayed recovery from sedation. Total adverse events were 22 and 7 in DEX and propofol groups, respectively (P = 0.009). CONCLUSION: Dexmedetomidine sedation during bronchoscopy did not show differences in oxygen saturation and transcutaneous CO2 level in comparison to propofol. Moreover, DEX sedation required a significantly higher number of rescue boluses, due to inadequate sedation and was associated with a higher rate of adverse events. Trial registration NCT04211298, registration date: 26.12.2019.

Long-Term Success of Metal Endobronchial Stents in Lung Transplant Recipients.

BACKGROUND: Bronchial stenosis is a common complication following lung transplantation. We evaluated long-term associations of the use of self-expandable metal stents (SEMSs) with lung function tests, patient safety, and survival. METHODS: A retrospective chart review of 582 lung transplantations performed at our institution between January 2002 and January 2018. Fifty-four patients with SEMSs (intervention group) were matched one-to-one to patients without SEMSs (control group) using propensity score matching for age, sex, the year, and type of transplantation (unilateral/bilateral), and underlying disease. Data regarding long-term lung function and survival were compared between the groups. RESULTS: During a median follow-up of 54.8 months, the difference in survival between the study groups was not statistically significant (p = 0.2). Following 5, 7.5 and 10 years, values of mean forced expiratory volume in 1 second (FEV1) were comparable between patients with and without SEMSs as follows: 59.5 versus 62.6% (p = 0.2), 55.9 versus 55.0% (p = 0.4), and 63.5 versus 61.9% (p = 0.3), respectively. In the intervention group, a significant increase in the mean FEV1 was observed in 60 days after stent insertion (from 41.9 ± 12.8 to 49.5 ± 16.7% days, p < 0.001). Long-term complications following stent insertion included severe bleeding (1.8%), stent fractures (7.4%), stent stenosis (7.4%), stent collapse (3.7%), endobronchial pressure ulcer (1.9%), and stent migration (1.9%). CONCLUSION: SEMS insertion is associated with a positive sustained effect on lung function, without increasing long-term mortality. Thus, airway stenosis after lung transplantation can be safely and successfully treated using endobronchial metal stenting, with tight bronchoscopic follow-up and maintenance.

Sertraline-Associated Interstitial Lung Disease: A case series and Literature Review.

Sertraline-associated interstitial lung disease (ILD) is a rare entity. A search of the English medical literature retrieved only 9 such cases. We report herein on an additional 12 patients who developed ILD during treatment with sertraline. The patients met the criteria for drug-induced pulmonary toxicity such as exposure to drug, correlation of the drug with clinical symptoms, lung imaging, lung biopsy findings, exclusion of other potential causes and improvement after drug removal. We review the available data and discuss various aspects of this entity. The possibility of drug-induced ILD should be considered in an individual who during treatment with sertraline develops dyspnea, cough, and radiographic findings compatible with ILD. Further epidemiological studies should be conducted to explore the association of sertraline treatment with ILD, and to delineate, substantiate, and broaden our knowledge of this rare entity.

Nontuberculous Mycobacterial Pulmonary Infection Among Lung Transplant Recipients.

OBJECTIVES: Data are limited regarding the clinical significance of nontuberculous mycobacteria pulmonary infections among lung transplant recipients. We investigated the incidence and characteristics of pulmonary nontuberculous mycobacteria infection in ourlung transplant patient population. MATERIALS AND METHODS: We obtaineddata of the patients who underwent lung transplant in our center from January 1997 to March 2019. RESULTS: Of 690 patients, nontuberculous mycobacteria were identified in 58 patients (8.4%) over a median follow-up of 3 years. Types of species were as follows: Mycobacterium simiae (n = 24), avium complex (n = 12), abscessus (n = 9), fortuitum (n = 6), chelonae (n = 2), szulgai (n = 1), kansasii (n = 1), lentiflavum (n = 1), and undefined mycobacteria (n = 2). When we compared infections in the early versus late period posttransplant (before and after 6 months), infections with Mycobacterium simiae (16 vs 8 incidents) and Mycobacterium fortuitum (5 vs 1 incident) were more often observed within the early period, whereas most Mycobacterium abscessus (7 vs 1 incident) and Mycobacterium avium complex (9 vs 3 incidents) were observed in the later period. The median forced expiratory volume in 1 second overtime did not differ significantly between patients with and without nontuberculous mycobacteria infection (P = .29). Nontuberculous mycobacteria acquisition was significantly associated with decreased survival (relative risk of 2.41, 95% CI, 1.70-3.43; P ⟨ .001). CONCLUSIONS: The nontuberculous mycobacteria species isolated varied according to the time elapsed since transplant. Among lung transplant recipients, nontuberculous mycobacteria infection was associated with increased mortality but not with lung dysfunction.

The LungVision navigational platform for peripheral lung nodule biopsy and the added value of cryobiopsy.

BACKGROUND: The LungVision system is a novel augmented-fluoroscopy-based real-time navigation and guidance technology for bronchoscopy that can be integrated with any standard biopsy tool, including the cryoprobe, to enable real-time visualization and localization of pulmonary nodules. OBJECTIVES: To evaluate the diagnostic yield and safety among patients undergoing peripheral pulmonary nodule biopsy with the LungVision system. METHODS: This prospective, single-center study was conducted at Rabin Medical Center in Israel. All patients that underwent peripheral pulmonary nodule biopsy with the LungVision system from January 2016 to August 2020 were included. All procedures were performed under moderate sedation. The primary outcome was tissue diagnosis by either identification of malignant cells or benign diagnosis. Secondary outcomes were safety and the added value of cryobiopsy. RESULTS: Sixty-three procedures were performed during the study period. Median lesion size (interquartile range) was 25.0 mm (18-28 mm). The diagnostic yield overall was 27/33 (81.8%) and for lesions smaller than 20 mm was 13/18 (72.2%). In nine cases the transbronchial cryobiopsy showed tissue with malignant cells that were not found in any other biopsy material taken with other sampling tools. One patient was treated with a chest tube for a pneumothorax. No other major complications were reported. CONCLUSIONS: The LungVision system showed good feasibility and safety for peripheral pulmonary nodule biopsy. The system is compatible with all biopsy tools, including the cryoprobe. Randomized controlled trials are needed to accurately ascertain its diagnostic yield.

Long-term outcomes of metallic endobronchial stents in lung transplant recipients are not affected by bacterial colonization.

OBJECTIVES: We evaluated associations of endobronchial stenting with airway bacterial colonization, the antimicrobial resistance profile, hospitalizations for pneumonia and survival in lung transplant recipients. METHODS: This is a retrospective single-centre study of 582 recipients of lung transplant during 2002-2018. We compared outcomes of 57 patients (9.7%) who received endobronchial stents (intervention group) to a control group of 57 patients without stents who were matched one to one for age, sex, year of transplantation, unilateral/bilateral transplantation and underlying disease. RESULTS: For the intervention compared to the control group, airway colonization was more common for Pseudomonas (86% vs 35%, P < 0.001), Acinetobacter (21% vs 7%, P = 0.05), Klebsiella (21% vs 5%, P = 0.02) and Staphylococcus species (11% vs 0%, P = 0.02). The respective proportions of patients with positive bronchoalveolar lavage cultures on the third post-transplantation day, the day of stent insertion and 6-month post-stent insertion were 47.4%, 50.9% and 65.4% for Pseudomonas sp.; 15.8%, 12.3% and 3.8% for Klebsiella sp.; and 8.8%, 5.3% and 5.8% for Acinetobacter sp. The mean number of hospitalizations for pneumonia per patient was higher, without statistical significance, in the intervention than the control group (1.5 ± 1.7 vs 0.9 ± 1.5, P = 0.1). Kaplan-Meier survival curves did not show a statistically significant difference between the intervention group and the entire group without endobronchial stents (n = 525) (P = 0.4). CONCLUSIONS: Lung transplant recipients with endobronchial stents were more likely to be colonized with pathologic bacteria and having pneumonia; however, stent placement was not associated with increased long-term mortality with appropriate stent maintenance.

Placement of self-expanding metallic tracheobronchial Y stent with laryngeal mask airway using conscious sedation under fluoroscopic guidance.

BACKGROUND: Central airway obstruction and fistula are treated with a tracheobronchial Y stent. In the currently used self-expandable metal Y stents, the delivery system is 8 mm in diameter and requires either a 9 mm tracheal tube or rigid bronchoscope to enable airway control during insertion. In this study we present a novel technique of laryngeal mask airway (LMA) assisted Y stent insertion, enabling airway control during deployment of the Y stent. METHODS: All procedures using LMA in assisting Y stent insertions between 2014-2020 were reviewed. Data collected included demographics, clinical diagnosis and disease characteristics, indication, procedural success rates, clinical outcome and survival. RESULTS: A total of 10 patients with a median age of 61.5 years (range 37-73) underwent LMA assisted Y stent insertion. Indications for stent insertion were malignant disease with central airway obstruction or fistula. In all cases airway patency was achieved leading to improvement of symptoms and performance status. No procedural complications were reported. The median survival was 4.5 weeks (range: 2-26). CONCLUSIONS: LMA assisted Y stent insertion enables airway control during the procedure. In comparison to silicone Y stent insertion, the procedure is less cumbersome, shorter in duration and does not require the use of general anesthesia or rigid bronchoscopy. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: LMA assisted Y stent insertion enables airway control during the implantation of metallic self-expanding Y stent. The procedure does not require the use of general anesthesia or rigid bronchoscopy. WHAT THIS STUDY ADDS: In this study we present the technique and outcomes of LMA assisted Y stent insertion. This method of Y stent insertion provides an additional treatment option for patients with central airway obstruction and fistula.

The Etiology and Prognosis of Delayed Postoperative Leukocytosis in Lung Transplant Recipients.

BACKGROUND: Leukocytosis (white blood cell count >12 000/µL) in the delayed postoperative period (4-7 days) after lung transplantation is due to diverse etiologies. We aimed to describe the etiologies of delayed postoperative leukocytosis in lung transplant recipients and to evaluate the association of leukocytosis causes with short-term survival. METHODS: A retrospective chart review of 274 lung transplantations performed in our institution during 2006 to 2013. RESULTS: Delayed postoperative leukocytosis was seen in 159 (58.0%) of lung transplant recipients. In 57 (35.8%) of them, the etiology of the leukocytosis was not identified. The etiologies of leukocytosis that were identified were infection (n = 39), second surgery, acute rejection (n = 12), primary graft dysfunction (n = 3), multiple etiologies (n = 17), and other causes (n = 10). On multivariate analysis, delayed postoperative leukocytosis was one of the variables that most significantly associated with decreased survival in the entire sample (hazard ratio [HR] = 1.52, 95% confidence interval [CI]: 1.01-2.29, P = .040). On additional analysis for mortality assessing each leukocytosis subgroup, the data were acute graft rejection (HR = 8.21, 95% CI: 4.09-16.49, P < .001), second surgery (HR = 2.05, 95% CI: 1.08-3.90, P = .020), primary graft dysfunction (HR = 2.72, 95% CI: 0.65-11.33, P = .169), other causes (HR = 1.30, 95% CI: 0.47-3.62, P = .620), and unknown etiology (HR = 0.94, 95% CI: 0.54-1.62, P = .800). CONCLUSIONS: Delayed post-lung transplant leukocytosis is a poor prognostic sign, especially when attributed to acute graft rejection, infection, and multiple etiologies. In the absence of an identifiable etiology, it can be attributed to postoperative reactive stress, is not associated with increased mortality, and likely does not warrant further diagnostic investigation.

Delayed versus classic orthostatic hypotension: clinical and prognostic implications.

Purpose: Orthostatic hypotension (OH) is a common disorder, especially among hospitalised patients. Classic OH is defined as occurring 3 or less minutes of orthostatic stress, and delayed OH as occurring after 3 min of stress. We aimed to compare clinical characteristics and prognosis between inpatients with classic vs. delayed OH.Methods: We performed a retrospective analysis of data from 358 inpatients, aged ≥60 years, who were evaluated for the occurrence of OH at the initial phase of ambulation in four previous prospective studies in our department. Demographic, clinical and prognostic data were compared between patients with (n = 191) vs. without (n = 167) OH, classic (n = 138) vs. delayed (n = 53) OH and seated (n = 115) vs. standing (n = 76) OH.Results: Demographic characteristics, duration of bed rest, the main reasons for admission and the use of offending medications were comparable between the delayed and classic OH groups. Mean maximal postural diastolic (p < .001) and systolic (p = .063) blood pressure falls were higher among patients with classic v. delayed OH. No statistically significant difference between the patients with classic and delayed OH were observed in the occurrence of OH-related symptoms (62.3 vs. 69.8%, p = .42). During a median follow-up of 5.5 years, no statistically significant differences in survival were observed between patients with vs. without OH (p = .14), classic vs. delayed OH (p = .68) and seated vs. standing OH (p = .067). On multivariate analysis, these variables remained not significantly associated with decreased survival.Conclusions: Among inpatients, delayed OH is associated with a lesser magnitude of orthostatic blood pressure fall than classic OH. However, rates of symptomatic OH and long-term mortality were comparable between the groups. Thus, among hospitalised patients, delayed OH should be considered as posing the same severity as classic OH.

Routine comprehensive Aspergillus screening of bronchoalveolar lavage samples in lung transplant recipients.

BACKGROUND: Invasive aspergillosis is a significant cause of morbidity and mortality in lung transplant recipients (LTRs). Early diagnosis may improve outcome, yet is challenging. We assessed the diagnostic yield of a routine, comprehensive, prospectively employed Aspergillus screening strategy in LTRs. METHODS: During a 6-month period, all bronchoalveolar lavage (BAL) samples (including post-transplant surveillance) obtained from LTRs at our center were routinely tested for Aspergillus PCR, galactomannan (GM), and fungal culture. Invasive aspergillosis (IA) was defined using EORTC/MSG and ISHLT criteria for proven and probable aspergillosis. RESULTS: Ninety-five consecutive BAL samples were tested. PCR, GM, and fungal culture were positive in 28.4%, 30.6%, and 7.4%, respectively. Five cases of IA (two proven, three probable) were identified. Fungal culture failed to detect 40% of IA cases, which were detected by a positive PCR and/or GM. However, the majority of positive PCR samples represented colonization (59.3%). Sensitivity of PCR, GM, and culture for IA was 80%, 60%, and 60%, respectively, and specificity was 74%, 71%, and 96%. CONCLUSIONS: In LTRs, a routine prospectively employed screening strategy in which all BAL samples were screened for Aspergillus PCR and GM, detected aspergillosis cases that were otherwise missed by a false-negative fungal culture, but resulted in more cases of colonization being detected. Clinical judgment is thus warranted to avoid unnecessary treatment of colonization.

Mucormycosis in lung transplant recipients: A systematic review of the literature and a case series.

BACKGROUND: Mucormycosis is a rare infection in lung transplant recipients (LTR). Our objective was to better define the clinical presentation and optimal management of this frequently lethal infection. METHODS: A systematic review of the literature was performed to identify all published cases of mucormycosis in LTR using PubMed/MEDLINE. These cases were analyzed together with a new case series from our clinic. RESULTS: Literature search yielded 44 articles matching the inclusion criteria, describing 121 cases. Six additional cases were identified from our clinic. Data regarding infection site and outcome were available for a total of 53 patients. The lungs were the most common site of infection (62%), followed by rhinocerebral and disseminated disease. Most cases (78%) developed in the first post-transplant year, with over 40% of them in the first month. Additional risk factors for mucormycosis were identified in over half of the patients. Surgical debridement was uncommon in pulmonary infection (9%). Posaconazole therapy was used in 35% of cases, mostly in combination with amphotericin B. Overall mortality was 32% but varied according to site of infection. CONCLUSION: Mucormycosis in LTRs tends to be an early post-surgical infection, associated with additional risk factors and intensified immunosuppressive states, and most often affects the lungs, where surgical debridement is rarely feasible. Posaconazole as first-line therapy should be further explored.

High compression leg bandaging prevents seated postural hypotension among elderly hospitalized patients.

Postural hypotension (PH) is a very common and often symptomatic disorder among elderly hospitalized patients. Little is known about measures for preventing previously unknown PH in this population. We evaluated the effectiveness of high compression leg bandaging in preventing seated PH during the initial phase of ambulation, among elderly inpatients without a history of PH. We compared the occurrence of seated PH between patients who were bandaged (n = 100) and unbandaged (n = 100). The rate of seated PH was significantly lower in the bandaged than the unbandaged group (27% vs. 51%, p < 0.001, relative risk reduction 47%, and the number of patients needed to treat 4.2). On multivariate analysis, not wearing leg bandaging was one of the variables most significantly associated with eventual occurrence of PH (p = 0.002, odds ratio 2.65, and 95% confidence interval 1.42-4.97). We conclude that during ambulation of elderly inpatients, high compression leg bandaging is beneficial to prevent seated PH.

Physiological Responses and Prognostic Value of Common Exercise Testing Modalities in Idiopathic Pulmonary Fibrosis.

PURPOSE: This pilot study aimed to compare physiological responses between cycle cardiopulmonary exercise tests (CPETs) and 6-min walk tests (6MWTs) and to assess their prognostic value among patients with idiopathic pulmonary fibrosis (IPF). METHODS: Thirty-four patients with IPF (68 ± 8 yr) underwent CPETs and 6MWTs and were followed up for 40 mo. Differences, levels of agreement, and relative risks for mortality were analyzed between measured and estimated peak responses for the 2 tests. RESULTS: Compared with the CPET, oxygen uptake ((Equation is included in full-text article.)O2), heart rate (HR), and the nadir of SpO2 were lower during the 6MWT, whereas work rate (WR) was higher. Mean differences were as follows: (Equation is included in full-text article.)O2 =-1.9 mL/kg/min, 95% CI, -1.1 to -2.7, P < .001; HR =-9 beats/min, 95% CI, -4 to -14, P = .002; SpO2 =-6%, 95% CI, -4 to -7, P < .001; and WR = 9 W/min, 95% CI, 3 to 16, P = .008. Interclass correlations ranged from 0.84 to 0.90 and both tests demonstrated prognostic value for mortality. CONCLUSIONS: Significant differences and variation in peak physiological responses were observed between cycle CPETs and 6MWTs in patients with IPF. However, good agreement was evident, suggesting that both tests provide value for clinical and research settings. Future studies should compare the physiological responses between treadmill CPETs and 6MWTs for prognostic utility in IPF.