Diagnostic yield of electromagnetic navigational bronchoscopy: A safety net community-based hospital experience in the United States.

INTRODUCTION: Electromagnetic navigational bronchoscopy (ENB) is an excellent tool to diagnose peripheral pulmonary nodules, especially in the setting of emphysema and pulmonary fibrosis. However, most of these procedures are done by interventional pulmonologists and academic tertiary centers under general anesthesia. Studies evaluating the diagnostic utility of this tool in safety-net community hospitals by pulmonologists not formally trained in this technology are lacking. The objective was to evaluate the diagnostic yield of ENB done in such a setting and its associated complications. METHODS: Retrospective chart review of consecutive ENB procedures over 5 years from 2014, since its inception in our institution-a safety-net community based hospital was performed. Multiple variables were analyzed to assess their impact on diagnostic yields. RESULTS: After exclusion criteria were applied, 72 patients with 76 procedures were eventually included within our study, with an overall 1-year diagnostic yield of 80.2%. Sensitivity for malignancy was 73% and negative predictive value of 65%. Primary lung cancer was the most common diagnosis obtained, followed by tuberculosis (TB). The overall complication rates were low, with only 1 patient (1.3%) requiring hospitalization due to pneumothorax needing tube thoracostomy. No deaths or respiratory failures were noted within the cohort. The only significant variable affecting diagnostic yield was forced expiratory volume in 1 s. The presence of emphysema did not affect diagnostic yield. CONCLUSIONS: ENB is safe and feasible with a high diagnostic success rate even when performed by pulmonologists not formally trained in interventional pulmonology in low resource settings under moderate sedation.

Pediatric size phlebotomy tubes and transfusions in adult critically ill patients: a pilot randomized controlled trial.

BACKGROUND: Transfusion of red blood cells (RBC) is common, can have adverse effects, and is a costly and limited resource. Interventions that reduce iatrogenic blood losses could reduce transfusions. The objectives of this pilot trial were to assess the feasibility (acceptability of the intervention and suitability of eligibility criteria) and potential effectiveness of pediatric size phlebotomy tubes in adult critically ill patients. METHODS: We conducted a pilot, randomized controlled trial in the medical intensive care unit (ICU) of a university-affiliated, tertiary care referral hospital from November 2017 to September 2018. A total of 200 patients with hemoglobin of at least 7 g/dL and without bleeding were randomized to pediatric or adult size phlebotomy tubes. Stratification was according to baseline hemoglobin (7-9.49 g/dL, 9.5-11.99 g/dL, and 12 g/dL or greater). Acceptability was measured via the number of blood test recollections and the number of patients that discontinued the use of pediatric tubes. The suitability of patient eligibility criteria was determined by identifying baseline characteristics associated with RBC transfusions. Potential effectiveness was estimated from the time to RBC transfusion or to hemoglobin level below 7 g/dL. RESULTS: The use of pediatric tubes was acceptable as patients experienced a low number of tests recollections (on average 1 every 57 days), and none of the participants discontinued their use. The baseline hemoglobin category was the only factor that appeared to be independently associated with RBC transfusions. A total of 6 patients (6%) in the pediatric tube group and 11 patients (11%) in the adult tube group (hazard ratio, 0.69; 95% CI, 0.25 to 1.9) received an RBC transfusion or reached hemoglobin below 7 g/dL. Almost all of these patients (16 of 17 participants) had baseline hemoglobin of 7-9.49 g/dL. CONCLUSIONS: This pilot study suggests that pediatric phlebotomy tubes are acceptable to patients and can therefore be used in adult ICU patients. A future study should focus on patients with hemoglobin levels below 9.5 g/dL, as these patients have a high risk of transfusions. This intervention has the potential of being successful in selected patients. A definitive trial is warranted. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03286465. Retrospectively registered on September 18, 2017.

A 45-Year-Old Woman With Multiple Pulmonary Nodules and Sjögren Syndrome.

CASE PRESENTATION: A 45-year-old woman presented for evaluation for 3 months of coughing and dyspnea. A recent chest CT scan done for workup of her symptoms revealed a 2-cm right-sided pulmonary nodule. She had a medical history of Sjögren syndrome, hypertension, and obesity. She also noted a weight loss of 30 lb over the last 3 years. She denied smoking, alcohol consumption, illicit drug use, or occupational exposures. A chest radiograph done 3 years prior did not reveal any pulmonary nodules. She had no personal or family history of arteriovenous malformations, hamartomas, or any malignancies and had been up to date with her breast cancer screening. She was treated with courses of hydroxychloroquine and mycophenolate mofetil for her Sjögren syndrome and did not have a history of opportunistic pulmonary infections. She denied any recent travel or exposure to TB.

A 32-Year-Old Man With HIV Infection, Pleural Effusions, and Lymphadenopathy.

CASE PRESENTATION: A 32-year-old man presented with fever, nonproductive cough, diffuse lymphadenopathy, and polyarticular pain for 2 weeks. His medical history included HIV diagnosed 10 years ago, anal intraepithelial neoplasia, Kaposi sarcoma, and herpes simplex virus-2 infection. The patient was not receiving antiretroviral therapy or antibiotic prophylaxis, and his last known CD4 count a month before was 45 cells/mm3. He was prescribed a course of doxycycline by his primary care physician, which did not improve his symptoms.