Positron emission tomography in the evaluation of pulmonary nodules among patients living in a coccidioidal endemic region.

BACKGROUND: Within a coccidioidal endemic region, pulmonary nodules due to coccidioidomycosis are common. Uptake of (18)fluorodeoxyglucose ((18)FDG) by positron emission tomography with computed axial tomography (PET/CT) has been used to assess whether pulmonary nodules are malignant but inflammatory lesions can be positive. The purpose of this study was to compare by PET/CT the (18)FDG uptake in pulmonary nodules likely due to coccidioidomycosis to that of nodules shown to be malignant among patients living in a coccidioidal endemic region. METHODS: We retrospectively reviewed patients who underwent a PET/CT at the Southern Arizona Veterans Affairs Health Care System between January 2008 and March 2012 who were subsequently found on biopsy to have pulmonary nodules that were coccidioidal or granulomatous or were due to malignancy. RESULTS: Among 245 diagnostic biopsies where the subject had a previous PET/CT, 15 (6.1 %) were either coccidioidal (n = 12) or granulomatous without an identified organism (n = 3). The median maximum standard unit of uptake (SUV(max)) on PET/CT of coccidioidal or granulomatous lesions was 2.0 compared to 9.8 for malignant lesions (P < 0.001). The maximum diameter of the coccidioidal or granulomatous nodules was 2.1 cm compared to 3.0 cm for the malignant lesions (P = 0.009). On multivariable analysis, an elevated SUV(max) was the only distinguishing feature between the malignant and the granulomatous lesions (OR 1.28, 95 % CI 1.05-1.55; P = 0.013). CONCLUSIONS: Coccidioidal pulmonary nodules take up significantly less (18)FDG than those due to malignancies, but there is considerable overlap between granulomatous and malignant lesions at lower SUV(max).

Critical care ultrasound training: a survey of US fellowship directors.

PURPOSE: The purpose of this study is to describe the current state of bedside ultrasound use and training among critical care (CC) training programs in the United States. MATERIALS AND METHODS: This was a cross-sectional survey of all program directors for Accreditation Council for Graduate Medical Education accredited programs during the 2012 to 2013 academic year in CC medicine, surgical CC, pulmonary and critical care, and anesthesia CC. Availability, current use, and barriers to training in CC ultrasound were assessed. RESULTS: Sixty of 195 (31%; 95% confidence interval [CI], 24%-38%) program directors responded. Most of the responding programs had an ultrasound system available for use (54/60, 90%; 95% CI, 79%-96%) and identified ultrasound training as useful (59/60, 98%; 95% CI, 91%-100%) but lacked a formal curriculum (25/60, 42%; 95% CI, 29%-55%) or trained faculty (mean percentage of faculty trained in ultrasound: pulmonary and critical care, 25%; surgical CC, 33%; anesthesia CC, 20%; CC medicine, 7%), and relied on informal teaching (45/60, 77%; 95% CI, 62%-85%). Faculty with expertise (53/60, 88%; 95% CI, 77%-95%), simulation training (60/60, 100%; 95% CI, 94%-100%), establishing and meeting required number of examinations (47/60, 78%; 95% CI, 66%-88%), and regular review sessions (49/60, 82%; 95% CI, 70%-90%) were identified as necessary to improve ultrasound training. Most responding programs (32/35 91%; 95% CI, 77%-98%) without a formal curriculum plan to create one in the next 5 years. CONCLUSIONS: This study identified deficiencies in current training, suggesting a need for a formal curriculum for bedside ultrasound training in CC fellowship programs.