Donald R. Lazarus

Acinetobacter Skin Carriage Among US Army Soldiers Deployed in Iraq

Skin carriage of Acinetobacter calcoaceticus-baumannii complex was not detected among a representative sample of 102 US Army soldiers stationed in Iraq. This observation refutes the hypothesis that preinjury skin carriage serves as the reservoir for the Acinetobacter infections seen in US military combat casualties.

Quality-Adjusted Survival Following Treatment of Malignant Pleural Effusions With Indwelling Pleural Catheters

BACKGROUND Malignant pleural effusions (MPEs) are a frequent cause of dyspnea in patients with cancer. Although indwelling pleural catheters (IPCs) have been used since 1997, there are no studies of quality-adjusted survival following IPC placement. METHODS With a standardized algorithm, this prospective observational cohort study of patients with MPE treated with IPCs assessed global health-related quality of life using the SF-6D to calculate utilities. Quality-adjusted life days (QALDs) were calculated by integrating utilities over time. RESULTS A total of 266 patients were enrolled. Median quality-adjusted survival was 95.1 QALDs. Dyspnea improved significantly following IPC placement (P < .001), but utility increased only modestly. Patients who had chemotherapy or radiation after IPC placement (P < .001) and those who were more short of breath at baseline (P = .005) had greater improvements in utility. In a competing risk model, the 1-year cumulative incidence of events was death with IPC in place, 35.7%; IPC removal due to decreased drainage, 51.9%; and IPC removal due to complications, 7.3%. Recurrent MPE requiring repeat intervention occurred in 14% of patients whose IPC was removed. Recurrence was more common when IPC removal was due to complications (P = .04) or malfunction (P < .001) rather than to decreased drainage. CONCLUSIONS IPC placement has significant beneficial effects in selected patient populations. The determinants of quality-adjusted survival in patients with MPE are complex. Although dyspnea is one of them, receiving treatment after IPC placement is also important. Future research should use patient-centered outcomes in addition to time-to-event analysis. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01117740; URL: www.clinicaltrials.gov.

Safety of flexible bronchoscopy, rigid bronchoscopy, and endobronchial ultrasound-guided transbronchial needle aspiration in patients with malignant space-occupying brain lesions

BACKGROUND Bronchoscopy in patients with space-occupying brain lesions is anecdotally felt to carry a high risk of neurologic complications. METHODS We conducted a retrospective cohort study of patients with evidence of a malignant, space-occupying brain lesion who were referred for flexible or rigid bronchoscopy or endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). The primary outcome of interest was the incidence of neurologic complications following the procedures in these patients. RESULTS Of the 103 enrolled patients, flexible bronchoscopy was performed in 41, rigid bronchoscopy in 12, and EBUS-TBNA in 50. Among these patients, 41 (40%) had evidence suggestive of increased intracranial pressure on imaging. Among all study patients, none (95% CI, 0-0.035) had neurologic, procedure-specific, or sedation-specific complications, and the level of care was not escalated in any of these patients. CONCLUSIONS On the basis of our findings, we recommend that procedures such as flexible or rigid bronchoscopy or EBUS-TBNA in patients with malignant space-occupying brain lesions should be considered reasonably safe as long as neurologic findings are stable.

How and when to use genetic markers for nonsmall cell lung cancer.

Purpose of review Many driver mutations that determine the malignant behavior of lung cancer have been identified in recent years. The promise of therapies targeted to the specific molecular pathways altered by such mutations has made genetic testing in nonsmall cell lung cancer (NSCLC) attractive to clinicians. We reviewed recent research on clinically relevant genetic and molecular tests for patients with NSCLC, with an emphasis on the tests linked to actionable mutations that influence therapy and improve outcomes. Recent findings Mutations in the epidermal growth factor receptor gene (EGFR) and translocations involving the anaplastic lymphoma kinase (ALK) gene have been shown to be common driver mutations in lung adenocarcinoma. The presence or absence of these mutations has been demonstrated to predict response to targeted therapy in many recent studies. Targeted therapies for patients with mutations in the EGFR domain or the echinoderm microtubule-associated protein-like 4 anaplastic lymphoma kinase translocation have been shown to be effective and are approved for use. Ongoing studies continue to define the extent of their utility and may continue to expand their indications. Sufficient tissue for genetic analysis can be obtained from cytologic samples, including those obtained from endobronchial ultrasound-guided transbronchial needle aspiration. Summary Genetic testing for driver mutations is useful in identifying patients with NSCLC who are likely to respond to targeted therapy. These tests are best used in patients with adenocarcinoma who have advanced-stage cancer.

Mediastinal Granulomatous Inflammation and Overall Survival in Patients with a History of Malignancy

RATIONALE Investigators have postulated that mediastinal granulomatous inflammation is associated with prolonged overall survival in patients with cancer. OBJECTIVES We sought to determine whether mediastinal granulomatous inflammation affects overall survival in patients with a history of treated cancer. METHODS Patients with a history of treated cancer who underwent endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) for evaluation of mediastinal or hilar lymphadenopathy were grouped based on whether they had mediastinal granulomatous inflammation or benign mediastinal lymphadenopathy without granulomas. Overall survival from the date of EBUS-TBNA to cancer-related death or to last follow-up in patient groups was compared. MEASUREMENTS AND MAIN RESULTS We reviewed the records of 106 patients (44 with mediastinal granulomatous inflammation and 62 with benign mediastinal lymphadenopathy). The 3-year survival rate was 90% overall and 93 and 88% in patients with mediastinal granulomatous inflammation and benign mediastinal lymphadenopathy, respectively (P=0.40). After multivariate adjustment, whether patients had mediastinal granulomatous inflammation or benign mediastinal lymphadenopathy did not significantly affect the risk of cancer death (mediastinal granulomatous inflammation to benign mediastinal lymphadenopathy hazard ratio, 1.27; P=0.76). CONCLUSIONS These results suggest that patients who develop mediastinal granulomatous inflammation after cancer treatment do not have an increased overall survival when compared with patients who develop benign mediastinal lymphadenopathy. EBUS-TBNA is warranted for patients with treated cancer who develop mediastinal and/or hilar lymphadenopathy to avoid erroneous upstaging or misdiagnosis of cancer recurrence that would lead to suboptimal management.

Persistent air leaks: a review with an emphasis on bronchoscopic management

Persistent air leak (PAL) is a cause of significant morbidity in patients who have undergone lung surgery and those with significant parenchymal lung disease suffering from a pneumothorax. Its management can be complex and challenging. Although conservative treatment with chest drain and observation is usually effective, other invasive techniques are needed when conservative treatment fails. Surgical management and medical pleurodesis have long been the usual treatments for PAL. More recently numerous bronchoscopic procedures have been introduced to treat PAL in those patients who are poor candidates for surgery or who decline surgery. These techniques include bronchoscopic use of sealants, sclerosants, and various types of implanted devices. Recently, removable one-way valves have been developed that are able to be placed bronchoscopically in the affected airways, ameliorating air-leaks in patients who are not candidates for surgery. Future comparative trials are needed to refine our understanding of the indications, effectiveness, and complications of bronchoscopic techniques for treating PAL. The following article will review the basic principles of management of PAL particularly focusing on bronchoscopic techniques.

Bronchoscopic Management of Prolonged Air Leaks With Endobronchial Valves in a Veteran Population

the proportion of missing data for 5 of the 11 comorbidity variables included within the mFI increased over time. Specifically, the variables “history of myocardial infarction,” “history of percutaneous intervention, coronary stenting or cardiac surgery,” “history of peripheral vascular disease, rest pain or gangrene,” “history of impaired sensorium,” and “history of transient ischemic attack” were missing for 100% of patients in 2013 compared with 54.9% of patients in 2011. Furthermore, the missing data were not missing at random. Although an increasing mFI score was associated with greater odds for postoperative mortality, the mFI demonstrated poor discrimination for the years between 2005 and 2013 (area under the curve: range, 0.56-0.65) (Table 2). To assess the extent of missing data within the data set, additional analyses were performed among patients undergoing an esophagectomy (Current Procedure Terminology code 43107, 43112, 43117, 43121, and 43122) or a total hip replacement (Current Procedure Terminology code 27130). Of note, a similar pattern of missing data was also observed among these patients. Of the variables “history of myocardial infarction,” “history of percutaneous intervention, coronary stenting or cardiac surgery,” “history of peripheral vascular disease, rest pain or gangrene,” “history of impaired sensorium,” and “history of transient ischemic attack,” 43.7% and 66.5% of data were missing for esophagectomyandtotalhipreplacement,respectively, in2011,whereas 100% of data was missing in 2013 for both esophagectomy and total hip replacement (data not shown).

Endobronchial ultrasound-guided diagnosis of pulmonary artery tumor embolus

A patient diagnosed with pulmonary embolism had persistent symptoms despite adequate therapy. Tissue sampling with endobronchial ultrasound-guided needle aspiration revealed endovascular metastasis from a prior early-stage colorectal cancer. We describe the challenges in the diagnosis and workup of suspected tumor emboli.

The solitary pulmonary nodule-deciding when to act?

Solitary pulmonary nodules (SPNs) are commonly encountered in pulmonary practice. Their management is complex, and multiple clinical factors must be considered. The three common management strategies applied to solitary pulmonary nodules are careful observation, diagnostic testing, and surgery. Fundamental concepts derived from decision analysis can be used to help clinicians choose optimal management strategies for individual patients with SPNs. This process begins with estimating the pretest probability of cancer. Then the consequences of treatment are considered-including the benefit of surgery if the patient has cancer and the harm of treatment if the patient does not have cancer. Patient comorbidities and competing risks affect the consequences of treatment. Knowledge of the benefits and harms of treatment allows clinicians to determine the treatment threshold and then rationally develop the optimal management plan. Probability revision using the pretest probability, test characteristics, and Bayes theorem is used to refine the probability of cancer until a decision threshold is reached and definitive treatment can be determined. Patients with very low pretest probability of cancer are managed with a strategy of careful observation by serial computed tomography (CT). Patients who have a high pretest probability of cancer merit surgical diagnosis. Patients with an intermediate pretest probability of cancer go on to further diagnostic testing, primarily with CT-guided fine needle aspiration or positron-emission tomography. Patient preferences are considered throughout the process because the absolute difference in outcome between some strategies may be small.

Bronchoscopic resection of a tracheobronchial leiomyoma in a pregnant patient

Flexible bronchoscopy, therapeutic bronchoscopy and other procedures requiring anesthesia are generally avoided in pregnancy and postponed until after delivery if possible. We report a case of a parturient with an abnormal chest radiograph and mild obstructive symptoms of unknown etiology. At bronchoscopy, a tumor associated with post-obstructive suppuration was found and excised using electrocautery snare and cryotherapy, for restoration of airway patency. Coordination between pulmonary, obstetric, anesthesia, neonatology and thoracic surgery services was essential in ensuring success and the safety of the mother and fetus.