Michael S. Eichenhorn

Endoscopic Findings in Sarcoidosis Characteristics and Correlations with Radiographic Staging and Bronchial Mucosal Biopsy Yield

Flexible fiberoptic bronchoscopy was performed in 101 patients with sarcoidosis, and the endoscopic findings were analyzed and correlated with radiographic stages and diagnostic bronchial biopsy. Endoscopic findings included bronchostenosis (26% of patients), mucosal nodularity (64%), hypervascularity (38%), and mucosal edema (55%). The only correlation between these findings and the radiographic stage was the presence of mucosal nodularity observed in 73% of stage I (14/19 patients), decreasing to only 48% in stage III (15/31 patients). Bronchial biopsy yield was 58% for stage I, 62% for stage II, and 46% for stage III, with overall yield of 57%. However, the addition of bronchial biopsies increased the diagnostic yield of the bronchoscopic procedure from 73 % for transbronchial biopsies alone to 88% when the two procedures were combined. In the presence of endobronchial stenosis, mucosal nodularity and hypervascularity, bronchial biopsy yield was 91 % vs 37% when these were absent. We conclude that the endoscopic characteristics, with the exception of nodularity, do not correlate with radiographic stages. Bronchial biopsy yield is higher in those patients with mucosal nodularity, increased vascularity, and bronchostenosis. Bronchial mucosal biopsy also improved the overall diagnostic yield when it is obtained in conjunction with transbronchial lung biopsy.

Active Tuberculosis In The Medical Intensive Care Unit: A 15-year Retrospective Analysis

Of approximately 6000 admissions to the Henry Ford Hospital medical ICU between October 1969 and September 1984, 61 (1%) had active tuberculosis (TB). Forty-three (70%) of these 61 had acute respiratory failure (ARF). TB was considered to be the sole cause of ARF in 12 and contributory in 31. Eighteen patients with TB but without ARF were admitted for treatment of other critical illnesses. Alcoholism was present in 31 (51%) of the TB patients. Only one of 12 whose ARF was caused primarily by TB had a history of known TB at the time of admission. Important factors contributing to ARF in TB patients included Gram-negative pneumonia and/or sepsis, chronic obstructive pulmonary disease, prior TB with anti-TB medication noncompliance, and malignancy. Six patients were not suspected of having TB when admitted to the medical ICU; three patients who had not been treated for TB were found to have TB on autopsy. The inhospital mortality rate for all patients with TB requiring intensive care was 67%, but was 81% in those with ARF.

Preoperative risk stratification for thoracic surgery using the American College of Surgeons National Surgical Quality Improvement Program data set: functional status predicts morbidity and mortality

BACKGROUND Preoperative risk stratification for noncardiac thoracic surgery focuses on predicting postoperative lung capacity and cardiac risk. We hypothesized that preoperative functional status may be a predictor of morbidity and mortality after thoracic surgery. METHODS The National Surgical Quality Improvement Program Participant Use Files from 2005 to 2009 were accessed, and current procedural terminology codes for procedures involving the lung and pleura were used to identify thoracic surgery patients. Patients were grouped by independent or dependent preoperative functional status. Risks of infectious and noninfectious complications were evaluated. Chi-square, Fisher exact, and multivariate analyses with stepwise logistic regression were used. This study was approved by the Institutional Review Board. RESULTS Of 6,373 patients, 812 had a preoperative dependent functional status. Dependent patients had significantly higher rates of infection, other adverse events, and mortality. They were 9.3 times more likely (odds ratio [OR] 9.3) to have prolonged ventilation (P < 0.001) and 3.1 times more likely to be reintubated (P < 0.001). Postoperative pneumonia occurred in 10% (OR 2.7, P < 0.001). Postoperative mortality was 7.7 times higher (P < 0.001). Preoperative functional status, wound classification 3, and emergency procedures were independent predictors of both morbidity and mortality. Performing a thoracotomy was an independent risk factor for postoperative morbidity but not mortality (P < 0.001, OR 2 versus P = 0.415, OR 1.1). CONCLUSIONS Thoracic surgery patients, classified as functionally dependent preoperatively are at high risk for major morbidity and mortality. Although a limited observational study, results show that functional status is an essential component of preoperative assessment for thoracic surgery patients.

Case Report: Marked Mature Neutrophilic Leukocytosis: A Leukemoid Variant Associated with Malignancy

Abstract Two cases of extreme granulocytosis are reported, emphasizing the clinical implications and differential diagnosis. Leukemoid reactions to malignancy, not chronic neutrophilic leukemia, will comprise the majority of such cases when the granulocytic response contains largely mature cells, whereas confusion with chronic granulocytic leukemia may result when peripheral immaturity is more manifest. Distinguishing features are discussed.

The sézary syndrome with rapid pulmonary dissemination

The authors report the case of a patient with long‐standing Sézary syndrome who developed the acute onset of bilateral pulmonary infiltration, severe hypoxemia, and hypotension. Initial diagnostic considerations centered around infection, but an open‐lung biopsy revealed “mycosis fungoides” without evidence of an infectious process. The patient showed striking improvement when given vincristine and cyclophosphamide, but ultimately died 3 months later of a nonpulmonary catheter‐related infection. This rare clinical association stresses the value of open lung biopsy as a diagnostic measure even in desperately ill individuals.

Exploring National Surgical Quality Improvement Program respiratory comorbidities: developing a predictive understanding of postoperative respiratory occurrences, Clavien 4 complications, and death

BACKGROUND For preoperative risk stratification, little is known about the implications of respiratory comorbidities in relation to postoperative complications in the diverse population of surgical patients. We hypothesized that patients with preoperative respiratory comorbidities would be at increased risk of postoperative respiratory occurrences and death. METHODS Under the data use agreement and with the approval of the Henry Ford Health System Institutional Review Board (IRB #6830), we reviewed 5 y (2005-2009) of National Surgical Quality Improvement Program participant use files. Respiratory comorbidities were defined as current smoker, chronic obstructive pulmonary disease, dyspnea, and current pneumonia. Respiratory outcomes tracked in the National Surgical Quality Improvement Program included reintubation, postoperative pneumonia, and prolonged ventilation. We defined Clavien 4 and 5 outcomes to include postoperative septic shock, postoperative dialysis, pulmonary embolism, myocardial infarction, cardiac arrest, prolonged ventilatory requirements, need for reintubation, and death. RESULTS Of 971,455 patients identified, 361,412 had respiratory comorbidities. As the number of respiratory comorbidities increased, we found a statistically significant increase in the occurrence of postoperative respiratory adverse events, including Clavien 4 and 5 complications. Multivariate regression analysis showed that respiratory comorbidities and age were independent predictors of mortality. All data reported here were significant at P < 0.001. CONCLUSIONS This study showed a significant association between respiratory comorbidities and postoperative adverse events, including Clavien 4 complications and death. Further prospective studies are required to explore this association.