Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the standard minimally invasive technique for mediastinal and hilar evaluation but as a cytologic specimen, is limited when histologic architecture or larger tissue volume is required. EBUS-guided mediastinal cryobiopsy (EBUS-MCB) extends diagnostic capability beyond TBNA by retrieving intact, architecturally preserved tissue cores through the same bronchoscope. Since introduction into clinical practice in 2020, cryobiopsy combined with standard TBNA has been adopted widely, recognised by many as a significant advance in endoscopic mediastinal diagnosis. Several studies show that MCB has higher diagnostic yield than corresponding TBNA, with the greatest benefit seen in benign granulomatous and lymphoproliferative disorders. MCB has also shown superior performance for molecular profiling in non-small-cell lung cancer as a secondary endpoint in several studies. Complications are uncommon, usually limited to minor bleeding, with serious adverse events reported in fewer than 2% of procedures. EBUS-MCB added in stepwise fashion to standard TBNA appears to be of greatest utility when paucicellular or non-diagnostic sampling is determined at rapid onsite cytological evaluation (ROSE) or at prior EBUS-TBNA procedure. In cases where there is high pre-test probability for lymphoma, EBUS-TBNA-MCB may reasonably be performed without ROSE feedback, potentially avoiding the need for more invasive and costly diagnostic procedures. Integration of MCB into selected EBUS procedures has the potential to meaningfully improve diagnostic yield and refine disease subtyping, with downstream implications for treatment selection and patient outcomes. Its use should be tailored to centre-specific resources, expertise and local disease epidemiology to maximise benefit and ensure appropriate implementation.
Objective:This study aimed to examine the intersectional effects of race and educational attainment on tobacco advertising exposure among adults in Baltimore, given the growing evidence on differential influence of education for Black and White populations. Methods:A survey was conducted in Baltimore, collecting data on educational attainment, demographics, and tobacco advertising exposure among adults (n = 3028, 22.7% 18 - 29, 17.9% 30 - 39, 23.4% 40 - 49, 20.9% 50-59, and 11.1% 60+ years old). The sample included both Black and White adult individuals. Logistic regression analyses were employed to assess the association between educational attainment and tobacco advertising exposure, without and with interaction with race, adjusting for relevant covariates such as age, gender, and employment. Sensitivity analysis also controlled for smoking status. Results:The study results indicated that while high educational attainment is associated with less exposure to tobacco ads, highly educated Black adults report significantly higher tobacco advertising exposure compared to highly educated White adults. Same results were observed after controlling for smoking status. Conclusion:Educational attainment may not exhibit a large protective effect against environmental risks such as tobacco ad exposure for Black populations, possibly because of segregation and racism that hinder highly educated Black people ability to move to low-risk neighborhoods.
Background: While previous research has established the role of depression as a correlate of tobacco use, limited research has been conducted on potential racial variations in these associations. Aims: This study had two objectives: (1) to investigate the associations between depression and smoking conventional and vaping e-cigarettes, and (2) to explore the role of race in modifying these associations. Methods: Data from the Health Information National Trends Survey (HINTS-2022) survey, which is a national probability sample of US adults, were analyzed. Variables of interest included lifetime and current smoking status, e-cigarette use, depression (PHQ-4), socioeconomic status (SES), and demographic characteristics. Binary logistic regression models were applied to assess the associations between depression as the independent variable and current and ever smoking conventional cigarettes and vaping e-cigarettes as dependent variables, adjusting for covariates (age, gender, education, marital status, and employment). We tested potential interactions between race/ethnicity (non-Hispanic Whites, non-Hispanic Blacks, Hispanic Whites and any other/mixed race/ethnicity) and depression on our outcomes. Results: The study findings indicated significant associations between depression and use of conventional cigarettes and e-cigarettes. Although individuals who were experiencing depression were more likely to use conventional cigarettes (p < 0.05) and e-cigarettes (p < 0.05) compared to those non-depressed, the positive associations between depression and lifetime and current smoking were stronger for Black than White individuals. Conclusions: This study suggests that depression may have a more salient role in smoking cigarettes and e-cigarette use for Black than White adults. It is unclear if Black adults are more likely to smoke if they are depressed, or if Black adults who smoke cigarettes are more likely to be depressed because of higher stigma and lower access to mental health care services.
With recent advancements in robotic bronchoscopy for peripheral pulmonary nodule biopsy, there has been notable improvements in reach, stability, and precision. Since 2017, the United States Food and Drug Administration (FDA) has approved two robotic devices, the Ion™ Endoluminal System (“Ion”) (Intuitive Surgical©, Sunnyvale, CA, USA) and the Monarch robotic system (Auris Health Inc, Redwood City, CA), for peripheral navigation and biopsy of lung lesions. We review these two robotic bronchoscopy systems and the literature that supports their use.
Idiopathic pulmonary fibrosis (IPF) is a specific form of chronic fibrosing interstitial lung disease associated with a pattern of Usual Interstitial Pneumonia (UIP) based on CT appearances or histology.
Interstitial lung diseases (ILDs) are the most common pulmonary manifestation of connective tissue diseases (CTDs) and are often the most serious complication. Lung involvement in CTDs is associated with decreased survival rates and higher overall mortality1,2. ILD may occur in almost all clinically diagnosed CTDs, but it is more prevalent in systemic sclerosis (SSc) and idiopathic inflammatory myopathies (IIM)3,4. The specific type of ILD can be characterized based on diverse patterns of lung damage seen on high resolution computed tomography (HRCT) and by histopathological analysis of lung biopsy specimens5,6. These diverse forms of ILD were discussed in previous chapter; they mainly comprise of the following types: usual interstitial pneumonia (UIP), nonspecific interstitial pneumonia (NSIP), diffuse alveolar damage pattern (DAD), lymphocytic interstitial pneumonia (LIP) and organizing pneumonia (OP)7,8. Management and treatment options for ILD-CTD have been extensively studied9,10, but they still pose a significant challenge due to the paucity of randomized controlled trials (RCTs). It should also be noted that there can be other pulmonary manifestations of CTDs (other than just ILD): these include pleural effusions and bronchiectasis seen with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). These effusions are usually bilateral, secondary to pleural inflammation and often resolve with treatment of underlying CTD.
Introduction: The study aimed to analyse the clinical response and short-term outcomes with the use of high-flow oxygen therapy (HFOT), non-invasive mechanical ventilation (NIMV) with bilevel positive airway pressure, or continuous positive airway pressure (CPAP) in severe COVID-19 patients. Methods: We conducted an observational, prospective, single-center study, approved by Ethics Committee of “Instituto de Investigación Sanitaria Fundación Jiménez Díaz” (EO102-20-HRJC). We included a total of 130 patients ≥18 years-old, with proved SARS-CoV-2 infection and secondary Acute Respiratory Failure (ARF) that required treatment with Non-invasive Respiratory Support (NIRS). We collected data about population demographic characteristics, clinical factors, and evolution during the incoming. A baseline of patients treated with HFO, CPAP and NIMV were compared with one-way ANOVA test, while categorical variables were expressed as numbers and percentages and were compared using the chi-square test or Fisher’s exact test when appropriate. Results: The cohort was distributed as follows: CPAP 54.6% (n = 71), NIMV 30% (n = 39), HFO 15.4% (n = 20). There were no differences between NIRS subgroups regarding age, comorbidity, or functional status. At the beginning of NIRS treatment, PaO2/FiO2 value was 149.3 ± 69.7. After 24 hours, PaO2/FiO2 was significantly higher in the CPAP group (CPAP vs NIMV, p-value = 0.0042; CPAP vs HFO, p-value = 0.000169). The overall ICU admission evaded rate was 69.1% and TF rate was 43.8%, without differences between the three therapies (p-value = 0.281). The mortality rate was 37.2%, without significant differences between subgroups. Conclusions: Our data suggest that CPAP versus treatment with NIMV or HFO improves PaO2/FiO2 rate in severe ARF patients, significantly reducing ICU admission. No differences were observed in mortality or therapeutic failure.
Sjögren’s syndrome (SS) is an autoimmune connective tissue disease characterized by lymphocytic infiltration of exocrine glands leading to progressive inflammation and destruction. This condition mainly involves the lacrimal and salivary glands and is associated with development of the classic dry eyes and mouth1. Additionally, an estimated third of the population develops extra-glandular manifestations involving the cutaneous, cardiovascular, neurologic, renal, pulmonary, and musculoskeletal system2,3.
Chronic obstructive pulmonary disease (COPD) is a respiratory disease with high prevalence. Many factors contribute to its development, and probably that leads to its various clinical pictures. Inflammation is the mechanism responsible for the structural alterations in the lungs. Despite its heterogeneity, there are a couple of primary symptoms characterizing it, which are chronic and productive cough and dyspnea. The understanding of dyspnea in COPD is based on theories deriving from the interaction of a network formed between the cardiorespiratory and the neuromuscular system and their receptors. Many factors contribute to its occurrence, making it complex and giving it a very subjective character for a person to perceive. Various methods are used to study COPD. Non-invasive ones seem to attract attention nowadays. One of them is the exhaled breath condensate. It is a biofluid with rich content, which can capture a picture of the pathological processes happening in the lungs. Its study has shown that some markers of inflammation and oxidative stress, such as 8-isoprostane and H2O2, are elevated and able to connect dyspnea and inflammation. Additionally, they seem to provide information of the ongoing inflammatory process in the lungs as well as a picture of the severity of the symptoms. This evidence may enhance the association of dyspnea with dysfunctional breathing. Despite these interesting findings, further research is necessary both in dyspnea and inflammation in COPD to clarify their mechanisms and connective pathways. The utility of non-invasive techniques such as the exhaled breath condensate could be of significant help, but its establishment in the medical field requires extra studies.
Usage of vaping and electronic cigarettes products is a growing trend among young adults, with rising rates worldwide. Such products are gaining popularity for many reasons including an alternative to smoking cigarettes, trying something new, or as a means to relax. While users may feel that these products are less harmful or a safer substitute to smoking traditional products, the side effect profile of vape inhalation has the potential for profound injury to the lung tissue and significant respiratory failure. We would like to present a case in which a young male who was evaluated at our Emergency department for acute onset respiratory failure subsequently requiring invasive mechanical ventilation in the setting of vaping associated lung injury (VALI). In the case report, we will highlight the patient’s clinical course as well as a summary of the current evidence surrounding evaluation, diagnosis and management of this emerging pathology. We want to emphasize the importance of a detailed history which should include the use of vaping products when a young patient presents with acute respiratory failure, allowing VALI to be in the differential diagnosis. Additionally, we want to compare the clinical presentation of VALI to that of COVID-19 pneumonia as they both have many similar attributes including symptoms and findings on lung imaging studies.
We present a 25-year-old Hispanic man with left-sided pleuritic chest pain and dyspnea for three days. His Chest radiograph and CTA revealed bilateral apical bullous disease with a 2.5 cm deep left sided pneumothorax. He was managed with 100% oxygen via non-rebreather mask and did not require invasive decompression. Patient reported a one-year history of vaping along with tobacco and cannabis smoking exposure from his late teen years. The pneumothorax improved and he was discharged to the pulmonary clinic. The authors review the multiplicative effect of vaping on smoking cannabis and tobacco leading to early apical bullous lung disease. Patients with such signiï¬cant smoking/vaping history may benefit from prolonged pulmonary and addiction medicine follow-up given the clinical bullous lung disease and risk for continued smoking/vaping. The case emphasizes the potential exponential effect of combining vaping with tobacco and marijuana smoke on lung health leading to disease at extremely young ages.
Cysts in covid-19 are considered an atypical CT finding, with cystic changes occurring in up to 10% of covid-19 patients 1 .Yet an increasing body of evidence points to the clinical relevance of cystic changes secondary to covid-19 2 .Subsequently there is a need to increase awareness and management of their potential sequelae.
On October 15th 2020, the Emergency Radiology Journal published our article entitled “COVID-19 pneumonia in the emergency department: correlation of initial chest CT findings with short-term outcome”, that evaluated clinical, laboratorial and imaging findings of laboratory confirmed COVID-19 patients as predictors of severe disease. In this paper, we will explore the context and significance of the early recognition of the disease severity on patients’ management.
COVID-19 pandemic has frightened people and governments all around the world. The common opinion is that there are no efficient preventive measures but masks, isolation, and social distancing. The deliverance is hoped from the SARS-CoV-2-specific vaccine, which must be efficient and cheap. But, so far nobody knows when, and if such a vaccine will be developed and mass-produced. Trained immunity with oral polio vaccine (OPV) was recently proposed as a temporal solution against the heavy course of COVID-19. However, politics do not seem to follow, and the scientific world should react because humanity has no time to lose. Below, we support this with our thoughts.
Bacillus Calmette-Guerin (BCG) is a live-attenuated strain of Mycobacterium bovis (M bovis), originally developed as a vaccine against tuberculosis.It is also used in the treatment of bladder cancer.We present a case of disseminated BCG-osis which was only discovered at post-mortem.An 89-year-old male was admitted to a tertiary referral centre in inner Sydney in December 2015 with fevers, night sweats, exertional dyspnoea and 8 kg weight loss.The patient developed progressive type 1 respiratory failure requiring non-invasive positive pressure ventilation and treatment for heart failure, but he died eleven days into his admission.On microbiological testing Mycobacterium.tuberculosis complex (MTBC) DNA was detected in lung tissue, by polymerase chain reaction (PCR), using the Xpert ® MTB/RIF (Cepheid) platform, the day after the patient's death.Later mycobacterial culture and genomic deletion analysis identified the specific organism as M bovis.This report describes an unusual presentation of systemic BCG-osis appearing more than three years after the last BCG instillation.This reinforces the fact that BCG instillation of the bladder for transitional cell carcinoma poses a potential risk of systemic spread even years after.
Lung cancer (LC) continues to be a significant worldwide public health issue. There are several publications addressing specifics of LC worldwide, but none concerning Georgia- a country with high number of smoking population and LC cases. Based on the above facts we conducted the first study in the country that aims both evaluating current pretreatment LC challenges, including barriers for early diagnostics and indicating the future strategies for improved LC care We first analyzed LC statistics and the smoking patterns in the country. Further, we identified other challenging issues in pretreatment diagnostics and staging aspects and finally, provided a survey among LC specialists all over the country to evaluate the situation regarding access and use of radiology investigations and other staging procedures. The survey questionnaire was distributed among LC specialists in main cancer hospitals (n=13) across the country. We identify multiple health challenges. Still there are a high number of smokers in the country which clearly indicates that additional measures focusing on smoking cessation are urgently needed. This is further materialized in the fact that the majority of patients with LC are diagnosed with either locally advanced or metastatic disease. Activation of preventive programs and implementation of LC screening for early detection should hopefully lead to further reduction of national LC mortality rates. We underline the urgent need for implementation of country-adapted diagnostic and therapeutic guidelines and protocols as well as enforcing multidisciplinary team meetings. The great need to introduce screening programs in high risk groups, improve access to modern treatment modalities and standardize national diagnostic and treatment protocols are of paramount importance for better LC care.
Influenza A is a very common cause for respiratory infections, which constitutes a major public health concern due to high rates of morbidity and mortality in high-risk population.In our previous publication, 'p53 and the Viral Connection: Back Into the Future', we discussed the involvement of the p53 tumor suppressor in the response to non-tumorigenic viruses, among which is the Influenza virus.In the current comment, we focus on the interplay between p53 and the influenza viral cycle.We discuss recent publications that provide evidence for the potential antiviral and pro-viral roles of p53 and its isoforms towards influenza, both in the host cell, as well as in the immune system.On the other side of the coin, we also discuss how the influenza virus may manipulate p53 to promote its own replication and spreading.An understanding of the interplay between p53 and the virus may lead to the development of a host-based influenza virus therapy.
Background: This case series assessed the clinical outcomes and characteristics of barotrauma in COVID19 patients. Methods:The electronic medical records of all patients admitted with confirmed COVID 19 infection who eventually developed barotrauma between March 17 th , 2020 and April 17 th , 2020 were reviewed, information about patient characteristics, pattern and characteristic of barotrauma were analyzed and reported in a descriptive manner.Results: 25 patients developed evidence of barotrauma on Chest Xray or Computed tomography (CT) with a mean age of 60.1 at the time of diagnosis, 12 (48%) developed severe ARDS with PaO2/FiO2 ratio of <100.14 (56%) patients developed pneumothorax, 7 had evidence of subcutaneous emphysema and 6 developed pneumomediastinum.More barotrauma occured in the first day of ventilation than any other day, the median time between mechanical ventilation and development of barotrauma is 3.5 days. Conclusion:Barotrauma in COVID 19 is associated with an increased mortality (64%) which may reflect worse acute lung injury in these cases.The median time to develop barotrauma in these patients is similar to the one described in ARDs literature.
