OBJECTIVE:Molecular subtyping of non-small cell lung cancer (NSCLC) is critical in the diagnostic evaluation of patients with advanced disease. This study aimed to examine whether samples from endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) of intrathoracic lymph nodes and/or lung lesions are adequate for molecular analysis across various institutions. METHODS:We retrospectively reviewed all cases of linear EBUS-TBNA with a final bronchoscopic diagnosis of NSCLC entered in the Stather Canadian Outcomes registry for chest ProcEdures database. The primary outcome was specimen inadequacy rate for each molecular target, as defined by the local laboratory or pathologist. RESULTS:A total of 866 EBUS-TBNA procedures for NSCLC were identified. Specimen inadequacy rates were 3.8% for EGFR, 2.5% for ALK-1 and 3.5% for PD-L1. Largest target size was not different between adequate and inadequate specimens, and rapid onsite evaluation did not increase specimen adequacy rates. One centre using next-generation sequencing for EGFR had lower adequacy rates than 2 others using matrix-assisted laser desorption/ionization time-of-flight mass spectrophotometry. CONCLUSION:EBUS-TBNA specimens have a very low-specimen inadequacy rate for molecular subtyping of non-small cell lung cancer.

RATIONALE: Patients with refractory hepatic hydrothorax (HH) are challenging to manage due to associated risks involved with repeated procedures required for drainage of the effusion. There is paucity of data describing the role of indwelling pleural catheters (IPC) in HH. We describe our experience with IPCs for management of refractory HH in collaboration with our homecare nursing services. OBJECTIVE: We are describing our Canadian experience using IPCs for HH, focusing on outcomes, safety, and complications to improve the management of this condition. METHODS: This is a retrospective study of a prospectively maintained database of all patients with HH who underwent IPC insertion between May 2006 and February 2019 at our tertiary center. Patients' characteristics, procedural variables, outcomes and estimated survival analysis post IPC insertion were analyzed. MEASUREMENTS AND MAIN RESULTS: A total of 40 patients underwent 43 IPC insertions. Seven catheters (17.5%) resulted in pleural infection, without any associated deaths. Mean pleural fluid protein level was lower among patients who developed pleural infection compared to those who did not (11.5 g/L vs 16 g/L; p= 0.0015). Median survival was 12.7 months (95%CI, 6.4-43.4). Twenty-one catheters were removed within 149days (+/- 50.2). Twelve patients died with the IPC in-situ within 69.5 days (+/- 48.7). CONCLUSION: In refractory HH, IPCs can be safely used. Associated complications can be mitigated with frequent clinical monitoring and intermittent drainage of the effusion by dedicated homecare nursing services. Further studies establishing the role for prophylactic antibiotics in high-risk population may be of value.

Background: Sarcoidosis is a multisystem disease characterized by noncaseating granulomatous inflammation that most commonly involves the lungs. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become an invaluable tool in the assessment of patients with mediastinal and/or hilar lymphadenopathy. Objective: It has been hypothesized that use of the larger 19-gauge (G) needle with EBUS-TBNA improves diagnostic sensitivity in sarcoidosis. However, it is unclear whether the existing literature supports this supposition. Data Sources: A literature search of Embase and Medline was performed by two reviewers. Included articles were evaluated for bias using the QUADAS-2 tool. Data Extraction: For quantitative analysis, we performed a meta-analysis using a binary random-effects model to determine pooled sensitivity. Subgroup analysis was performed based on needle size, use of rapid on-site evaluation (ROSE), study design, and prevalence of sarcoidosis in study group. Synthesis: Sixty-five studies with a total of 4,242 patients were included in the meta-analysis. Overall pooled sensitivity for diagnosis of sarcoidosis was 83.99% (95% confidence interval [CI], 81.22-86.53) among all studies. The 19G subgroup had a significantly higher sensitivity (93.73%; 95% CI, 89.72-97.74%; I2 = 0.00%; P < 0.01) compared with the 21G subgroup (84.61%; 95% CI, 78.80-90.42%; I2 = 69.83%), 22G subgroup (84.07%; 95% CI, 80.90-87.24%; I2 = 85.21%) or unspecified 21G/22G subgroup (78.85%; 95% CI, 70.81-86.90%; I2 = 84.47%). There were no significant differences with use of ROSE or prevalence of sarcoidosis or by study design. Conclusions: The use of 19G needles during EBUS-TBNA had the highest diagnostic sensitivity based on available studies. Further randomized controlled trials using 19G needles should be considered in patients with suspected sarcoidosis.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is commonly used to evaluate mediastinal lymphadenopathy. Studies focusing on malignant lymphadenopathy have compared 21-and 22-gauge (21G and 22G, respectively) needles and have not identified an advantage of one needle size over the other in terms of diagnostic yield. RESEARCH QUESTION: Does the 19-gauge (19G) EBUS needle offer greater diagnostic yield and sensitivity vs the 21G and 22G EBUS needles for a diagnosis of sarcoidosis, lymphoma, or mediastinal lymphadenopathy not yet diagnosed? STUDY DESIGN AND METHODS: This study retrospectively examined records of 730 patients from the Stather Canadian Outcomes Registry for Chest Procedures (SCOPE) database who underwent EBUS-TBNA for a diagnosis of suspected sarcoidosis, lymphoma, or mediastinal lymphadenopathy not yet diagnosed. A propensity score analysis of two groups was per-formed. One group comprised patients undergoing EBUS-TBNA with a 19G needle, the other with a 21G or 22G needle. Cases for analysis were selected with a 1:2 ratio of 19G vs 21/ 22G using logistic regression and random matching with all eligible 19G cases included. RESULTS: There were 137 patients (312 targets) in the 19G group and 274 patients (631 targets) in the 21/22G group in the propensity score analysis. The diagnostic yield was 107 of 137 (78.1%) in the 19G group vs 194 of 274 (70.8%) in the 21/22G group (difference, 7.3%; 95% CI, -1.9 to 15.6; P = .116). The sensitivity of EBUS-TBNA for sarcoidosis was 80 of 83 (96.4%) in the 19G group vs 150 of 156 (96.2%) in the 21/22G group (difference, 0.24%; 95% CI, -6.6 to 85.1; P = .93). In patients with a final diagnosis of lymphoma, EBUS was diagnostic in 10 of 13 (76.9%) in the 19G group vs 12 of 12 (100%) in the 21/22G group (difference, 23.1%; 95% CI, -5.4 to 50.3; P = .08). INTERPRETATION: The study did not identify an advantage of the 19G EBUS needle over the 21/22G EBUS needles for diagnostic yield nor sensitivity for sarcoidosis or lymphoma.

Objectives: Proton pump inhibitor (PPI) therapy is a potentially modifiable risk factor for recurrent Clostridioides difficile infection (CDI). Citing an absence of clinical trials, many guidelines do not provide recommendations for addressing PPI management. Our aim was to perform an updated systematic review and meta-analysis evaluating the association between PPI use and recurrent CDI addressing prior methodological limitations. Methods: Data sources were MEDLINE and EMBASE. Eligible studies were cohort and case-control studies; there were no restrictions on study setting or duration of follow-up. Participants were adults with prior CDI who did or did not receive PPI therapy and were assessed for recurrent CDI. Summary (unadjusted) odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random effects model. Prespecified subgroup analyses were performed to explore heterogeneity including study design, study quality, duration of follow-up, adjustment for confounders, and outcome definition. Results: Sixteen studies were included in the meta-analysis, comprising 57 477 patients with CDI, of whom 6870 (12%) received PPIs. The rate of recurrent CDI was 24% in patients treated with PPIs versus 18% in those who were not. A meta-analysis that pooled unadjusted odds ratios demonstrated higher odds of recurrent CDI in patients who received PPIs (OR 1.69, 95%CI 1.46-1.96) versus those who did not. There was moderate heterogeneity between studies (I-2 56%); however, a sensitivity analysis restricted to studies with 56 days of follow-up substantially reduced the heterogeneity (OR 1.59, 95%CI 1.36-1.85; I2 12%). An analysis restricted to multivariate studies that combined adjusted ORs also demonstrated higher odds of recurrent CDI in patients who received PPIs (OR 1.49, 95%CI 1.12-2.00). No publication bias was identified. Conclusions: We found significantly higher odds of recurrent CDI among users of PPIs that persisted across multiple sensitivity analyses. These results support stronger recommendations for PPI stewardship at CDI diagnosis. (C) 2021 The Author(s). Published by Elsevier Ltd on behalf of European Society of Clinical Microbiology and Infectious Diseases.

INTRODUCTION:The Stather Canadian Outcomes registry for chest ProcedurEs (SCOPE registry) is a Canadian multicentre registry of chest procedures.METHODS AND ANALYSIS:The SCOPE registry is designed as a multicentre prospective database of specific bronchoscopic or other pulmonary procedures. Each procedure of interest will be associated with a registry module, and data capture designed to evaluate effectiveness of procedures on relevant patient outcomes. Participating physicians will be asked to enter data for all procedures performed in a given module. The anonymised dataset will be housed in a web-based electronic secure database. Specific modules included will be based on participating physician suggestions, capacity and consensus of the steering committee and relevance of hypotheses/research potential.ETHICS AND DISSEMINATION:The central registry is under approval from the Conjoint Health Research Ethics Board at the University of Calgary. We aim for registry data to lead to publication of manuscripts in international medical journals as the primary mode of dissemination. Data may also be used by local investigators for personal and/or institutional quality control purposes as well as to inform health policies. Data requests from non-participating investigators for use under ethics approved research protocols can be considered.

OBJECTIVES:Long-term indwelling pleural catheters (IPC), used for the management of malignant pleural mesothelioma (MPM), may lead to catheter tract metastasis (CTM). While computed tomography (CT) is valuable for diagnosis, no studies have assessed CT manifestations of CTM. Our goal is to describe the incidence, CT appearances, and temporal evolution of CTM in MPM.METHODS:A retrospective review of CT of 90 consecutive patients with MPM and IPC. In patients with CTM, a longitudinal assessment was performed for CT appearance at diagnosis and over time, interval from insertion to diagnosis and rate of progression.RESULTS:The incidence of CTM was 26% (23/90), in 22 men (54-83 years, mean 73 years). CTM manifested with focal lesion (3 to 60 mm, mean 25 mm) in the subcutaneous tissue at the insertion site. Abnormalities of sub-adjacent skin and fat stranding were present in 16/24 (66%) and 11/24 (46%), respectively, enlargement of chest wall musculature in 11/24 (46%), and dilated subcutaneous vessels in 4/24 (17%) patients. On follow-up, 53% had enlargement of focal lesion. The average rate of progression was 3.5 mm/month, compared to 0.79 mm/month for pleural thickening (p = 0.03). The time between IPC insertion and CTM diagnosis varied from 58 to 1375 days (median 408 days); 83% occurred after IPC removal. Reporting radiologists described focal abnormality at the insertion site in only 9/23 (39%) patients.CONCLUSIONS:CTM is commonly overlooked and underreported by radiologists. CT invariably demonstrates focal subcutaneous lesion in the procedure tract, most commonly after IPC removal. Ancillary findings, notably serratus or latissimus dorsi muscle enlargement, are novel finding that can assist in CT detection and diagnosis.KEY POINTS:• Catheter tract metastasis (CTM), resulting from indwelling pleural catheter to manage malignant pleural mesothelioma, invariably manifested on CT as a focal subcutaneous lesion at the site of insertion, more commonly after catheter removal. • Ipsilateral muscle enlargement is a newly described CT finding that can assist in the detection and diagnosis. • Catheter tract metastasis was commonly overlooked by radiologists, reported in only 39% of cases.

Abstract Total Canadian health expenditure has been increasing over the past 40 years to a total of $248 billion dollars (2017 Canadian Dollars). In 2017, the Canadian Institute for Health Information forecasted that hospital spending would reach 28.3% of total health expenditure. Innovation to reduce costs while improving care is necessary to maintain a high quality, sustainable healthcare system. Patients with malignant pleural effusion (MPE) are suffering from advanced cancer; providers should support an increased focus on interventions that maximize patients’ time in their home environment. Video-assisted Thoracoscopic Surgery Pleuroscopy (VATS-P) and Medical Pleuroscopy (MP) are two equivalent procedures in the diagnosis of MPE. The purpose of this study was to model the 5-year budget impact of adopting the MP procedure from the perspective of the hospital system. Pleuroscopy cost data were collected from 2 tertiary, academic hospitals in Ontario and from published literature. Resources including: hospitalization, RN staffing, laboratory/diagnostics and allied health were created using hospital administrative data through the Ontario Case-Costing Initiative (OCCI). The cost model was conducted using OCCI data and cost data from published literature, for the years 2018–2023. Base case analysis shows the mean per-procedure costs of MP was $6,146.16 lower than VATS-P. Budget impact for a shift from VATS-P to MP showed potential savings of $10,243,088.74 (2023 Canadian dollars) (−41.6%) for pleuroscopy in Ontario over 5 years (n = 1,616). In conclusion, this paper describes the significant cost savings for the hospital system from a shift to MP from VATS-P for the diagnosis of undifferentiated pleural effusion.