The Robotic Endoscopic System (Auris Health, Inc., Redwood City, CA) has the potential to overcome several limitations of contemporary guided-bronchoscopic technologies for the diagnosis of lung ...lesions. Our objective is to report on the initial post-marketing feasibility, safety and diagnostic yield of this technology.
We retrospectively reviewed data on consecutive cases in which robot-assisted bronchoscopy was used to sample lung lesions at four centers in the US (academic and community) from June 15th, 2018 to December 15th, 2018.
One hundred and sixty-seven lesions in 165 patients were included in the analysis, with an average follow-up of 185 ± 55 days. The average size of target lesions was 25.0 ± 15.0 mm. Seventy-one percent were located in the peripheral third of the lung. Pneumothorax and airway bleeding occurred in 3.6 and 2.4% cases, respectively. Navigation was successful in 88.6% of cases. Tissue samples were successfully obtained in 98.8%. The diagnostic yield estimates ranged from 69.1 to 77% assuming the cases of biopsy-proven inflammation without any follow-up information (N = 13) were non-diagnostic and diagnostic, respectively. The yield was 81.5, 71.7 and 26.9% for concentric, eccentric and absent r-EBUS views, respectively. Diagnostic yield was not affected by lesion size, density, lobar location or centrality.
RAB implementation in community and academic centers is safe and feasible, with an initial diagnostic yield of 69.1-77% in patients with lung lesions that require diagnostic bronchoscopy. Comparative trials with the existing bronchoscopic technologies are needed to determine cost-effectiveness of this technology.
Tuberculous pleural effusion (TPE) is the second most common presentation of extrapulmonary tuberculosis. The paucibacillary nature of the effusion poses diagnostic challenges. Biomarkers like ...adenosine deaminase and interferon-γ have some utility for diagnosing TPEs, as do cartridge-based polymerase chain reaction (PCR) methods. When these fluid studies remain indeterminate, pleural biopsies must be performed to confirm the diagnosis. This review article elaborates on the scientific evidence available for various diagnostic tests and presents a practical approach to the diagnosis of TPEs.
•Less than 10% of tuberculous pleural effusions (TPE) are AFB positive.•Bedside inoculation and liquid media cultures of TPE have a yield of about 45%.•Typical sensitivity (SE) and specificity (SP) for ADA is 0.9 and 0.9, respectively.•Reported sensitivity for Xpert Ultra PCR on TPE is low (0.38–0.75).•If clinical suspicion is high, a pleuroscopy (∼100% SE/SP) has to be performed.
Computational subphenotyping, a data-driven approach to understanding disease subtypes, is a prominent topic in medical research. Numerous ongoing studies are dedicated to developing advanced ...computational subphenotyping methods for cross-sectional data. However, the potential of time-series data has been underexplored until now. Here, we propose a Multivariate Levenshtein Distance (MLD) that can account for address correlation in multiple discrete features over time-series data. Our algorithm has two distinct components: it integrates an optimal threshold score to enhance the sensitivity in discriminating between pairs of instances, and the MLD itself. We have applied the proposed distance metrics on the k-means clustering algorithm to derive temporal subphenotypes from time-series data of biomarkers and treatment administrations from 1039 critically ill patients with COVID-19 and compare its effectiveness to standard methods. In conclusion, the Multivariate Levenshtein Distance metric is a novel method to quantify the distance from multiple discrete features over time-series data and demonstrates superior clustering performance among competing time-series distance metrics.
•Quantifying the distance from multiple nominal features over time-series data is crucial for leveraging temporal information for subphenotypes.•While ongoing efforts have been made to develop novel metrics for discrete multiple features over temporal data, many methods are prone to substantial information loss or multicollinearity issues.•We propose a multivariate Levenshtein distance, an expansion of the generalized Levenshtein distance that can analyze multiple nominal features over time-series data.•We evaluated the proposed distance metric to the clustering analysis on the time-series data of biomarkers and treatment administrations from 1,039 critically ill patients with COVID-19, and showed the highest clustering performance among competing time-series distance metrics.
The role of tracheostomy during the coronavirus disease 2019 (COVID-19) pandemic remains unknown. The goal of this consensus statement is to examine the current evidence for performing tracheostomy ...in patients with respiratory failure from COVID-19 and offer guidance to physicians on the preparation, timing, and technique while minimizing the risk of infection to health care workers (HCWs).
A panel including intensivists and interventional pulmonologists from three professional societies representing 13 institutions with experience in managing patients with COVID-19 across a spectrum of health-care environments developed key clinical questions addressing specific topics on tracheostomy in COVID-19. A systematic review of the literature and an established modified Delphi consensus methodology were applied to provide a reliable evidence-based consensus statement and expert panel report.
Eight key questions, corresponding to 14 decision points, were rated by the panel. The results were aggregated, resulting in eight main recommendations and five additional remarks intended to guide health-care providers in the decision-making process pertinent to tracheostomy in patients with COVID-19-related respiratory failure.
This panel suggests performing tracheostomy in patients expected to require prolonged mechanical ventilation. A specific timing of tracheostomy cannot be recommended. There is no evidence for routine repeat reverse transcription polymerase chain reaction testing in patients with confirmed COVID-19 evaluated for tracheostomy. To reduce the risk of infection in HCWs, we recommend performing the procedure using techniques that minimize aerosolization while wearing enhanced personal protective equipment. The recommendations presented in this statement may change as more experience is gained during this pandemic.
Guidelines recommend testing for driver mutations and programmed death ligand 1 (PD-L1) expression at the time of initial diagnosis and during disease progression to help determine prognosis and ...initiate personalized therapy. In this article we review the updated literature and techniques of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) in obtaining adequate tissue for molecular analysis by using next-generation sequencing (NGS) and for assessing PD-L1 expression through immunohistochemistry.
Abstract Background The predictive role of lactate in critically ill patients with acute upper gastrointestinal bleeding (UGIB) remains to be elucidated. Objective The primary objective of this study ...was to assess the value of lactate level on admission to predict in-hospital death in patients with UGIB admitted to the intensive care unit (ICU). The secondary objective was to assess whether lactate level adds predictive value to the clinical Rockall score in these patients. Methods This was a retrospective cohort study that included 133 patients with acute UGIB admitted to the ICU. Inclusion criteria were age > 18 years and presence of UGIB on admission to the ICU. Results Mean age was 55.4 years old and 64.7% were male. The most common cause of gastrointestinal bleeding was peptic ulcer disease, followed by erosive esophagitis/gastritis. The in-hospital mortality was 22.6%. Median lactate level in survivors and nonsurvivors was 2.0 (interquartile range IQR 1.2–4.2 mmol/L) and 8.8 (IQR 3.4–13.3 mmol/L; p < 0.01), respectively. The receiver operating characteristic (ROC) area to predict in-hospital death for clinical Rockall score and lactate level (0.82) was significantly higher than the ROC area for the clinical Rockall score alone (0.69) ( p < 0.01). Conclusions In patients admitted to the ICU with acute UGIB, lactate level on admission has a high sensitivity but low specificity for predicting in-hospital death. Lactate level adds to the predictive value of the clinical Rockall score. Given its high sensitivity, lactate level can be used in addition to other prediction tools to predict outcomes in patients with UGIB.
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Guideline-discordant care of COPD is not uncommon. Further, there is a push to incorporate quality ...improvement (QI) training into internal medicine (IM) residency curricula. This study compared quality of care of COPD patients in an IM residents' clinic and a pulmonary fellows' clinic and, subsequently, the results of a quality improvement program in the residents' clinic. Pre-intervention rates of quality measure adherence were compared between the IM teaching clinic (
= 451) and pulmonary fellows' clinic (
= 177). Patient encounters in the residents' teaching clinic after quality improvement intervention (
= 119) were reviewed and compared with pre-intervention data. Prior to intervention, fellows were significantly more likely to offer smoking cessation counseling (
= 0.024) and document spirometry showing airway obstruction (
< 0.001). Smoking cessation counseling, pneumococcal vaccination, and diagnosis of COPD by spirometry were targets for QI. A single-cycle, resident-led QI project was initiated. After, residents numerically improved in the utilization of spirometry (66.5% vs. 74.8%) and smoking cessation counseling (81.8% vs. 86.6%), and significantly improved rates of pneumococcal vaccination (
= 0.024). One cycle of resident-led QI significantly improved the rates of pneumococcal vaccination, with numerical improvement in other areas of COPD care.
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