Major issues in the implementation of screening for lung cancer by means of low-dose computed tomography (CT) are the definition of a positive result and the management of lung nodules detected on ...the scans. We conducted a population-based prospective study to determine factors predicting the probability that lung nodules detected on the first screening low-dose CT scans are malignant or will be found to be malignant on follow-up.
We analyzed data from two cohorts of participants undergoing low-dose CT screening. The development data set included participants in the Pan-Canadian Early Detection of Lung Cancer Study (PanCan). The validation data set included participants involved in chemoprevention trials at the British Columbia Cancer Agency (BCCA), sponsored by the U.S. National Cancer Institute. The final outcomes of all nodules of any size that were detected on baseline low-dose CT scans were tracked. Parsimonious and fuller multivariable logistic-regression models were prepared to estimate the probability of lung cancer.
In the PanCan data set, 1871 persons had 7008 nodules, of which 102 were malignant, and in the BCCA data set, 1090 persons had 5021 nodules, of which 42 were malignant. Among persons with nodules, the rates of cancer in the two data sets were 5.5% and 3.7%, respectively. Predictors of cancer in the model included older age, female sex, family history of lung cancer, emphysema, larger nodule size, location of the nodule in the upper lobe, part-solid nodule type, lower nodule count, and spiculation. Our final parsimonious and full models showed excellent discrimination and calibration, with areas under the receiver-operating-characteristic curve of more than 0.90, even for nodules that were 10 mm or smaller in the validation set.
Predictive tools based on patient and nodule characteristics can be used to accurately estimate the probability that lung nodules detected on baseline screening low-dose CT scans are malignant. (Funded by the Terry Fox Research Institute and others; ClinicalTrials.gov number, NCT00751660.).
Malignant pleural effusions (MPEs) are a common cause of dyspnea in patients with advanced cancer. Tunnelled pleural catheters (TPCs) can be used in patients with this condition, but the published ...experience with them is limited.
To describe the use of TPCs in the management of MPE in a large group of patients in a clinical setting.
Retrospective analysis of 250 sequential TPC insertions in patients with MPEs in a single center.
Two hundred fifty TPC procedures for MPE were performed in 223 patients (19 contralateral procedures and 8 repeat ipsilateral procedures) during a 3-year period. Symptom control was complete following 97 procedures (38.8%), was partial in 125 procedures (50%), and was absent in 9 procedures (3.6%); in addition, there were 10 failed TPC insertions (4.0%) and 9 TPC insertions (3.6%) without assessment of symptoms at the 2-week follow-up visit. Spontaneous pleurodesis occurred following 103 of the 240 successful TPC procedures (42.9%) and was more frequent when ≤ 20% of the hemithorax contained fluid at the 2-week follow-up visit (57.2% vs 25.3%, respectively; p < 0.001). Catheters stayed in place for a median duration of 56 days. Following successful TPC placement, no further ipsilateral pleural procedures were required in 90.1% of cases. The overall median survival time following TPC insertion was 144 days. Complication rates were low and compared favorably with those seen with other treatment options.
TPC placement is an effective method of palliation for MPE that allows outpatient management and low complication rates. The insertion of a TPC should be considered as a first-line treatment option in the management of patients with MPE.
Background: Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) of mediastinal lymph nodes has been found
to be more accurate than standard TBNA in the setting of ...malignancy. In patients with suspected sarcoidosis, the smaller ultrasound
needle may yield inadequate material to make a histologic diagnosis of granulomatous inflammation. The aim of this study was
to compare the diagnostic yield of EBUS-guided TBNA to TBNA performed with a standard 19-gauge needle in patients with mediastinal
adenopathy and a clinical suspicion of sarcoidosis.
Methods: A randomized controlled trial was performed in a university medical center, enrolling 50 patients (of 61 screened, 2 declined,
and 9 did not meet entry criteria) with hilar and/or mediastinal adenopathy and a clinical suspicion of sarcoidosis. Twenty-four
patients were randomized to undergo EBUS-guided TBNA and 26 to undergo TBNA using a standard 19-gauge needle.
Results: The primary outcome measure of diagnostic yield was 53.8% vs 83.3% in favor of the EBUS-guided TBNA group, an absolute increase
of 29.5% (p < 0.05; 95% confidence interval CI, 8.6 to 55.4%). After blinded research pathology review, diagnostic yield
was 73.1% vs 95.8%, in favor of the EBUS-guided TBNA group, an absolute increase of 22.7% (p = 0.05; 95% CI, 1.9 to 42.2%).
Sensitivity and specificity were 60.9% and 100%, respectively, in the standard TBNA group, and 83.3% and 100%, respectively,
in the EBUS-guided TBNA group (absolute increase in sensitivity, 22.5%; p = 0.085; 95% CI, 3.2 to 44.9%).
Conclusions: The diagnostic yield of EBUS-guided TBNA is superior to TBNA using a standard 19-gauge needle for sampling of mediastinal
lymph nodes in patients with a clinical suspicion of sarcoidosis.
Trial registration: ClinicalTrials.gov Identifier: NCT00373555
To determine the impact of body mass index (BMI) on outcomes in critically ill patients.
Retrospective analysis of a large multi-institutional ICU database.
The influence of BMI classification ...(underweight, < 20 kg/m2; normal control subjects, 20 to 25 kg/m2; overweight, 25 to 30 kg/m2; obese, 30 to 40 kg/m2; severe obesity, > 40 kg/m2) on hospital survival, functional status at hospital discharge, and ICU/hospital length of stay (LOS) was analyzed via multivariate analysis, adjusting for age, gender, type of hospital admission, and severity score (ie, simplified acute physiologic score SAPS II and mortality prediction model MPM at time zero). Univariate analysis also was performed according to the quartile of the severity score. All comparisons were to the normal BMI group.
Of 63,646 patient datasets, 41,011 were complete for height, weight, and at least one of the two severity scores. We found increased mortality in underweight patients (odds ratio OR of death: SAPS group, 1.19; MPM group, 1.26) but not in overweight, obese, or severely obese patients. ICU and hospital LOS were increased in both the severely obese (OR of discharge: ICU, 0.81 and 0.84, respectively; hospital, 0.83 and 0.87, respectively) and underweight groups (OR of discharge: ICU, 0.96 and 0.94, respectively; hospital, 0.91 and 0.90, respectively). Only in the SAPS group did the obese group have increased ICU LOS (OR, 0.96) and hospital LOS (OR, 0.96). Functional status at discharge was impaired in underweight patients (OR of disability: ICU, 1.11; hospital, 1.19). Overweight patients had decreased discharge disability (OR of disability: SAPS, 0.93; MPM, 0.94), while the results in the obese group were discordant between the two severity score groups (SAPS, not significant; MPM, 0.91; p < 0.05 for all ORs).
Low BMI, but not high BMI, is associated with increased mortality and worsened hospital discharge functional status. LOS is increased in severely obese patients and, to a lesser extent, in underweight patients. Patients in the overweight and obese BMI groups may have improved mortality and discharge functional status.
Background Malignant pleural effusion (MPE) is a common complication of advanced malignancy, but little is known regarding its prevalence and overall burden on a population level. Methods We ...conducted a retrospective analysis of MPE-associated hospitalizations using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, Agency for Healthcare Research and Quality (HCUP-NIS 2012). Cases were included if MPE was coded as a primary or secondary diagnosis or if an unspecified pleural effusion was coded in addition to a diagnosis of cancer with either of these being the primary diagnosis. Results A weighted sample of 126,825 admissions (0.35%) for MPE was identified among the 36,484,846 weighted admissions included in the database in 2012. Of these admissions, 70,750 (55.8%) were for female patients. The median age at admission was 68.0 years (interquartile range IQR), 58.4-77.2 years). Lung (37.8%), breast (15.2%), hematologic (11.2%), GI tract (11.0%), and gynecologic (9.0%) cancers were the most common primary malignancies associated with MPE. The median length of stay was 5.5 days (IQR, 2.7-10.1 days), and the inpatient mortality rate was 11.6%. Median hospitalization total charges were $42,376 (IQR, $21,618-$84,679). In the multivariate analyses, female sex, large fringe county residential area, Medicare insurance, and elective type of admission were independently associated with a lower risk of inpatient mortality. Conclusions There is a considerable inpatient burden and high inpatient mortality associated with MPE in the United States, with potential demographic, geographic, and socioeconomic disparities.
The burden of hospitalizations and mortality for hemoptysis due to bronchiectasis is not well characterized. The primary outcome of our study was to evaluate in-hospital mortality in patients ...admitted with hemoptysis and bronchiectasis, as well as the rates of bronchial artery embolization, length of stay, and hospitalization costs.
The authors queried the Nationwide Inpatient Sample (NIS) claims database for hospitalizations between 2016 and 2017 using the ICD-10-CM codes for hemoptysis and bronchiectasis in the United States. Multivariable regression was used to evaluate predictors of in-hospital mortality, embolization, length of stay, and hospital costs.
There were 8240 hospitalizations (weighted) for hemoptysis in the United States from 2016 to 2017. The overall in-hospital mortality was 4.5%, but higher in males compared to females. Predictors of in-hospital mortality included undergoing three or more procedures, age, and congestive heart failure. Bronchial artery embolization (BAE) was utilized during 2.1% of hospitalizations and was more frequently used in those with nontuberculous mycobacteria and aspergillus infections, but not pseudomonal infections. The mean length of stay was 6 days and the median hospitalization cost per patient was USD $9,610. Having comorbidities and procedures was significantly associated with increased length of stay and costs.
Hemoptysis is a frequent indication for hospitalization among the bronchiectasis population. In-hospital death occurred in approximately 4.5% of hospitalizations. The effectiveness of BAE in treating and preventing recurrent hemoptysis from bronchiectasis needs to be explored.
The chemistry of mercury in freshwater systems, particularly man-made reservoirs, has received a great deal of attention owing to the high toxicity of the most common organic form, methylmercury. ...Although methylmercury bioaccumulation in reservoirs and natural lakes has been extensively studied at all latitudes, the fate of the different forms of mercury (total vs. dissolved; organic vs. inorganic) along the entire river-estuary continuum is less well documented. In fact, the difficulty of integrating the numerous parameters involved in mercury speciation in such large study areas, combined with the technical difficulties in sampling and analyzing mercury, have undoubtedly hindered advances in the field. At the same time, carbocentric science has grown exponentially in the last 25 years, and the common fate of carbon and mercury in freshwater has become increasingly clear with time. This literature review, by presenting the knowledge acquired in these two fields, aims to better understand the extent of mercury export from boreal inland waters to estuaries and to investigate the possible downstream ecotoxicological impact of reservoir creation on mercury bioavailability to estuarine food webs and local communities.
We present here the first comprehensive assessment of the carbon (C) footprint associated with the creation of a boreal hydroelectric reservoir (Eastmain‐1 in northern Québec, Canada). This is the ...result of a large‐scale, interdisciplinary study that spanned over a 7‐years period (2003–2009), where we quantified the major C gas (CO2 and CH4) sources and sinks of the terrestrial and aquatic components of the pre‐flood landscape, and also for the reservoir following the impoundment in 2006. The pre‐flood landscape was roughly neutral in terms of C, and the balance between pre‐ and post‐flood C sources/sinks indicates that the reservoir was initially (first year post‐flood in 2006) a large net source of CO2 (2270 mg C m−2 d−1) but a much smaller source of CH4 (0.2 mg C m−2 d−1). While net CO2 emissions declined steeply in subsequent years (down to 835 mg C m−2 d−1 in 2009), net CH4 emissions remained constant or increased slightly relative to pre‐flood emissions. Our results also suggest that the reservoir will continue to emit carbon gas over the long‐term at rates exceeding the carbon footprint of the pre‐flood landscape, although the sources of C supporting these emissions have yet to be determined. Extrapolation of these empirical trends over the projected life span (100 years) of the reservoir yields integrated long‐term net C emissions per energy generation well below the range of the natural‐gas combined‐cycle, which is considered the current industry standard.
Key Points
The landscape to be flooded by a new boreal hydropower reservoir was close to C
The reservoir was initially a large source of both CO2 and CH4
Long‐term C emissions per energy generation reach approx. 43 t C‐CO2eq TWh
The emissions of carbon dioxide (CO2) and methane (CH4) from the Petit Saut hydroelectric reservoir (Sinnamary River, French Guiana) to the atmosphere were quantified for 10 years since impounding in ...1994. Diffusive emissions from the reservoir surface were computed from direct flux measurements in 1994, 1995, and 2003 and from surface concentrations monitoring. Bubbling emissions, which occur only at water depths lower than 10 m, were interpolated from funnel measurements in 1994, 1997, and 2003. Degassing at the outlet of the dam downstream of the turbines was calculated from the difference in gas concentrations upstream and downstream of the dam and the turbined discharge. Diffusive emissions from the Sinnamary tidal river and estuary were quantified from direct flux measurements in 2003 and concentrations monitoring. Total carbon emissions were 0.37 ± 0.01 Mt yr−1 C (CO2 emissions, 0.30 ± 0.02; CH4 emissions, 0.07 ± 0.01) the first 3 years after impounding (1994–1996) and then decreased to 0.12 ± 0.01 Mt yr−1 C (CO2, 0.10 ± 0.01; CH4, 0.016 ± 0.006) since 2000. On average over the 10 years, 61% of the CO2 emissions occurred by diffusion from the reservoir surface, 31% from the estuary, 7% by degassing at the outlet of the dam, and a negligible fraction by bubbling. CH4 diffusion and bubbling from the reservoir surface were predominant (40% and 44%, respectively) only the first year after impounding. Since 1995, degassing at an aerating weir downstream of the turbines has become the major pathway for CH4 emissions, reaching 70% of the total CH4 flux. In 2003, river carbon inputs were balanced by carbon outputs to the ocean and were about 3 times lower than the atmospheric flux, which suggests that 10 years after impounding, the flooded terrestrial carbon is still the predominant contributor to the gaseous emissions. In 10 years, about 22% of the 10 Mt C flooded was lost to the atmosphere. Our results confirm the significance of greenhouse gas emissions from tropical reservoir but stress the importance of: (1) considering all the gas pathways upstream and downstream of the dams and (2) taking into account the reservoir age when upscaling emissions rates at the global scale.
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