Local and systemic responses to SARS-CoV-2 infection in children and adults.

It is not fully understood why COVID-19 is typically milder in children1-3. Here, to examine the differences between children and adults in their response to SARS-CoV-2 infection, we analysed paediatric and adult patients with COVID-19 as well as healthy control individuals (total n = 93) using single-cell multi-omic profiling of matched nasal, tracheal, bronchial and blood samples. In the airways of healthy paediatric individuals, we observed cells that were already in an interferon-activated state, which after SARS-CoV-2 infection was further induced especially in airway immune cells. We postulate that higher paediatric innate interferon responses restrict viral replication and disease progression. The systemic response in children was characterized by increases in naive lymphocytes and a depletion of natural killer cells, whereas, in adults, cytotoxic T cells and interferon-stimulated subpopulations were significantly increased. We provide evidence that dendritic cells initiate interferon signalling in early infection, and identify epithelial cell states associated with COVID-19 and age. Our matching nasal and blood data show a strong interferon response in the airways with the induction of systemic interferon-stimulated populations, which were substantially reduced in paediatric patients. Together, we provide several mechanisms that explain the milder clinical syndrome observed in children

Navigational transbronchial needle aspiration, percutaneous needle aspiration and its future

Peripheral lung nodule evaluation represents a clinical challenge. Given that many nodules will be incidentally found with lung cancer screening following the publication of the National Lung Screening Trial (NLST), the goal is to find an accurate, safe and minimally-invasive diagnostic modality to biopsy the concerning lesions. Unfortunately, conventional bronchoscopic techniques provide a poor diagnostic yield of 18-62%. In recent years advances in technology have led to the introduction of electromagnetic navigational bronchoscopy (ENB) as a tool to guide sampling of peripheral lung nodules. The same principle has also recently been expanded and applied to the transthoracic needle biopsy, referred to as electromagnetic transthoracic needle aspiration (E-TTNA). An improved diagnostic yield has afforded this technology a recommendation by the 2013 3(rd) Edition ACCP Guidelines for the Diagnosis and Management of Lung Cancer which state that "in patients with peripheral lung lesions difficult to reach with conventional bronchoscopy, ENB is recommended if the equipment and the expertise are available (Grade 1C)". In this review we will discuss the technology, devices that are available, techniques and protocols, diagnostic yield, safety, cost effectiveness and more

Etiologies of bilateral pleural effusions

SummaryBackgroundTo evaluate the safety, etiology and outcomes of patients undergoing bilateral thoracentesis.MethodsThis is a prospective cohort study of 100 consecutive patients who underwent bilateral thoracenteses in an academic medical center from July 2009 through November 2010. Pleural fluid characteristics and etiologies of the effusions were assessed. Mean differences in levels of fluid characteristics between right and left lungs were tested. Associations between fluid characteristics and occurrence of bilateral malignant effusions were evaluated. The rate of pneumothorax and other complications subsequent to bilateral thoracentesis was determined.ResultsExudates were more common than transudates, and most effusions had multiple etiologies, with 83% having two or more etiologies. Bilateral malignant effusions occurred in 19 patients, were the most common single etiology of exudative effusions, and were associated with higher levels of protein and LDH in the pleural fluid. Among 200 thoracenteses performed with a bilateral procedure, seven resulted in pneumothoraces, three of which required chest tube drainage and four were ex vacuo.ConclusionsMore often than not, there are multiple etiologies that contribute to pleural fluid formation, and of the combinations of etiologies observed congestive heart failure was the most frequent contributor. Exudative effusions are more common than transudates when bilateral effusions are present. Malignancy is a common etiology of exudative effusions. This study suggests that the overall complication rate following bilateral thoracentesis is low and the rate of pneumothorax subsequent to bilateral thoracentesis is comparable to unilateral thoracentesis

Heavy ion cocktail beams at the 88 inch Cyclotron

Cyclotrons in combination with ECR ion sources provide the ability to accelerate ''cocktails'' of ions. A cocktail is a mixture of ions of near-identical mass-to-charge (m/q) ratio. The different ions cannot be separated by the injector mass-analyzing magnet and are tuned out of the ion source together. The cyclotron then is utilized as a mass analyzer by shifting the accelerating frequency. This concept was developed soon after the first ECR ion source became operational at the 88-Inch Cyclotron and has since become a powerful tool in the field of heavy ion radiation effects testing. Several different ''cocktails'' at various energies are available at the 88-Inch cyclotron for radiation effect testing, covering a broad range of linear energy transfer and penetration depth. Two standard heavy ion cocktails at 4.5 MeV/nucleon and 10 MeV/nucleon have been developed over the years containing ions from boron to bismuth. Recently, following requests for higher penetration depths, a 15MeV/nucleon heavy ion cocktail has been developed. Up to nine different metal and gaseous ion beams at low to very high charge states are tuned out of the ion source simultaneously and injected together into the cyclotron. It is therefore crucial to balance the ion source very carefully to provide sufficient intensities throughout the cocktail. The paper describes the set-up and tuning of the ion source for the various heavy ion cocktails

Heavy ion cocktail beams at the 88 inch Cyclotron

Cyclotrons in combination with ECR ion sources provide the ability to accelerate "cocktails" of ions. A cocktail is a mixture of ions of near-identical mass-to-charge (m/q) ratio. The different ions cannot be separated by the injector mass-analyzing magnet and are tuned out of the ion source together. The cyclotron then is utilized as a mass analyzer by shifting the accelerating frequency. This concept was developed soon after the first ECR ion source became operational at the 88-Inch Cyclotron and has since become a powerful tool in the field of heavy ion radiation effects testing. Several different "cocktails" at various energies are available at the 88-Inch cyclotron for radiation effect testing, covering a broad range of linear energy transfer and penetration depth. Two standard heavy ion cocktails at 4.5 MeV/nucleon and 10 MeV/nucleon have been developed over the years containing ions from boron to bismuth. Recently, following requests for higher penetration depths, a 15MeV/nucleon heavy ion cocktail has been developed. Up to nine different metal and gaseous ion beams at low to very high charge states are tuned out of the ion source simultaneously and injected together into the cyclotron. It is therefore crucial to balance the ion source very carefully to provide sufficient intensities throughout the cocktail. The paper describes the set-up and tuning of the ion source for the various heavy ion cocktails

Use of Tracheostomy During the COVID-19 Pandemic: American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/Association of Interventional Pulmonology Program Directors Expert Panel Report

BACKGROUND: The role of tracheostomy during the 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). METHODS: 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. RESULTS: 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. CONCLUSION: 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

Assessment of Ergonomic Strain and Positioning During Bronchoscopic Procedures: A Feasibility Study.

BACKGROUND: Poor ergonomics place health care workers at risk for work-related overuse injuries. Repetitive and prolonged hand maneuvers, such as those performed during endoscopic procedures, may lead to musculoskeletal complaints and work-related injuries. However, the prevalence of health care-related work injuries among physicians is thought to be underreported and there is a paucity of literature investigating the impact of ergonomic strain on bronchoscopy. We designed a feasibility study to explore the differences in ergonomic strain and muscle activity of bronchoscopists. MATERIALS AND METHODS: A prospective study of bronchoscopic procedures was performed in a simulated environment. Preselected target areas were identified and airway sampling was performed with real-time ergonomic assessment utilizing electromyogram (EMG), grip strength, and musculoskeletal use and motion analysis. RESULTS: Procedural data was obtained for all procedures (78 bronchoscopies by 13 subjects) for both ergonomic and EMG scores. Experienced bronchoscopists demonstrated less EMG burden (P=0.007) and improved ergonomic positioning (P=0.007) during bronchoscopy when compared with less experienced bronchoscopists. Procedures performed with rotational-head bronchoscopes trended toward improved ergonomics (P=0.15) and lower EMG scores (P=0.88). A significant improvement in ergonomic scores was seen with the rotational-head bronchoscope when targeting the left upper lobe (P=0.036). CONCLUSION: Poor ergonomic positioning and excessive muscle strain appear present within bronchoscopy procedures but may be improved in those with more bronchoscopy experience. Technological advances in bronchoscope design may also have the potential to improve procedural ergonomics. Additional prospective studies are warranted to define the long-term impact on bronchoscopic ergonomics