Safety and diagnostic performance of pulmonologists performing electromagnetic guided percutaneous lung biopsy (SPiNperc)

Background and objectivePercutaneous lung biopsy for diagnostic sampling of peripheral lung nodules has been widely performed by interventional radiologists under computed tomography (CT) guidance. New technology allows pulmonologists to perform percutaneous lung biopsies using electromagnetic (EM) guided technology. With the adoption of this new technique, the safety, feasibility and diagnostic yield need to be explored. The goal of this study was to determine the safety, feasibility and diagnostic yield of EMâ guided percutaneous lung biopsy performed by pulmonologists.MethodsWe conducted a retrospective, multicentre study of 129 EMâ guided percutaneous lung biopsies that occurred between November 2013 and March 2017. The study consisted of seven academic and three community medical centres.ResultsThe average age of participants was 65.6â years, BMI was 26.3 and 50.4% were females. The majority of lesions were in the right upper lobe (37.2%) and left upper lobe (31.8%). The mean size of the lesions was 27.31â mm and the average distance from the pleura was 13.2â mm. Practitioners averaged two fineâ needle aspirates and five core biopsies per procedure. There were 23 (17.8%) pneumothoraces, of which 16 (12.4%) received smallâ bore chest tube placement. The diagnostic yield of percutaneous lung biopsy was 73.7%. When EMâ guided bronchoscopic sampling was also performed during the same procedural encounter, the overall diagnostic yield increased to 81.1%.ConclusionIn this large multicentred series, the use of EM guidance for percutaneous lung biopsies was safe and feasible, with acceptable diagnostic yield in the hands of pulmonologists. A prospective multicentre trial to validate these findings is currently underway (NCT03338049).Lung cancer screening has led to the discovery of over 1â million pulmonary nodules each year. New technology allows pulmonologists to perform percutaneous lung biopsies using electromagnetic (EM) guided technology. In this retrospective analysis, we demonstrate that EM percutaneous needle biopsy is safe, feasible and provides an acceptable diagnostic yield.See related EditorialPeer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/149341/1/resp13471.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149341/2/resp13471_am.pd

31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016) : part two

Background The immunological escape of tumors represents one of the main ob- stacles to the treatment of malignancies. The blockade of PD-1 or CTLA-4 receptors represented a milestone in the history of immunotherapy. However, immune checkpoint inhibitors seem to be effective in specific cohorts of patients. It has been proposed that their efficacy relies on the presence of an immunological response. Thus, we hypothesized that disruption of the PD-L1/PD-1 axis would synergize with our oncolytic vaccine platform PeptiCRAd. Methods We used murine B16OVA in vivo tumor models and flow cytometry analysis to investigate the immunological background. Results First, we found that high-burden B16OVA tumors were refractory to combination immunotherapy. However, with a more aggressive schedule, tumors with a lower burden were more susceptible to the combination of PeptiCRAd and PD-L1 blockade. The therapy signifi- cantly increased the median survival of mice (Fig. 7). Interestingly, the reduced growth of contralaterally injected B16F10 cells sug- gested the presence of a long lasting immunological memory also against non-targeted antigens. Concerning the functional state of tumor infiltrating lymphocytes (TILs), we found that all the immune therapies would enhance the percentage of activated (PD-1pos TIM- 3neg) T lymphocytes and reduce the amount of exhausted (PD-1pos TIM-3pos) cells compared to placebo. As expected, we found that PeptiCRAd monotherapy could increase the number of antigen spe- cific CD8+ T cells compared to other treatments. However, only the combination with PD-L1 blockade could significantly increase the ra- tio between activated and exhausted pentamer positive cells (p= 0.0058), suggesting that by disrupting the PD-1/PD-L1 axis we could decrease the amount of dysfunctional antigen specific T cells. We ob- served that the anatomical location deeply influenced the state of CD4+ and CD8+ T lymphocytes. In fact, TIM-3 expression was in- creased by 2 fold on TILs compared to splenic and lymphoid T cells. In the CD8+ compartment, the expression of PD-1 on the surface seemed to be restricted to the tumor micro-environment, while CD4 + T cells had a high expression of PD-1 also in lymphoid organs. Interestingly, we found that the levels of PD-1 were significantly higher on CD8+ T cells than on CD4+ T cells into the tumor micro- environment (p < 0.0001). Conclusions In conclusion, we demonstrated that the efficacy of immune check- point inhibitors might be strongly enhanced by their combination with cancer vaccines. PeptiCRAd was able to increase the number of antigen-specific T cells and PD-L1 blockade prevented their exhaus- tion, resulting in long-lasting immunological memory and increased median survival

A Prospective, Ex Vivo Trial of Endobronchial Blockade Management Utilizing 3 Commonly Available Bronchial Blockers.

BACKGROUND: Lung isolation with bronchial blockers is a well-described and accepted procedure, often described for use during the management of massive hemoptysis. Recommendations for balloon inflation are sparse, with some advocating for saline whereas other suggest air, including the manufacturers. We sought to evaluate the optimal method for balloon inflation in an ex vivo trial. METHODS: We performed a prospective trial utilizing 3 commercially available bronchial blockers commonly described for use in lung isolation and massive hemoptysis management. We utilized the Arndt Endobronchial Blocker (Cook Medical), the Cohen Tip Deflecting Endobronchial Blocker (Cook Medical), and the Fogarty Venous Thrombectomy Catheter (Edwards LifeSciences). Balloon size and deflation assessment were tested within 3 different scenarios comparing air versus saline. Welch t test was performed to compare means between groups, and a generalized estimating equation model was utilized to compare balloon diameter over time to account for correlation among repeated measures from the same balloon. RESULTS: All 3 endobronchial blocker systems were observed in triplicate. During free-standing balloon inflation, all 3 endobronchial systems displayed a greater degree of balloon deflation over time with air as opposed to saline (P \u3c .001). Within a stent-based model, inflation with air of all 3 endobronchial systems, according to manufacturer recommendations, demonstrated significantly decreased time until fluid transgression occurred when compared to a saline model (P \u3c .001). Within a stent-based model, inflation with air, according to clinical judgment, demonstrated significantly decreased time until fluid transgression in the Arndt (P = .016) and the Fogarty (P \u3c .001) system, but not the Cohen (P = .173) system, when compared with saline. CONCLUSIONS: The utilization of saline for balloon inflation during bronchial blockade allows for more consistent balloon inflation. The use of saline during balloon inflation appears to delay passive, spontaneous balloon deflation time when compared to air during a model of endobronchial blockade. The approach of saline inflation should be tested in humans to demonstrate the overall applicability and validity of the current findings

Association of language concordance and restraint use in adults receiving mechanical ventilation

PURPOSEClinician-patient language concordance improves patient outcomes in non-intensive care unit (ICU) settings. We sought to assess the association of ICU nurse-patient language concordance with delirium-related outcomes. METHODSWe conducted a retrospective cohort study of adult English- or Spanish-speaking mechanically ventilated ICU patients admitted to ICUs at the University of Miami Hospital and Clinics (January 2021-September 2022). Our primary exposure was nurse-patient language concordance on each shift. We used mixed-effects multivariable regression to evaluate the association of language concordance with the primary outcome of restraint use, and secondary outcomes of agitation and identification of delirium, during each shift (with patient as a random effect). RESULTSOur cohort included 4326 shifts (3380 [78.1%] with language concordance) from 548 patients and 157 nurses. Spanish language was preferred by 269 (49.1%) of patients. English-speaking patients tended to be younger (65 [53, 75] vs 73 [61, 83], p < 0.001) and of non-Hispanic ethnicity (55.5% vs 7.1%, p < 0.001). English-speakers had restraints ordered on fewer of their included shifts (0 [0, 3] vs 1 [0, 3], p = 0.005). After adjustment, the odds of restraint use on shifts with language concordance was significantly lower (odds ratio [OR, 95% confidence interval [CI]]: 0.50 [0.39-0.63], p < 0.001). Agitation (18.6% vs 25.2%; OR [95% CI]: 0.71 [0.55-0.92], p = 0.009) and delirium identification (34.5% vs 41.3%; OR [95% CI]: 0.54 [0.34-0.88], p = 0.014) were also less common. CONCLUSIONSWe identified a twofold reduction in the odds of restraint use among mechanically ventilated patients for language concordant nurse-patient dyads. Ensuring nurse-patient language concordance may improve ICU delirium, agitation, and restraint use

Real world SARS-COV-2 vaccine effectiveness in a Miami academic institution

To assess the effectiveness of messenger RNA vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) in preventing emergency department (ED) presentations for acute respiratory illness. We conducted a retrospective study assessing adult presentations (age ≥ 18) to the University of Miami Hospital's ED from January 1st through August 25th, 2021, with a SARS-COV-2 PCR test and acute respiratory infection symptoms. Vaccine effectiveness was calculated using a test-negative design. Both univariable and multivariable (adjusted for age, gender, race, insurance status, imputed body mass index [BMI], vaccine type, week of presentation) regression analyses were conducted for the full cohort and subgroups. The cohort consisted of 13,203 ED presentations—3134 (23.7%) fully vaccinated and SARS-COV-2 negative, 108 (0.8%) fully vaccinated and SARS-COV-2 positive, 8817 (66.8%) unvaccinated and SARS-COV-2 negative, and 1144 (8.7%) unvaccinated and SARS-COV-2 positive. Unadjusted vaccination effectiveness was 73.4% (95% confidence interval: 67.5%,78.3%) and, after adjustment, 73.8% (66.2%,79.7%). The Moderna vaccine's effectiveness was numerically higher (unadjusted: 78.2% [68.8%, 84.7%]; adjusted: 78.0% [68.1%, 84.9%]) than the Pfizer vaccine's (unadjusted: 70.8% [62.9%, 76.9%]; adjusted: 73.9% [66.3%,79.8%]). We found a significant difference in adjusted vaccine effectiveness across categories was BMI (p < 0.001)—BMI <25: 66.3% (45.3%,79.2%); BMI 25–29: 71.3% (56.1%, 81.2%); BMI 30–34: 84.5% (71.7%, 91.5%); and BMI ≥35: 72.7% (50.5%, 84.9%). We demonstrated excellent real-world effectiveness of mRNA vaccines in preventing ED presentation for SARS-COV-2 in a diverse U.S. cohort. Notably, vaccine effectiveness improved with increasing BMI (until class 2 obesity)

Same-Day Computed Tomographic Chest Imaging for Pulmonary Nodule Targeting with Electromagnetic Navigation Bronchoscopy May Decrease Unnecessary Procedures

Bronchoscopy is commonly used for the diagnosis of suspicious pulmonary nodules discovered on computed tomographic (CT) imaging of the chest. Procedural CT imaging for bronchoscopy planning is often completed weeks to months before the date of a scheduled bronchoscopy, which may not allow discovery of a decrease in nodule size or resolution before the bronchoscopic procedure. To determine whether same-day CT imaging of the chest discovers partial or total resolution of some lung nodules and thereby reduces unnecessary bronchoscopic procedures. We performed a prospective case series study of patients undergoing navigational bronchoscopy using a new technology requiring same-day preprocedural CT imaging at one university teaching hospital. Patients scheduled to undergo bronchoscopy who were found to have partial or complete resolution of their lesion on the same-day CT exam leading to the cancellation of their procedure were identified and further characterized. From January 2015 to June 2016, 116 patients were scheduled for navigational bronchoscopy for the diagnosis of a pulmonary lesion. Of the 116 patients scheduled, 8 (6.9%) had a decrease in size or resolution of their lesion, leading to the cancellation of their procedure. The number needed to screen to prevent one unnecessary procedure was 15. For cancelled cases, the average time from initial CT prompting referral for bronchoscopy to the day of procedure scan was 53 days. Time from initial imaging to day of procedure is variable, occasionally allowing enough time for lesions to resolve, thereby obviating the need for biopsy. Same-day imaging may decrease unnecessary procedural risk

Stylet Use Does Not Improve Diagnostic Outcomes in Endobronchial Ultrasonographic Transbronchial Needle Aspiration: A Randomized Clinical Trial

Endobronchial ultrasonographically guided transbronchial needle aspiration (EBUS-TBNA) of thoracic structures is a commonly performed tissue sampling technique. The use of an inner-stylet in the EBUS needle has never been rigorously evaluated and may be unnecessary. In a prospective randomized single-blind controlled clinical trial, patients with a clinical indication for EBUS-TBNA underwent lymph node sampling using both with-stylet and without-stylet techniques. Sample adequacy, diagnostic yield, and various cytologic quality measures were compared. One hundred twenty-one patients were enrolled, with 194 lymph nodes sampled, each using both with-stylet and without-stylet techniques. There was no significant difference in sample adequacy or diagnostic yield between techniques. The without-stylet technique resulted in adequate samples in 87% of the 194 study lymph nodes, which was no different from the with-stylet adequacy rate (82%; P = .371). The with-stylet technique resulted in a diagnosis in 50 of 194 samples (25.7%), which was similar to the without-stylet group (49 of 194 [25.2%]; P = .740). There was a high degree of concordance in the determination of adequacy (84.0%; 95% CI, 78.1-88.9) and diagnostic sample generation (95.4%; 95% CI, 91.2-97.9) between the two techniques. A similar qualitative number of lymphocytes, malignant cells, and bronchial respiratory epithelia were recovered using each technique. Omitting stylet use during EBUS-TBNA does not affect diagnostic outcomes and reduces procedural complexity. ClinicalTrials.Gov: No. NCT 02201654; URL:www.clinicaltrials.gov