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Introduction Transbronchial lung cryobiopsy (TBLC) is an accepted alternative to surgical lung biopsy (SLB) for diagnosing diffuse parenchymal lung disease (DPLD) that is less invasive and results in comparable diagnostic yields. Performing lung biopsies on hospitalized patients, however, has increased risk due to the patient’s underlying disease severity. Data evaluating the safety and efficacy of TBLC in hospitalized patients are limited. We present a comparison of TBLC for hospitalized and outpatients and provide the safety and diagnostic yields in these populations. Methods Demographic data, pulmonary function values, chest imaging pattern, procedural information, and diagnosis were recorded from enrolled patients. Complications from the procedure were the primary outcomes and diagnostic yield was the secondary outcome. Results 77 patients (n = 22 hospitalized vs n = 55 outpatient) underwent TBLC during the study period. Comparing adverse events between hospitalized and outpatients revealed no statistically significant differences in pneumothorax (9%, n = 2 vs 5%,n = 3), tube thoracostomy placement (5%, n = 1 vs 2%, n = 1), grade 2 bleeding (9%, n = 2 vs 0%, n = 0), escalation in level of care (5%, n = 1 vs 0%, n = 0), 30-day mortality (9%, n = 2 vs 2%, n = 1), and 60-day mortality (9%, n = 2 vs 4%, n = 2) (p > 0.05 for all). No deaths were attributed to the procedure. 95% of cases received a multidisciplinary conference diagnosis (hospitalized 100%, n = 22 vs outpatients 93%, n = 51, p = 0.32). Conclusion Our experience supports that TBLC may be a safe and effective modality for acutely ill-hospitalized patients with DPLD. Further efforts to enhance procedural safety and to determine the impact of an expedited tissue diagnosis on patient outcomes are needed.

Lung cancer is the most common cancer worldwide and is also one of the leading causes of cancer related deaths. The 5-year survival rate depends largely on stage at diagnosis. Multiple large randomized controlled trials have demonstrated the clinical utility of lung cancer screening. Low dose computed tomography is recommended for lung cancer screening in several guidelines. Lung cancer is often diagnosed at more advanced stages owing to the nonspecific symptoms with which it presents. Diagnosis relies primarily upon imaging and biopsy. Diagnosis and staging should be performed simultaneously, if possible, by performing a biopsy at the site that will confer the highest stage. Sufficient material should be obtained to allow for molecular testing. Liquid biopsy may have a complementary role in detecting actionable mutations in non-small cell lung cancer. Treatment is predicated upon stage and may involve surgery, targeted chemotherapy, radiation therapy, immunotherapy, or some combination thereof.

A 39-year-old woman with systemic lupus erythematosus that was complicated by end-stage renal disease that had required a deceased donor renal transplant 16 years ago was referred for evaluation of chronic, nonproductive cough for 2 years. She was a lifetime nonsmoker whose condition was maintained on prednisone 5 mg daily, tacrolimus 3 mg twice day, mycophenolate mofetil 500 mg twice a day for her immunosuppression regimen, valacyclovir 500 mg twice a day for prophylaxis, and clonidine 0.1 mg daily and metoprolol succinate 100 mg twice daily for hypertension.

Determining the cause of diffuse parenchymal lung disease (DPLD) is challenging. While surgical lung biopsy has been the standard approach, transbronchial lung cryobiopsy (TBLC) represents a minimally invasive alternative with an acceptable safety profile and reasonable accuracy. In this study, we prospectively assessed whether the use of cone beam CT (CBCT) coupled with a novel bronchoscope holder and prophylactic administration of vasoconstricting medications decreases potential complications and improves diagnostic accuracy when performing TBLC. 33 patients presenting for evaluation of newly diagnosed DPLD were enrolled. Demographic data, pulmonary function values, chest imaging pattern, procedural information, and diagnosis were recorded. Mean patient age was 67, with the majority Caucasian (n = 26, 79%) and male (n = 20, 61%). Mean pulmonary function values revealed restrictive lung disease (76 ± 14% predicted) and diffusing capacity impairment (52 ± 16%). A non-usual interstitial pneumonia imaging pattern was commonly seen (n = 20, 61%). CBCT guided TBLC was performed in one lobe (n = 29, 88%) or two lobes (n = 4, 12%) with mean probe-to-pleura distance of 4.2 ± 1.3 mm. No peri or post procedural complications occurred. 32 patients (97%) received a histological diagnosis with a final multidisciplinary conference diagnosis possible for 32 (97%). CBCT guided TBLC coupled with a novel articulating scope holder and prophylactic phenylephrine administration has the potential to increase safety and diagnostic yield for patients with newly identified DPLD. Future studies comparing different aspects of this approach in isolation and with other modalities have the potential to refine this procedure to improve patient care.

The sensitivity of suspicious lung nodules biopsied by currently available techniques is suboptimal. Robotic-assisted navigation bronchoscopy (RANB) is a novel method for biopsying lung nodules. Our study objective was to determine the sensitivity for malignancy and overall diagnostic accuracy for RANB when combined with cone beam CT (CBCT) for secondary confirmation. 52 consecutive patients were prospectively enrolled. Demographic data, nodule characteristics, procedural information, and follow-up results were obtained. Mean patient age was 66, with the majority Caucasian (73%) females (65%) with a similar number of never (46%) and former (46%) smokers. 15 patients had a history of cancer and 3 had a prior thoracic surgery. 59 total nodules were included as 7 patients had two nodules biopsied. Mean nodule diameter was

BackgroundA genomic classifier for usual interstitial pneumonia (gUIP) has been shown to predict histological UIP with high specificity, increasing diagnostic confidence for idiopathic pulmonary fibrosis (IPF). Whether those with positive gUIP classification exhibit a progressive, IPF-like phenotype remains unknown.MethodsA pooled, retrospective analysis of patients who underwent clinically indicated diagnostic bronchoscopy with gUIP testing at seven academic medical centres across the USA was performed. We assessed the association between gUIP classification and 18-month progression-free survival (PFS) using Cox proportional hazards regression. PFS was defined as the time from gUIP testing to death from any cause, lung transplant, ≥10% relative decline in forced vital capacity (FVC) or censoring at the time of last available FVC measure. Longitudinal change in FVC was then compared between gUIP classification groups using a joint regression model.ResultsOf 238 consecutive patients who underwent gUIP testing, 192 had available follow-up data and were included in the analysis, including 104 with positive gUIP classification and 88 with negative classification. In multivariable analysis, positive gUIP classification was associated with reduced PFS (hazard ratio 1.58, 95% CI 0.86–2.92; p=0.14), but this did not reach statistical significance. Mean annual change in FVC was −101.8 mL (95% CI −142.7– −60.9 mL; pConclusionsgUIP classification was not associated with differential rates of PFS or longitudinal FVC decline in a multicentre interstitial lung disease cohort undergoing bronchoscopy as part of the diagnostic evaluation.

Bronchoscopic sampling of pulmonary lesions suspicious for lung cancer is frequently nondiagnostic. A genomic sequencing classifier utilizing bronchial brushings obtained at the time of the bronchoscopy has been shown to provide an accurate reclassification of the risk of malignancy (ROM) based on pre-procedure risk. Our objectives for this study were to determine the frequency with which the classifier up- or down-classifies risk in regular clinical practice and to model the potential clinical utility of that reclassification.This observational study retrospectively assessed data from four clinical sites that regularly use the genomic classifier in the bronchoscopic evaluation of indeterminate lesions. Demographics and pre-bronchoscopy ROM were recorded. The frequency of up- and down-classification was calculated. Modeling based on reclassification rates and the performance characteristics of the classifier was performed to demonstrate the potential clinical utility of the result.86 patients who underwent classifier testing following a nondiagnostic bronchoscopy were included. 45% of patients with high ROM prior to bronchoscopy were reclassified very high-risk. 38% of patients with intermediate ROM were up-or down-classified. 56% of patients with low ROM were reclassified to very low-risk. Overall, 42% of patients had a change in classification. 35% of the study cohort could potentially have avoided additional unnecessary procedures with subsequent guideline-adherent management.The classifier can guide decision-making following a nondiagnostic bronchoscopy, reclassifying risk in a significant percentage of cases. Use of the classifier should allow more patients with early-stage cancer to proceed directly to curative therapy while helping more patients with benign disease avoid further unnecessary procedures.

Central airway obstruction (CAO) remains a challenging disease for both patients who are suffering from it and for physicians who are managing it. Patients will frequently present with acute symptoms of respiratory failure that require management in an intensive care unit (ICU). While the true prevalence and incidence of CAO in the ICU setting is unknown, recent estimates suggest that approximately 20-30% of patients with a cancer diagnosis may present with CAO or develop it after diagnosis. Therapeutic bronchoscopy focuses on performing minimally invasive procedures using multiple ablative modalities to recanalize the central airway and alleviate the obstruction. While procedures are usually technically successful, they appear to be underutilized. An individually tailored approach is often used based on patient characteristics, operator preference, and available equipment. After therapeutic bronchoscopy procedures are completed, many patients are successfully liberated from mechanical ventilation (MV) or immediately transferred out of the ICU. Data reviewing the effects of therapeutic bronchoscopy have also shown success in palliation of symptoms, with significant improvement in subjective measures such as patient quality of life and dyspnea and objective values like pulmonary function studies. Given the potential benefits with a low risk profile and high likelihood of technical success, treatment of CAOs with therapeutic bronchoscopy represents a reasonable consideration for patients with acute respiratory failure in the ICU.

Determining the cause of diffuse parenchymal lung disease (DPLD) is challenging. While surgical lung biopsy has been the standard approach, transbronchial lung cryobiopsy (TBLC) represents a minimally invasive alternative with an acceptable safety profile and reasonable accuracy. In this study, we prospectively assessed whether the use of cone beam CT (CBCT) coupled with a novel bronchoscope holder and prophylactic administration of vasoconstricting medications decreases potential complications and improves diagnostic accuracy when performing TBLC.33 patients presenting for evaluation of newly diagnosed DPLD were enrolled. Demographic data, pulmonary function values, chest imaging pattern, procedural information, and diagnosis were recorded.Mean patient age was 67, with the majority Caucasian (n = 26, 79%) and male (n = 20, 61%). Mean pulmonary function values revealed restrictive lung disease (76 ± 14% predicted) and diffusing capacity impairment (52 ± 16%). A non-usual interstitial pneumonia imaging pattern was commonly seen (n = 20, 61%). CBCT guided TBLC was performed in one lobe (n = 29, 88%) or two lobes (n = 4, 12%) with mean probe-to-pleura distance of 4.2 ± 1.3 mm. No peri or post procedural complications occurred. 32 patients (97%) received a histological diagnosis with a final multidisciplinary conference diagnosis possible for 32 (97%).CBCT guided TBLC coupled with a novel articulating scope holder and prophylactic phenylephrine administration has the potential to increase safety and diagnostic yield for patients with newly identified DPLD. Future studies comparing different aspects of this approach in isolation and with other modalities have the potential to refine this procedure to improve patient care.

While there is significant mortality and morbidity with lung cancer, early stage diagnoses carry a better prognosis. As lung cancer screening programs increase with more pulmonary nodules detected, expediting definitive treatment initiation for newly diagnosed patients is imperative. The objective of our analysis was to determine if the use of a dedicated interventional pulmonology practice decreases time delay from new diagnosis of lung cancer or metastatic disease to the chest to treatment initiation. Retrospective chart analysis was done of 87 consecutive patients with a new diagnosis of primary lung cancer or metastatic cancer to the chest from our interventional pulmonology procedures. Demographic information and time intervals from abnormal imaging to procedure and to treatment initiation were recorded. Patients were older (mean age 69) and former or current smokers (72%). A median of 27 days (1–127 days) passed from our diagnostic biopsy to treatment initiation. A median of 53 total days (2–449 days) passed from abnormal imaging to definitive treatment. Endobronchial ultrasound-guided transbronchial needle aspiration was the most commonly used diagnostic procedure (59%), with non-small cell lung cancer the majority diagnosis (64%). For surgical patients, all biopsy-negative lymph nodes from our procedures were cancer-free at surgical excision. Compared to prior reports from international and United States cohorts, obtaining a tissue biopsy diagnosis through a gatekeeper interventional pulmonology practice decreases median delay from abnormal imaging to treatment initiation. This finding has the potential to positively impact patient outcomes and requires further evaluation.

Spray cryotherapy (SCT) ablation of airway obstructions is an evolving field of clinical practice and research in thoracic disease (1). The third generation truFreeze System (CSA Medical, Lexington, MA) is the only SCT device approved for airway use. Using a series of valves to regulate the flow of the liquid nitrogen cryogen from the storage dewar to the exit point at the catheter tip, this current system creates a more even flow of liquid nitrogen without nitrogen gas pocket development. This regulated liquid nitrogen release enables greater stability during the transition to nitrogen gas at the treatment site than prior systems and facilitates uniform elastic recoil of the lung for safe nitrogen gas evacuation.

ALK-rearranged lung cancer defines a distinctive molecular cohort of patients whose outcomes are significantly improved by the availability of ALK inhibitors. Thus, it is imperative for clinicians to screen appropriate patients for this driver mutation with a molecular testing platform capable of capturing all ALK fusions. Here, we report a novel VKORC1L1-ALK fusion and an ALK T1151K resistance mutation detected in a lung cancer patient who had been on crizotinib for over 8 years. Alectinib induced a dramatic response in this patient demonstrating its clinical activity against T1151K. This case illustrates the importance of performing repeat biopsy to explore mechanism(s) of resistance when patients experience disease progression on an ALK inhibitor. The approach has a direct therapeutic impact particularly when an ALK resistance mutation is identified.

Rationale: This is the first multicenter randomized controlled trial to evaluate the effectiveness and safety of Zephyr Endobronchial Valve (EBV) in patients with little to no collateral ventilation out to 12 months.Objectives: To evaluate the effectiveness and safety of Zephyr EBV in heterogeneous emphysema with little to no collateral ventilation in the treated lobe.Methods: Subjects were enrolled with a 2:1 randomization (EBV/standard of care [SoC]) at 24 sites. Primary outcome at 12 months was the Delta EBV-SoC of subjects with a post-bronchodilator FEV1 improvement from baseline of greater than or equal to 15%. Secondary endpoints included absolute changes in post-bronchodilator FEV1, 6-minute-walk distance, and St. George's Respiratory Questionnaire scores.Measurements and Main Results: A total of 190 subjects (128 EBV and 62 SoC) were randomized. At 12 months, 47.7% EBV and 16.8% SoC subjects had a Delta FEV1 greater than or equal to 15% (P Conclusions: Zephyr EBV provides clinically meaningful benefits in lung function, exercise tolerance, dyspnea, and quality of life out to at least 12 months, with an acceptable safety profile in patients with little or no collateral ventilation in the target lobe.

A 32-year-old man presented with a 3-week history of productive cough and intermittent haemoptysis. 14 months prior, he underwent tricuspid valve replacement, pacemaker insertion, and coil embolisation of bilateral mycotic aneurysms due to endocarditis complicated by pulmonary and septic emboli in the setting of intravenous drug use. Chest X-ray (CXR) revealed right middle lobe (RML) consolidation with a coil extending centrally into the trachea (figure 1A). Figure 1 Chest x-ray showing (A) a migrated and uncoiled right middle lobe pulmonary pseudoaneurysm embolisation coil (red arrows). (B) Interval removal without residual coil in the airway immediately postprocedure, and (C) no further migration of remaining coils 7 weeks postprocedure. He was evaluated by interventional radiology (IR) for management of the migrated coil and referred to interventional pulmonology (IP) and thoracic surgery. Multidisciplinary consensus was to proceed with …

The sensitivity of suspicious lung nodules biopsied by currently available techniques is suboptimal. Robotic-assisted navigation bronchoscopy (RANB) is a novel method for biopsying lung nodules. Our study objective was to determine the sensitivity for malignancy and overall diagnostic accuracy for RANB when combined with cone beam CT (CBCT) for secondary confirmation.52 consecutive patients were prospectively enrolled. Demographic data, nodule characteristics, procedural information, and follow-up results were obtained.Mean patient age was 66, with the majority Caucasian (73%) females (65%) with a similar number of never (46%) and former (46%) smokers. 15 patients had a history of cancer and 3 had a prior thoracic surgery. 59 total nodules were included as 7 patients had two nodules biopsied. Mean nodule diameter was 2 cm in all dimension with the majority solid (41, 70%) and located in the upper lobes (left: 22, 37%; right: 17, 29%). Bronchus sign was absent (32, 54%) or present (27, 46%) in a similar number. All nodules were successfully reached with nine (15%) requiring minor directional changes after initial cone beam CT. A tissue diagnosis was obtained in 83% (49/59) of biopsied nodules, with malignancy (31, 65%) most common. Including all biopsy results and follow-up imaging, we obtained an 84% (31/37) procedural sensitivity for malignancy and an overall 86% (51/59) diagnostic yield.RANB with CBCT increases sensitivity for malignancy and diagnostic accuracy of lung nodule biopsies. Combining these modalities has the potential to shift the diagnostic approach to pulmonary nodules.

Case Presentation A woman in her late 40s with a history of recurrent deep vein thromboses and hypersensitivity pneumonitis (HP) presented to the ED with progressive exertional dyspnea and productive cough. She recently had started oral corticosteroids after HP was confirmed via transbronchial lung cryobiopsy from both the right upper and lower lobes, which showed poorly formed granulomas with mild interstitial and perivascular lymphocytic infiltrates. A causative antigen for her HP was never clearly identified.

Granulomatous and lymphocytic interstitial lung disease is a pulmonary complication of common variable immune deficiency with significant morbidity and increased mortality. Diagnosis has historically been obtained by surgical lung biopsy as transbronchial biopsy typically yields insufficient tissue for definitive diagnosis from a disease process with a patchy distribution. However, the potential for significant morbidity and mortality with surgical lung biopsy exists, necessitating the development of alternative diagnostic approaches. We present a case of granulomatous and lymphocytic interstitial lung disease confirmed through minimally invasive transbronchial lung cryobiopsy and discuss the role of this modality in diagnosing interstitial lung disease.

Rationale: Bronchoscopic lung volume reduction with Zephyr Valves improves lung function, exercise tolerance, and quality of life of patients with hyperinflated emphysema and little to no collateral ventilation. Objectives: Post hoc analysis of patient-reported outcomes (PROs), including multidimensional measures of dyspnea, activity, and quality of life, in the LIBERATE (Lung Function Improvement after Bronchoscopic Lung Volume Reduction with Pulmonx Endobronchial Valves used in Treatment of Emphysema) study are reported. Methods: A total of 190 patients with severe heterogeneous emphysema and little to no collateral ventilation in the target lobe were randomized 2:1 to the Zephyr Valve or standard of care. Changes in PROs at 12 months in the two groups were compared: dyspnea with the Transitional Dyspnea Index (TDI), focal score; the Chronic Obstructive Pulmonary Disease Assessment Test (CAT; breathlessness on hill/stairs); Borg; the EXAcerbations of Chronic pulmonary disease Tool–PRO, dyspnea domain; activity with the TDI, magnitude of task/effort/functional impairment, CAT (limited activities), and the St. George’s Respiratory Questionnaire (SGRQ), activity domain; and psychosocial status with the SGRQ, impacts domain, and CAT (confidence and energy). Results: At 12 months, patients using the Zephyr Valve achieved statistically significant and clinically meaningful improvements in the SGRQ; CAT; and the TDI, focal score, compared with standard of care. Improvements in the SGRQ were driven by the impacts and activity domains (P

Objectives Airway obstructions (AOs) in the central airway or lobar bronchi develop due to malignant or benign disease. Because of the morbidity and mortality associated with AO, it is important to develop additional therapeutic ablative techniques. CoreCath2.7S is a novel monopolar radiofrequency electrosurgical device approved to treat obstructions of the upper airway and tracheobronchial tree by both cutting soft tissue and providing electrosurgical hemostasis. We present a large case series describing its use. Methods Retrospective chart review was performed of all patients with AO undergoing airway recanalization with CoreCath2.7S at 2 interventional pulmonology practices from October 2017 to May 2019. Demographic information, AO etiology, location, and degree, and therapeutic modalities used were recorded. Results Fifty-three patients underwent 64 procedures for AO due to malignant (n=30, 57%) or benign (n=23, 43%) disease. AOs were treated in the trachea (n=28), mainstem bronchi (n=23), and lobar bronchi (n=17). All AO occluded the airway at least 50%. Adjunctive therapeutic modalities were commonly used (n=60, 94%), including flexible cryoprobe (n=33), balloon dilation (n=23), rigid bronchoscopy (n=19), spray cryotherapy (n=19), argon plasma coagulation (n=14), and stenting (n=5). Restoration of airway patency was achieved in all cases without any periprocedural or immediate postprocedural complications. Conclusion CoreCath2.7S was successfully used to treat patients with AO due to malignant or benign disease. Airway patency was restored with no periprocedural or immediate postprocedural complications. It should be considered as another therapeutic modality in the growing field of ablative techniques for the treatment of AO.

The use of complementary and alternative medicine (CAM) among cancer patients is widespread. Using these therapies may lead to treatment delays or confound the clinical picture when problems arise. Inquiry regarding CAM therapies used is an important part of a thorough history for any cancer patient. A 48-year-old man with a history of stage IV pancreatic adenocarcinoma was referred for a second opinion for a worsening dry cough in the setting of cavitary ground-glass opacities and non-cavitating nodules found on chest CT. Previous workup was non-diagnostic and his CT findings were atypical for pulmonary metastasis. Due to his extensive alternative therapy use, he was diagnosed with interstitial lung disease (ILD). Flexible bronchoscopy with transbronchial cryobiopsies revealed adenocarcinoma with intestinal/pancreatobiliary differentiation, consistent with metastatic pancreatic cancer. Adjacent alveolar parenchyma was without evidence of ILD. Atypical CT patterns of pulmonary metastasis should lead to an investigation regarding other possible causes.

Background: False negatives in nasopharyngeal swab testing for coronavirus disease 2019 (COVID-19) are a concern due to implications of a missed diagnosis on medical decision making and transmission risk. We aimed to characterize the presentation of patients diagnosed with COVID-19 on lower airway sampling following negative nasopharyngeal swab. Methods: We performed a retrospective observational study to identify COVID-19 patients in whom nasopharyngeal swab testing was negative. Characteristics of patients were collected including demographics, presenting symptoms, and number of false negatives prior to diagnosis. Results: We identified 8 patients in whom COVID-19 diagnosis was assisted by lower airway sampling following between 1 and 4 negative nasopharyngeal swabs. While presenting characteristics of such patients were non-specific, we identify those with negative nasopharyngeal testing on initial presentation versus later in illness, who subsequently tested positive on lower airway sampling. Conclusions: Presentations of patients with COVID-19 in whom nasopharyngeal swab is negative are non-specific. A high degree of clinical suspicion is required in approaching patients with persistent, unexplained respiratory symptoms given the high prevalence of COVID-19. It is imperative to correctly identify patients positive for COVID-19, and lower airway sampling with tracheal aspirate or bronchoalveolar lavage (BAL) may be of value in cases of high suspicion by expediting the diagnosis, though further study is required. © Journal of Public Health and Emergency. All rights reserved.

Background Sarcoidosis is a granulomatous inflammatory disease with limited blood markers to predict outcomes. The interferon-gamma (IFN-γ)-inducible chemotactic cytokines (chemokines), CXCL9 and CXCL10, are both increased in sarcoidosis patients, yet they possess important molecular differences. Our study determined if serum chemokines correlated with different aspects of disease severity. Methods We measured CXCL9 and CXCL10 serum levels at initial study visits and longitudinally in sarcoidosis subjects using ELISA. We examined these chemokines’ relationships with pulmonary and organ involvement outcomes, their gene expression, peripheral blood immune cell populations, and immunosuppression use. Results Higher CXCL10 levels negatively correlated with FVC, TLC, and DLCO at subjects’ initial visit and when measured repeatedly over two years. CXCL10 also positively correlated with longitudinal respiratory symptom severity. Additionally, for every log10(CXCL10) increase, the risk of longitudinal pulmonary function decline increased 8.8 times over the 5-year study period (95% CI 1.6–50, p = 0.014, log10(CXCL0) range 0.84–2.7). In contrast, CXCL9 levels positively correlated with systemic organ involvement at initial study visit (1.5 additional organs involved for every log10(CXCL9) increase, 95% CI 1.1–2.0, p = 0.022, log10(CXCL9) range 1.3–3.3). CXCL10, not CXCL9, positively correlated with its own blood gene expression and monocyte level. Immunosuppressive treatment was associated with lower levels of both chemokines. Conclusions In sarcoidosis subjects, serum CXCL9 levels correlated with systemic organ involvement and CXCL10 levels strongly correlated with respiratory outcomes, which may ultimately prove helpful in clinical management. These differing associations may be due to differences in cellular regulation and tissue origin.

Interventional radiology plays an integral role in the management of massive and recurrent submassive hemoptysis. Risks of bronchial artery embolization (BAE) are well described and include spinal ischemia and paralysis, most often related to nontarget embolization of the artery of Adamkiewicz or other large radiculomedullary artery supplying the anterior spinal artery. There is increasing literature regarding spinal infarction following BAE when arterial supply to the spinal cord was not evident. The existence of unrecognized patient comorbidities may further contribute to procedural risks.

Rationale: Pulmonary sarcoidosis is classically defined by T-helper (Th) cell type 1 inflammation (e.g., IFN-gamma production by CD4(+) effector T cells). Recently, IL-17A-secreting cells have been found in lung lavage, invoking Th17 immunity in sarcoidosis. Studies also identified IL-17A-secreting cells that expressed IFN-gamma, but their abundance as a percentage of total CD4(+) cells was either low or undetermined. Objectives: Based on evidence that Th17 cells can be polarized to Th17.1 cells to produce only IFN-gamma, our goal was to determine whether Th17.1 cells are a prominent source of IFN-gamma in sarcoidosis. Methods: We developed a single-cell approach to define and isolate major Th-cell subsets using combinations of chemokine receptors and fluorescence-activated cell sorting. We subsequently confirmed the accuracy of subset enrichment by measuring cytokine production. Measurements and Main Results: Discrimination between Th17 and Th17.1 cells revealed very high percentages of Th17.1 cells in lung lavage in sarcoidosis compared with controls in two separate cohorts. No differences in Th17 or Th1 lavage cells were found compared with controls. Lung lavage Th17.1-cell percentages were also higher than Th1-cell percentages, and approximately 60% of Th17.1-enriched cells produced only IFN-gamma. Conclusions: Combined use of surface markers and functional assays to study CD4(+) T cells in sarcoidosis revealed a marked expansion of Th17.1 cells that only produce IFN-gamma. These results suggest that Th17.1 cells could be misclassified as Th1 cells and may be the predominant producer of IFN-gamma in pulmonary sarcoidosis, challenging the Th1 paradigm of pathogenesis.

Objective To describe the frequency of migraine and predictors of having migraine in sarcoidosis patients. Methods The ID migraine questionnaire was administered to a well-phenotyped observational cohort of sarcoidosis patients (most of whom were seeking specialty care) and healthy controls. Predictors of migraine status were examined using univariate and multivariable logistic regression. Results Migraine was seen in 29% of 96 patients with sarcoidosis and 13% of 39 healthy controls, ( p = 0.049). Among those with sarcoidosis, in univariate regression analysis only female sex was predictive of having migraine, and in a multivariable regression female sex remained significant (OR 4.6, 95% CI 1.2–18.2). There was no association between migraine and age, depression, dyspnea, immunosuppression use, or ESR. Conclusions Migraine is a common comorbidity in sarcoidosis patients. As such, better recognition and targeted treatment of migraine has the potential to improve quality of life as part of a comprehensive care plan for sarcoidosis patients.