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We report a complication of the novel H1N1 influenza A viral infection not yet described during this 2007-2009 pandemic. Pulmonary hemorrhage is a known complication of influenza pneumonia, including well documented reports from previous pandemics. A 57-year-old African American female presented with fevers, progressive shortness of breath, and cough. After being admitted with an initial diagnosis of myocardial infarction, hemoptysis developed. Nasopharyngeal swabs rapid testing was negative for influenza A and B antigen, but a polymerase chain reaction test for influenza A type H1N1 was positive. A fiberoptic bronchoscopy for ongoing hemoptysis demonstrated diffuse erythema and bleeding, and bronchoalveolar lavage was consistent with alveolar hemorrhage. Progressive hypoxemic respiratory failure ensued, eventually leading to her demise. Our case highlights one of the more feared complications that may have been more common in prior outbreaks, such as the 1918 'Spanish Flu.' Autopsy studies from the 1918 influenza pandemic found severe tracheobronchitis (oftentimes hemorrhagic), septal edema, necrotizing bronchiolitis, alveolitis, and extensive hemorrhage, as opposed to the more benign laryngitis and tracheobronchitis that is commonplace in other influenza infections. Similar pathology appearances, including pulmonary hemorrhage, have also been described in H5N1 outbreaks in China and Thailand. It is crucial for pandemic preparedness planning that additional careful and complete autopsy study of this present pandemic influenza infection be performed and reported to answer questions regarding the natural history, pathology, and pathogenesis of this novel H1N1 influenza. [ABSTRACT FROM AUTHOR]

Esta investigación busca elaborar el primer análisis de cinco fuerzas para conocer la situación actual del mercado inmobiliario, se pretende que sirva como herramienta para tomar decisiones con relación a la inversión del sector inmobiliario y que sirva como base para futuras investigaciones científicas y para la creación de metodología de ingreso. El objetivo primordial de este análisis es identificar como se comportan las cinco fuerzas competitivas de Porter. El lugar escogido para la producción de este estudio fue el Gran Santo Domingo(Distrito Nacional y los municipios de la provincia de Santo Domingo: Santo Domingo Este, Santo Domingo Oeste, Santo Domingo Norte, Boca Chica y los Alcarrizos). Los resultados muestran que la mayor fuerza del sector es la rivalidad entre competidores existentes, esto se debe a la presencia de grandes empresas y a la gran cantidad de empresas en el mercado, eso en primer lugar, en segundo lugar esta el aspecto relativo al poder de los compradores: la fuerza de estos radica en la facilidad de cambios y la similitud de los productos ofertados, en tercer lugar tenemos el poder de los proveedores seguido de la amenaza de nuevos entrantes y con menor influencia en el sector y la amenaza de productos sustitutos. Para el estudio también se analizo la llamada sexta fuerza que son los productores complementarios, en este caso, la banca y el gobierno.

Background: Endobronchial ultrasound-guided transbronchial aspiration (EBUS-TBNA) has become the standard for initial lung cancer diagnosis and staging. Previous guidelines have generally focused on the "when" and "how" of EBUS-TBNA; however, little guidance is available on handling and processing specimens during and after acquisition to help optimize both diagnostic yield and tissue integrity for ancillary studies. This document examines the available literature on EBUS-TBNA specimen processing and handling., Study Design and Methods: Rigorous methodology was applied to provide a trustworthy evidence-based guideline and expert panel report. Panelists developed key clinical questions utilizing the Population, Intervention, Comparator, and Outcome (PICO) format, addressing specific topics in EBUS-TBNA specimen processing. MEDLINE (via PubMed) and the Cochrane Library were systematically searched to identify relevant literature, supplemented by manual searches. References were screened for inclusion with document evaluation tools to assess the quality of included studies, extract meaningful data, and grade the level of evidence to support each recommendation or suggestion., Results: Our systematic review and critical analysis of the literature of the 9 PICO questions related to handling and processing EBUS-TBNA specimens resulted in 9 evidence-based statements., Interpretation: Evidence of the handling and processing of EBUS-TBNA specimens varies in strength but is satisfactory in some areas to guide clinicians in certain aspects of specimen handling. Additional research in many aspects of specimen handling and processing is needed to help improve our knowledge base., Competing Interests: Financial/Nonfinancial Disclosures Panelists’ conflicts of interest are detailed in e-Appendix 2., (Copyright © 2024 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Pleural effusions in post-operative thoracic surgery patients are common. Effusions can result in prolonged hospitalizations or readmissions, with prior studies suggesting mixed effects of pleural drainage on hypoxia. We aimed to define the impact of pleural drainage on pulse oximetry (SpO2) in post-thoracic surgery patients., Methods: A retrospective study of post-operative thoracic surgery patients undergoing pleural drainage was performed. SpO2 and supplemental oxygen (FiO2) values were recorded at pre- and post-procedure. The primary outcome was difference in pre-procedural and post-procedural SpO2., Results: We identified 95 patients with a mean age of 65 (SD - 13.8) years undergoing 122 pleural drainage procedures. Mean drainage volume was 619 (SD-423) mL and the majority of procedures (88.5 %) included a drainage of <1000 mL. SpO2 was associated with an increase from 94.0 % (SD-2.6) to 97.3 % (SD-2.0) at 24-h (p < 0.0001). FiO2 was associated with a decrease from 0.31 (SD-0.15) to 0.29 (SD-0.12) at 24-h (p = 0.0081). SpO2/FiO2 was associated with an increase from 344.5 (SD-99.0) to 371.9 (SD-94.7) at 24-h post-procedure (p < 0.0001)., Conclusions: Pleural drainage within post-operative thoracic surgery patients offers statistically significant improvements in oxygen saturation by peripheral pulse oximetry and oxygen supplementation; however the clinical significance of these changes remains unclear. Pleural drainage itself may be requested for numerous reasons, including diagnostic (fevers, leukocytosis, etc.) or therapeutic (worsening dyspnea) evaluation. However, pleural drainage may offer minimal clinical impact on pulse oximetry in post-operative thoracic surgery patients., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Management of complicated pleural infections (CPIs) had historically been surgical; however, following the publication of the second multicenter intrapleural sepsis trial (MIST-2), combination tissue plasminogen (tPA) and dornase (DNase) offers a less invasive and effective treatment. Our aim was to assess the quality of life (QOL) and functional ability of patients' recovery from a CPI managed with either intrapleural fibrinolytic therapy (IPFT) or surgery., Methods: We identified 565 patients managed for a CPI between January 1, 2013 and March 31, 2018. There were 460 patients eligible for contact, attempted through 2 phone calls and one mailer. Two questionnaires were administered: the Short Form 36-Item Health Survey (SF-36) and a functional ability questionnaire., Results: Contact was made in 35% (159/460) of patients, and 57% (90/159) completed the survey. Patients had lower QOL scores compared to average US citizens; those managed with surgery had higher scores in physical functioning (surgery: 80, IPFT: 70, P=0.040) but lower pain scores (surgery: 58, IPFT: 68, P=0.045). Of 52 patients who returned to work, 48% (25) reported an impact on their work effectiveness during recovery, similarly between management strategies (IPFT: 50%, 13/26 vs. surgery: 46%, 12/26; P=0.781)., Conclusion: Patients with a CPI had a lower QOL compared with average US citizens. Surgically managed patients reported improved physical functioning but worse pain compared with patients managed with IPFT. Patients returned to work within 4 weeks of discharge, and nearly half reported their ability to work effectively was impacted by their recovery. With further research into recovery timelines, patients may be appropriately counselled for expectations., Competing Interests: Disclosure: There is no conflict of interest or other disclosures., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Advanced diagnostic bronchoscopy targeting the lung periphery has developed at an accelerated pace over the last two decades, whereas evidence to support introduction of innovative technologies has been variable and deficient. A major gap relates to variable reporting of diagnostic yield, in addition to limited comparative studies. Objectives: To develop a research framework to standardize the evaluation of advanced diagnostic bronchoscopy techniques for peripheral lung lesions. Specifically, we aimed for consensus on a robust definition of diagnostic yield, and we propose potential study designs at various stages of technology development. Methods: Panel members were selected for their diverse expertise. Workgroup meetings were conducted in virtual or hybrid format. The cochairs subsequently developed summary statements, with voting proceeding according to a modified Delphi process. The statement was cosponsored by the American Thoracic Society and the American College of Chest Physicians. Results: Consensus was reached on 15 statements on the definition of diagnostic outcomes and study designs. A strict definition of diagnostic yield should be used, and studies should be reported according to the STARD (Standards for Reporting Diagnostic Accuracy Studies) guidelines. Clinical or radiographic follow-up may be incorporated into the reference standard definition but should not be used to calculate diagnostic yield from the procedural encounter. Methodologically robust comparative studies, with incorporation of patient-reported outcomes, are needed to adequately assess and validate minimally invasive diagnostic technologies targeting the lung periphery. Conclusions: This American Thoracic Society/American College of Chest Physicians statement aims to provide a research framework that allows greater standardization of device validation efforts through clearly defined diagnostic outcomes and robust study designs. High-quality studies, both industry and publicly funded, can support subsequent health economic analyses and guide implementation decisions in various healthcare settings.

Background: Lung cancer is the leading cause of cancer mortality among American Indian and Alaska Native populations. American Indian and Alaska Native people use commercial tobacco products at higher rates compared with all other races and ethnicities. Moreover, they show lower adherence to cancer screening guidelines., Research Question: How do American Indian and Alaska Native adults perceive and use lung cancer screening?, Study Design and Methods: We conducted a study in which we recorded and transcribed data from three focus groups consisting of American Indian and Alaska Native adults. Participants were recruited through convenience sampling at a national health conference. Transcripts were analyzed by inductive coding., Results: Participants (n = 58) of 28 tribes included tribal Elders, tribal leaders, and non-Native volunteers who worked with tribal communities. Limited community awareness of lung cancer screening, barriers to lung cancer screening at health care facilities, and health information-seeking behaviors emerged as key themes in discussions. Screening knowledge was limited except among people with direct experiences of lung cancer. Cancer risk factors such as multigenerational smoking were considered important priorities to address in communities. Limited educational and diagnostic resources are significant barriers to lung cancer screening uptake in addition to limited discussions with health care providers about cancer risk., Interpretation: Limited access to and awareness of lung cancer screening must be addressed. American Indian and Alaska Native adults use several health information sources unique to tribal communities, and these should be leveraged in designing screening programs. Equitable partnerships between clinicians and tribes are essential in improving knowledge and use of lung cancer screening., Competing Interests: Financial/Nonfinancial Disclosures None declared., (Copyright © 2023 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Symptomatic pleural effusions and anticoagulant/antiplatelet medication use in postoperative cardiac surgery are common. Guidelines and recommendations are currently mixed regarding medication management related to invasive procedure performance. We aimed to describe the outcomes of postoperative cardiac surgery patients referred for outpatient, symptomatic pleural effusion management., Methods: A retrospective study of post-cardiac surgery patients undergoing outpatient thoracentesis from 2016 to 2021 was performed. Demographics, operative details, pleural disease characteristics, outcomes, and complications were collected. Odds ratios with confidence intervals were estimated and adjusted by multivariate logistic regression to investigate the association with multiple thoracenteses., Results: A total of 110 patients underwent 332 thoracenteses. The median age was 68 years and most common operation was coronary artery bypass. Anticoagulation or antiplatelet use was identified in 97%. Thirteen complications were identified, with all major complications (n=3) related to bleeding. The amount of fluid present at the time of initial thoracentesis (>1500 milliliters) was associated with increased odds ratio of subsequent multiple thoracentesis (Unadjusted odds ratio, 6.75 (CI - 1.43 to 31.9). No other variables had a significant association with the need for multiple procedures., Conclusion: Within a postoperative cardiac surgery population presenting with symptomatic pleural disease, we observed that thoracentesis performed on antiplatelet and/or anticoagulant medication is relatively safe. We also identified that many patients can be managed as outpatients and that most pleural effusions remain self-limited. The presence of larger amounts of pleural fluid at initial thoracentesis may be associated with increased odds for additional drainage., Competing Interests: Disclosure: There is no conflict of interest or other disclosures., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Rationale: Strict adherence to procedural protocols and diagnostic definitions is critical to understand the efficacy of new technologies. Electromagnetic navigational bronchoscopy (ENB) for lung nodule biopsy has been used for decades without a solid understanding of its efficacy, but offers the opportunity for simultaneous tissue acquisition via electromagnetic navigational transthoracic biopsy (EMN-TTNA) and staging via endobronchial ultrasound (EBUS). Objective: To evaluate the diagnostic yield of EBUS, ENB, and EMN-TTNA during a single procedure using a strict a priori definition of diagnostic yield with central pathology adjudication. Methods: A prospective, single-arm trial was conducted at eight centers enrolling participants with pulmonary nodules (<3 cm; without computed tomography [CT]- and/or positron emission tomography-positive mediastinal lymph nodes) who underwent a staged procedure with same-day CT, EBUS, ENB, and EMN-TTNA. The procedure was staged such that, when a diagnosis had been achieved via rapid on-site pathologic evaluation, the procedure was ended and subsequent biopsy modalities were not attempted. A study finding was diagnostic if an independent pathology core laboratory confirmed malignancy or a definitive benign finding. The primary endpoint was the diagnostic yield of the combination of CT, EBUS, ENB, and EMN-TTNA. Measurements and Main Results: A total of 160 participants at 8 centers with a mean nodule size of 18 ± 6 mm were enrolled. The diagnostic yield of the combined procedure was 59% (94 of 160; 95% confidence interval [CI], 51-66%). Nodule regression was found on same-day CT in 2.5% of cases (4 of 160; 95% CI, 0.69-6.3%), and EBUS confirmed malignancy in 7.1% of cases (11 of 156; 95% CI, 3.6-12%). The yield of ENB alone was 49% (74 of 150; 95% CI, 41-58%), that of EMN-TTNA alone was 27% (8 of 30; 95% CI, 12-46%), and that of ENB plus EMN-TTNA was 53% (79 of 150; 95% CI, 44-61%). Complications included a pneumothorax rate of 10% and a 2% bleeding rate. When EMN-TTNA was performed, the pneumothorax rate was 30%. Conclusions: The diagnostic yield for ENB is 49%, which increases to 59% with the addition of same-day CT, EBUS, and EMN-TTNA, lower than in prior reports in the literature. The high complication rate and low diagnostic yield of EMN-TTNA does not support its routine use. Clinical trial registered with www.clinicaltrials.gov (NCT03338049).

Introduction: Malignant pleural effusions are common in advanced malignancy and associated with overall poor survival. The presence of sarcopenia (decreased muscle mass) is associated with poor outcomes in numerous disease states, however, its relationship to malignant pleural disease has not been defined. We sought to understand if there was an association between decreased survival and decreased muscle mass in patients with malignant pleural effusion., Methods: Patients with malignant pleural disease undergoing indwelling tunneled pleural catheter placement were retrospectively reviewed. Computed tomography was reviewed and cross-sectional area of pectoralis and paraspinous muscle areas were calculated. Overall survival and associations with muscle mass were calculated., Results: A total of 309 patients were available for analysis, with a median age of 67 years and the majority female (58%). The median survival was 129 days from initial pleural drainage to death. Regression analysis and Kaplan-Meier survival analysis did not reveal an association with survival and muscle mass for the entire population. However, Kaplan-Meier survival analysis of the lung cancer subgroup revealed the presence of decreased muscle mass and decreased survival time., Conclusion: The presence of decreased muscle mass within a lung cancer population that has malignant pleural effusions are associated with decreased survival. However, the presence of decreased muscle mass within a heterogenous population of malignant pleural disease was not associated with decreased overall survival time. Further study of the role that sarcopenia may play in malignant pleural disease is warranted., Competing Interests: Declaration of competing interest No conflict of interest., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Importance: There is a paucity of high-quality prospective randomized clinical trials comparing intrapleural fibrinolytic therapy (IPFT) with surgical decortication in patients with complicated pleural infections., Objective: To assess the feasibility, safety, and efficacy of an algorithm comparing tissue plasminogen activator plus deoxyribonuclease therapy with surgical decortication in patients with complicated pleural infections., Design, Setting, and Participants: This parallel pilot randomized clinical trial was performed at a single urban community-based center from March 1, 2019, to December 31, 2021, with follow-up for 90 days. Seventy-four individuals were screened and 48 were excluded. Twenty-six patients 18 years or older with clinical pleural infection and positive findings of pleural fluid analysis were included. Of these, 20 patients underwent randomized selection (10 in each group), and 6 were observed., Interventions: Intrapleural tissue plasminogen activator plus deoxyribonuclease therapy vs surgical decortication., Main Outcomes and Measures: Primary outcomes were the percentage of patients enrolled to study completion and multidisciplinary adherence. Secondary outcomes included the number of patients with and the reason for inadequate screening, screening to enrollment failures, time to accrual of 20 patients or the number accrued at 1 year, and clinical data., Results: Twenty-six patients were enrolled, 10 were randomized to each group, and 6 were observed. There was 100% enrollment to study completion in each treatment group, no protocol deviations, 2 minor protocol amendments, and no screening to enrollment failures. It took 32 months to enroll 26 patients. The 20 randomized patients had a median age of 57 (IQR, 46-65) years, were predominantly men (15 [75%]), and had a median RAPID (Renal, Age, Purulence, Infection Source, and Dietary Factors) score of 2 (IQR, 1-3). Treatment failure occurred in 1 patient and 2 crossover treatments occurred, all of which were in the IPFT group. Intraprocedure and postprocedure complications were similar between the groups. There were no reoperations or in-hospital deaths. Median duration of chest tube use was comparable in the IPFT (5 [IQR, 4-8] days) and surgery (4 [IQR, 3-5] days) groups (P = .21). Median hospital stay tended to be longer in the IPFT (11 [IQR, 4-18] days) vs surgery (5 [IQR, 4-6] days) groups, although the difference as not significantly different (P = .08). There were no 30-day readmissions or 30- or 90-day deaths., Conclusions and Relevance: In this pilot randomized clinical trial, the study algorithm was feasible, safe, and efficacious. This provides evidence to move forward with a multicenter randomized clinical trial., Trial Registration: ClinicalTrials.gov Identifier: NCT03873766.

Purpose: Early referral of patients with stage IV non-small cell lung cancer (NSCLC) to outpatient palliative care has been shown to increase survival and reduce unnecessary healthcare resource utilization. We aimed to determine outpatient palliative care referral rate and subsequent resource utilization in patients with stage IV NSCLC in a multistate, community-based hospital network and identify rates and reasons for admissions within a local healthcare system of Washington State., Methods: A retrospective chart review of a multistate hospital network and a local healthcare system. Patients were identified using ICD billing codes. In the multistate network, 2844 patients diagnosed with stage IV NSCLC between January 1, 2013, and March 1, 2018, were reviewed. In the state healthcare system, 283 patients between August 2014 and June 2017 were reviewed., Results: Referral for outpatient palliative care was low: 8% (217/2844) in the multistate network and 11% (32/283) in the local healthcare system. Early outpatient palliative care (6%, 10/156) was associated with a lower proportion of patients admitted into the intensive care unit in the last 30 days of life compared to no outpatient palliative care (15%, 399/2627; p = 0.003). Outpatient palliative care referral was associated with improved overall survival in Kaplan Meier survival analysis. Within the local system, 51% (104/204) of admissions could have been managed in outpatient setting, and of the patients admitted in the last 30 days of life, 59% (87/147) experienced in-hospital deaths., Conclusion: We identified underutilization of outpatient palliative care services within stage IV NSCLC patients. Many patients with NSCLC experience hospitalization the last month of life and in-hospital death., (© 2022. The Author(s).)

Background: Combination intrapleural fibrinolytic and enzyme therapy (IET) has been established as a therapeutic option in pleural infection. Despite demonstrated efficacy, studies specifically designed and adequately powered to address complications are sparse. The safety profile, the effects of concurrent therapeutic anticoagulation, and the nature and extent of nonbleeding complications remain poorly defined., Research Question: What is the bleeding complication risk associated with IET use in pleural infection?, Study Design and Methods: This was a multicenter, retrospective observational study conducted in 24 centers across the United States and the United Kingdom. Protocolized data collection for 1,851 patients treated with at least one dose of combination IET for pleural infection between January 2012 and May 2019 was undertaken. The primary outcome was the overall incidence of pleural bleeding defined using pre hoc criteria., Results: Overall, pleural bleeding occurred in 76 of 1,833 patients (4.1%; 95% CI, 3.0%-5.0%). Using a half-dose regimen (tissue plasminogen activator, 5 mg) did not change this risk significantly (6/172 [3.5%]; P = .68). Therapeutic anticoagulation alongside IET was associated with increased bleeding rates (19/197 [9.6%]) compared with temporarily withholding anticoagulation before administration of IET (3/118 [2.6%]; P = .017). As well as systemic anticoagulation, increasing RAPID score, elevated serum urea, and platelets of < 100 × 10 9 /L were associated with a significant increase in bleeding risk. However, only RAPID score and use of systemic anticoagulation were independently predictive. Apart from pain, non-bleeding complications were rare., Interpretation: IET use in pleural infection confers a low overall bleeding risk. Increased rates of pleural bleeding are associated with concurrent use of anticoagulation but can be mitigated by withholding anticoagulation before IET. Concomitant administration of IET and therapeutic anticoagulation should be avoided. Parameters related to higher IET-related bleeding have been identified that may lead to altered risk thresholds for treatment., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Rationale: When drainage of complicated pleural space infections alone fails, there exists two strategies in surgery and dual agent-intrapleural fibrinolytic therapy; however, studies comparing these two management strategies are limited. Objectives: To determine the outcomes of surgery versus fibrinolytic therapy as the primary management for complicated pleural space infections (CPSI). Methods: A retrospective review of adults with a CPSI managed with surgery or fibrinolytics between 1/2015 and 3/2018 within a multicenter, multistate hospital system was performed. Fibrinolytics was defined as any dose of dual-agent fibrinolytic therapy and standard fibrinolytics as 5-6 doses twice daily. Treatment failure was defined as persistent infection with a pleural collection requiring intervention. Crossover was defined by any fibrinolytics after surgery or surgery after fibrinolytics. Logistic regression with inverse probability of treatment weighting (IPTW) were employed to account for selection bias effect of management strategies in treatment failure and crossover. Results: We identified 566 patients. Surgery was the initial strategy in 55% (311/566). The surgery group had less additional treatments (surgery: 10% [32/311] versus fibrinolytics: 39% [100/255], P   <  0.001), treatment failures (surgery: 7% [22/311] versus fibrinolytics: 29% [74/255], P   <  0.001), and crossovers (surgery: 6% [20/311] versus fibrinolytics: 19% [49/255], P   <  0.001). Logistic regression analysis with IPTW demonstrated a lower odds of treatment failure with surgery compared with any fibrinolytics (odds ratio [OR], 0.20; 95% confidence interval [CI], 0.10-0.30; P  < 0.001); and compared with standard fibrinolytics (OR, 0.20; 95% CI, 0.11-0.35; P  < 0.001). Conclusions: Although there is a lack of consensus as to the optimal management strategy for patients with a CPSI, in surgical candidates, operative management may offer more benefits and could be considered early in the management course. However, our study is retrospective and nonrandomized; thus, prospective trials are needed to explore this further.

Hepatic hydrothorax can be present in 5% to 15% of patients with underlying cirrhosis and portal hypertension, often reflecting advanced liver disease. Its impact can be variable, because patients may have small pleural effusions and minimal pulmonary symptoms or massive pleural effusions and respiratory failure. Management of hepatic hydrothorax can be difficult because these patients often have a number of comorbidities and potential for complications. Minimal high-quality data are available for guidance specifically related to hepatic hydrothorax, potentially resulting in pulmonary or critical care physician struggling for best management options. We therefore provide a Case-based presentation with management options based on currently available data and opinion. We discuss the role of pleural interventions, including thoracentesis, tube thoracostomy, indwelling tunneled pleural catheter, pleurodesis, and surgical interventions. In general, we recommend that management be conducted within a multidisciplinary team including pulmonology, hepatology, and transplant surgery. Patients with refractory hepatic hydrothorax that are not transplant candidates should be managed with palliative intent; we suggest indwelling tunneled pleural catheter placement unless otherwise contraindicated. For patients with unclear or incomplete hepatology treatment plans or those unable to undergo more definitive procedures, we recommend serial thoracentesis. In patients who are transplant candidates, we often consider serial thoracentesis as a standard treatment, while also evaluating the role indwelling tunneled pleural catheter placement may play within the course of disease and transplant evaluation., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Disclosure: There is no conflict of interest or other disclosures.

Background: Indwelling tunneled pleural catheters (IPCs) are used regularly for recurrent pleural effusion management. Catheter obstruction is not uncommon, often requiring intrapleural medications instillation (ie, alteplase) to restore flow. The safety profile of intrapleural medications has been reported previously; however, most studies exclude anticoagulated patients., Research Question: What is the safety profile of intrapleural alteplase, dornase alfa, or both when used in patients with IPCs, including in those who may be undergoing active anticoagulation?, Study Design and Methods: Retrospective review of patients with previously placed IPCs from January 2009 through February 2020 undergoing intrapleural alteplase therapy. Basic demographics, laboratory studies, anticoagulation medication use, and complications were collected. Descriptive statistics were used to report demographics and outcomes. Univariate Firth's logistic regression analyses were used to identify factors associated with complications, followed by multivariate regression analyses., Results: A total of 94 patients underwent IPC placement and intrapleural instillation. The median age of patients was 66.1 years (interquartile range, 57.6-74.9 years). Intrapleural medications were administered 71 times in 30 anticoagulated patients and 172 times in 64 patients who were not anticoagulated. A total of 20 complications were identified in 18 patients, with one patient experiencing more than one complication. Five bleeding complications occurred with no significant increased risk with anticoagulation use (in 2 anticoagulated patients and 3 patients who were not anticoagulated; P = .092). Multivariate Firth's logistic regression demonstrated that alteplase dose (P = .04) and anticoagulation use (P = .05) were associated with any complication, but were not associated with bleeding complications., Interpretation: We report a relatively low incidence of complications and, in particular, bleeding complications in patients receiving intrapleural alteplase for nondraining IPCs. Bleeding episodes occurred in five of 94 patients (5.3%) with no apparent increased risk of bleeding complication, regardless of whether receiving anticoagulation. Additional study is warranted to identify risk factors for complications, in particular bleeding complications, in this patient population., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Complex pleural space infections are commonly managed with antibiotics, pleural drainage, intrapleural fibrinolytic therapy, and surgery. These strategies often utilize radiographic imaging during management, however little data is available on cumulative radiation exposure received during inpatient management. We aimed to identify the type and quantity of radiographic studies along with the resultant radiation exposure during the management of complex pleural space infections., Methods: Retrospective review of community network healthcare system from January 2015 to July 2018. Patients were identified through billing databases as receiving intrapleural fibrinolytic therapy and/or surgical intervention. Patient demographics, clinical outcomes, and inpatient radiographic imaging was collected to calculate cumulative effective dose., Results: A total of 566 patients were identified with 7275 total radiographic studies performed and a median cumulative effective dose of 16.9 (IQR 9.9-26.3) mSv. Multivariable linear regression analysis revealed computed tomography use was associated with increased cumulative dose, whereas increased age was associated with lower cumulative dose. Over 74% of patients received more than 10 mSv, with 7.4% receiving more than 40 mSv., Conclusions: The number of radiographic studies and overall cumulative effective dose in patients hospitalized for complex pleural space infection was high with the median cumulative effective dose > 5 times normal yearly exposure. Ionizing radiation and modern radiology techniques have revolutionized medical care, but are likely not without risk. Additional study is warranted to identify the frequency and imaging type needed during complex pleural space infection management, attempting to keep ionizing radiation exposure as low as reasonably possible.

Recurrent pleural effusions can be managed with indwelling tunneled pleural catheters (IPC), with some patients undergoing IPC removal after appropriate palliation has occurred. Little data exists regarding complications related to IPC removal. We report on retained granulation cuffs after successful IPC removal. We identified 122 IPC removals of which 6 (4.9%) were complicated by retained granulation cuff. No additional procedures or need for retrieval were identified over a median follow-up time of 423.5 (IQR-204-1489) days. Clinicians should be aware of this potential complication, but that retained granulation cuffs appear to offer no sequelae and aggressive interventions for retrieval/removal are likely not warranted., Competing Interests: Disclosure: There is no conflict of interest or other disclosures., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

The first indwelling pleural catheter (IPC) received Federal Drug Administration approval in 1997, nearly 40 years after John Chambers first described instillation of talc into the pleural space for palliation of malignant pleural effusions. Since then IPCs have revolutionized the management of malignant pleural effusions, providing an effective means of controlling dyspnea in the end stages of life without the pain and prolonged hospital stays long associated with chemical sclerosing agents. While palliation of symptoms is the primary purpose of IPCs, development of pleurodesis in the outpatient setting is often an important secondary goal. Historically, decisions regarding IPC drainage frequency have been largely arbitrary and only recently has the evidence started to emerge regarding the effects of specific drainage strategies on both symptom control and pleurodesis development. This focused clinical review explores the current literature regarding IPC drainage strategies as well as novel methods designed to improve the efficacy of IPCs in a thorough and systematic manner. In addition, this review provides an in-depth analysis and synthesis of the data focusing on key considerations needed to develop patient-centered and cost-effective strategies for the use of IPCs in malignancy., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Rationale: Patients with malignant or paramalignant pleural effusions (MPEs or PMPEs) may have tunneled pleural catheter (TPC) management withheld because of infection concerns from immunosuppression associated with antineoplastic therapy. Objectives: To determine the rate of infections related to TPC use and to determine the relationship to antineoplastic therapy, immune system competency, and overall survival (OS). Methods: We performed an international, multiinstitutional study of patients with MPEs or PMPEs undergoing TPC management from 2008 to 2016. Patients were stratified by whether or not they underwent antineoplastic therapy and/or whether or not they were immunocompromised. Cumulative incidence functions and multivariable competing risk regression analyses were performed to identify independent predictors of TPC-related infection. Kaplan-Meier method and multivariable Cox proportional hazards modeling were performed to examine for independent effects on OS. Results: A total of 1,408 TPCs were placed in 1,318 patients. Patients had a high frequency of overlap between antineoplastic therapy and an immunocompromised state (75-83%). No difference in the overall (6-7%), deep pleural (3-5%), or superficial (3-4%) TPC-related infection rates between subsets of patients stratified by antineoplastic therapy or immune status was observed. The median time to infection was 41 (interquartile range, 19-87) days after TPC insertion. Multivariable competing risk analyses demonstrated that longer TPC duration was associated with a higher risk of TPC-related infection (subdistribution hazard ratio, 1.03; 95% confidence interval [CI], 1.00-1.06; P  = 0.028). Cox proportional hazards analysis showed antineoplastic therapy was associated with better OS (hazard ratio, 0.84; 95% CI, 0.73-0.97; P  = 0.015). Conclusions: The risk of TPC-related infection does not appear to be increased by antineoplastic therapy use or an immunocompromised state. The overall rates of infection are low and comparable with those of immunocompetent patients with no relevant antineoplastic therapy. These results support TPC palliation for MPE or PMPEs regardless of plans for antineoplastic therapy.

Background: Recent studies have identified poor adherence to recommended guidelines in diagnosing and staging patients with non-small cell lung cancer (NSCLC), and this practice has been associated with numerous negative downstream effects. However, these reports consist predominantly of large administrative databases with inherent limitations. We aimed to describe guideline-inconsistent care and identify any associated factors within the Swedish Cancer Institute health care system., Methods: A review of patients with a diagnosis of primary NSCLC between January 1, 2014 and December 31, 2014 within our community hospital network was performed. Univariate and multivariable logistic regression analyses were performed to identify factors associated with guideline-inconsistent care., Results: Guideline-inconsistent care was identified in 24% (98 of 406) of patients: 58% (46 of 81) in clinical stage III and 29% (52 of 179) in stage IV. Of the 46 clinical stage III patients with guideline-inconsistent care, 43% (20) had no invasive mediastinal lymph node sampling before treatment initiation. Patients with guideline-inconsistent care more frequently underwent additional invasive procedures and had a delay in management. Regression analyses identified clinical stage III disease, stage IV with distant metastases, and specialty ordering the diagnostic test to be associated with guideline-inconsistent care., Conclusions: Guideline-inconsistent diagnosis and staging of patients with NSCLC, particularly patients with stage III disease, are highly prevalent. This finding is associated with incomplete staging, a higher number of additional procedures, and a delay in management. The identification of this vulnerable population may serve as a target for quality improvement interventions aimed to increase adherence to guidelines while decreasing unnecessary procedures and time to treatment., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The management of recurrent pleural effusions remains a challenging issue for clinicians. Advances in management have led to increased use of indwelling tunneled pleural catheters (IPC) because of their effectiveness and ease of outpatient placement. However, with the increase in IPC placement there have also been increasing reports of complications, including infections. Currently there is minimal guidance in IPC-related management issues after placement., Research Question: Our objective was to formulate clinical consensus statements related to perioperative and long-term IPC catheter management based on a modified Delphi process from experts in pleural disease management., Study Design and Methods: Expert panel members used a modified Delphi process to reach consensus on common perioperative and long-term management options related to IPC use. Members were identified from multiple countries, specialties, and practice settings. A series of meetings and anonymous online surveys were completed. Responses were used to formulate consensus statements among panel experts, using a modified Delphi process. Consensus was defined a priori as greater than 80% agreement among panel constituents., Results: A total of 25 physicians participated in this project. The following topics were addressed during the process: definition of an IPC infection, management of IPC-related infectious complications, interventions to prevent IPC infections, IPC-related obstruction/malfunction management, assessment of IPC removal, and instructions regarding IPC management by patients and caregivers. Strong consensus was obtained on 36 statements. No consensus was obtained on 29 statements., Interpretation: The management of recurrent pleural disease with IPC remains complex and challenging. This statement offers statements for care in numerous areas related to IPC management based on expert consensus and identifies areas that lack consensus. Further studies related to long-term management of IPC are warranted., (Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Patients with locally advanced, non-small cell lung cancer treated with definitive chemoradiotherapy alone often demonstrate persistent or recurrent disease. In the absence of systemic progression, salvage lung resection after definitive chemoradiotherapy has been used as a treatment option. Given the paucity of data, we sought to evaluate the safety and efficacy of salvage pulmonary resections occurring greater than 90 days after definitive chemoradiotherapy., Methods: Retrospective institutional database review identified patients undergoing salvage lung resection at least 90 days after the completion of definitive chemoradiotherapy. Primary outcomes evaluated were overall survival and recurrence-free survival., Results: Thirty patients met inclusion criteria between January 1, 2004 and December 31, 2015. Median time to surgery after definitive radiotherapy was 279 days (interquartile range, 168-474 days). Extended resections were performed in 11 patients (37%). Ottawa Thoracic Morbidity and Mortality Classification System grade IIIA or greater complications occurred in 12 patients (40%). Thirty-day mortality was 6.7% (2 patients). Median overall survival after salvage resection was 24 months. Median overall survival for an R1 resection was 5.3 months vs 108 months for an R0 resection (P = .001). Persistent pN1-positive salvage resections also did less well compared with pN0 (8.9 vs 28.2 months; P = .06). For patients who underwent nonextended salvage resection (simple lobectomy or simple pneumonectomy), median overall survival was 108.4 months, vs 8.9 months for extended salvage resections (P = .02)., Conclusions: With proper patient selection, salvage lung resections can be performed with acceptable morbidity, mortality, and oncologic outcomes, particularly when a ypN0R0 resection can be achieved by nonextended surgical means., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Context.—: The need for appropriate specimen use for ancillary testing has become more commonplace in the practice of pathology. This, coupled with improvements in technology, often provides less invasive methods of testing, but presents new challenges to appropriate specimen collection and handling of these small specimens, including thoracic small biopsy and cytology samples., Objective.—: To develop a clinical practice guideline including recommendations on how to obtain, handle, and process thoracic small biopsy and cytology tissue specimens for diagnostic testing and ancillary studies., Methods.—: The College of American Pathologists convened an expert panel to perform a systematic review of the literature and develop recommendations. Core needle biopsy, touch preparation, fine-needle aspiration, and effusion specimens with thoracic diseases including malignancy, granulomatous process/sarcoidosis, and infection (eg, tuberculosis) were deemed within scope. Ancillary studies included immunohistochemistry and immunocytochemistry, fluorescence in situ hybridization, mutational analysis, flow cytometry, cytogenetics, and microbiologic studies routinely performed in the clinical pathology laboratory. The use of rapid on-site evaluation was also covered., Results.—: Sixteen guideline statements were developed to assist clinicians and pathologists in collecting and processing thoracic small biopsy and cytology tissue samples., Conclusions.—: Based on the systematic review and expert panel consensus, thoracic small specimens can be handled and processed to perform downstream testing (eg, molecular markers, immunohistochemical biomarkers), core needle and fine-needle techniques can provide appropriate cytologic and histologic specimens for ancillary studies, and rapid on-site cytologic evaluation remains helpful in appropriate triage, handling, and processing of specimens.

The National Comprehensive Cancer Network expanded their lung cancer screening (LCS) criteria to comprise one additional clinical risk factor, including chronic obstructive pulmonary disease (COPD). The electronic medical record (EMR) is a source of clinical information that could identify high-risk populations for LCS, including a diagnosis of COPD; however, an unsubstantiated COPD diagnosis in the EMR may lead to inappropriate LCS referrals. We aimed to detect the prevalence of unsubstantiated COPD diagnosis in the EMR for LCS referrals, to determine the efficacy of utilizing the EMR as an accurate population-based eligibility screening "trigger" using modified clinical criteria. We performed a multicenter review of all individuals referred to three LCS programs from 2012 to 2015. Each individual's EMR was searched for COPD diagnostic terms and the presence of a diagnostic pulmonary functionality test (PFT). An unsubstantiated COPD diagnosis was defined by an individual's EMR containing a COPD term with no PFTs present, or the presence of PFTs without evidence of obstruction. A total of 2834 referred individuals were identified, of which 30% (840/2834) had a COPD term present in their EMR. Of these, 68% (571/840) were considered unsubstantiated diagnoses: 86% (489/571) due to absent PFTs and 14% (82/571) due to PFTs demonstrating no evidence of postbronchodilation obstruction. A large proportion of individuals referred for LCS may have an unsubstantiated COPD diagnosis within their EMR. Thus, utilizing the EMR as a population-based eligibility screening tool, employing expanded criteria, may lead to individuals being referred, potentially, inappropriately for LCS., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Candice L. Wilshire et al.)

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.

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 < .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 < .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 < .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.

Purpose of Review: Talc remains a common sclerosant utilized for pleurodesis. However, the use of talc has documented complications and debate has persisted regarding the safety of talc as well as the differences in talc preparations available throughout the world. We sought to describe an up-to-date review of talc preparations available and the impact these preparations may have on the safety profile of talc., Recent Findings: Within laboratory-based examinations, talc particle size available within the United States appears to be more consistent with prior reported 'safe' particle sizes. The presence of talc within protein-based solutions appears to modify the overall milieu of the solution and likely results in particle aggregation., Summary: The use of talc remains well accepted for pleurodesis as evidenced by inclusion by multiple guidelines. The medical fields' current understanding of talc and its basic interactions within the pleural space remain limited. Multiple questions related to the pleural space and pleurodesis remain unanswered.

Objective: The National Lung Screening Trial demonstrated the benefits of lung cancer screening, but the potential high incidence of unnecessary invasive testing for ultimately benign radiologic findings causes concern. We aimed to review current biopsy patterns and outcomes in our community-based program, and retrospectively apply malignancy prediction models in a lung cancer screening population, to identify the potential impact these calculators could have on biopsy decisions., Methods: Retrospective review of lung cancer-screening program participants from 2013 to 2016. Demographic, biopsy, and outcome data were collected. Malignancy risk calculators were retrospectively applied and results compared in patients with positive imaging findings., Results: From 520 individuals enrolled in the screening program, pulmonary nodule(s) ≥6 mm were identified in 166, with biopsy in 30. Malignancy risk probabilities were significantly higher (Brock p < 0.00001; Mayo p < 0.00001) in those undergoing diagnostic sampling than those not undergoing sampling. However, there was no difference in the Brock ( p = 0.912) or Mayo ( p = 0.435) calculators when discriminating a final diagnosis of cancer from not cancer in those undergoing sampling., Conclusions: In our screening program, 5.7% of individuals undergo invasive testing, comparable with the National Lung Screening Trial (6.1%). Both Brock and Mayo calculators perform well in indicating who may be at risk of malignancy, based on clinical and radiologic factors. However, in our invasive testing group, the Brock and Mayo calculators and Lung Cancer Screening Program clinical assessment all lacked clarity in distinguishing individuals who have a cancer from those with a benign abnormality.

Background: Pulmonary nodules are a common but difficult issue for physicians as most identified on imaging are benign but those identified early that are cancerous are potentially curable. Multiple diagnostic options are available, ranging from radiographic surveillance, minimally invasive biopsy (bronchoscopy or transthoracic biopsy) to more invasive surgical biopsy/resection. Each technique has differences in diagnostic yield and complication rates with no established gold standard. Currently, the safest approach is bronchoscopic but it is limited by variable diagnostic yields. Percutaneous approaches are limited by nodule location and complications. With the recent advent of electromagnetic navigation (EMN), a combined bronchoscopic and transthoracic approach is now feasible in a single, staged procedure. Here, we present the study design and rationale for a single-arm trial evaluating a staged approach for the diagnosis of pulmonary nodules., Methods: Participants with 1-3 cm, intermediate to high-risk pulmonary nodules will undergo a staged approach with endobronchial ultrasound (EBUS) followed by EMN-bronchoscopy (ENB), then EMN-transthoracic biopsy (EMN-TTNA) with the procedure terminated at any stage after a diagnosis is made via rapid onsite cytopathology. We aim to recruit 150 EMN participants from eight academic and community settings to show significant improvements over other historic bronchoscopic guided techniques. The primary outcome is overall diagnostic yield of the staged approach., Conclusion: This is the first study designed to evaluate the diagnostic yield of a staged procedure using EBUS, ENB and EMN-TTNA for the diagnosis of pulmonary nodules. If effective, the staged procedure will increase minimally invasive procedural diagnostic yield for pulmonary nodules., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Concerns for infections resulting from antineoplastic therapy-associated immunosuppression may deter referral for symptom palliation with a tunneled pleural catheter (TPC) in patients with malignant/para-malignant pleural effusions (MPE/PMPE). While rates of TPC-related infections range from 1 to 21%, those in patients receiving antineoplastic therapy with correlation to immune status has not been established. We aimed to assess TPC-related infection rates in patients on antineoplastic therapy, determine relation to immune system competency, and assess impact on the patient., Methods: Patients with a MPE/PMPE undergoing TPC management associated with antineoplastic therapy, from 2008 to 2016, were reviewed and categorized into those with an immunocompromised versus immunocompetent immune status., Results: Of the 150 patients, a TPC-related infection developed in 13 (9%): pleural space in 11 (7%) and superficial in 2 (1%). Ninety-three percent (139/150) were identified to be immunocompromised during their antineoplastic therapy. No difference in TPC-related infections was seen in patients with an immunocompromised (9%, 12/139) versus immunocompetent status (9%, 1/11); p = 0.614. The presence of a catheter-related infection did not negatively impact overall survival over a median follow-up of 144 days (interquartile range 41-341); p = 0.740., Conclusions: These results suggest that antineoplastic therapy may not significantly increase the overall risk of TPC-related infections, as the rate remains low and comparable to rates in patients not undergoing antineoplastic therapy. Regardless of immune status, the presence of a catheter-related infection did not negatively impact overall survival. These results should reassure clinicians that the need to initiate antineoplastic therapy should not delay definitive pleural palliation with a TPC.

Background: Widespread use of talc pleurodesis remains controversial for many providers concerned by adverse events such as respiratory failure, which are sometimes fatal. Particle talc size has been implicated in these adverse effects, mainly on the basis of animal studies utilizing large amounts of talc or in observational studies performed on different continents with different talc preparations and doses. Our aim was to determine the particle size and distribution of only the commercially available US-talc preparations and whether the fluid content can affect this distribution., Methods: Commercially available US talc was evaluated under scanning electron microscopy and dynamic light scattering (DLS). Distribution of talc particle size was obtained in saline and various protein-based solutions., Results: Talc particle size by DLS was performed with commercially available Sterile Talc Powder and Sclerosol Intrapleural Aerosol. Sterile Talc Powder demonstrated a median diameter of 26.57 μm with a range of particle sizes from 0.399 μm to 100.237 μm. Sclerosol demonstrated a median diameter of 24.49 μm with a range of particle sizes from 0.224 μm to 100.237 μm. The exposure of talc to a protein rich environment (bovine serum albumin and human pleural fluid) led to the development of measureable, new, larger aggregated particle (>100 μm)., Conclusions: Currently available US talc seems to have size characteristics similar to previous described "graded" talc preparations. The exposure of talc to a protein rich environment seems to modify the overall distribution of talc particle size when examined by DLS.

Objective: Lung cancer screening programs have become increasingly prevalent within the United States after the National Lung Screening Trial results. We aimed to review the financial impact after programmatic implementation of Advanced Registered Nurse Practitioner-led programs of Lung Cancer Screening and Tobacco Related Diseases, Incidental Pulmonary Nodule Clinic, and Tobacco Cessation Services., Methods: We reviewed revenue from 2013 to 2016 by our nurse practitioner-led program. Encounters were queried for charges related to outpatient evaluation and management, professional procedures, and facility charges related to both outpatient and inpatient procedures. Revenue was normalized using 2016 data tables and the national Medicare conversion factor (35.8043)., Results: Our program evaluated 694 individuals, of whom 75% (518/694) are enrolled within the lung cancer-screening program. Overall revenue associated with the programs was $733,336. Outpatient evaluation and management generated revenue of $168,372. In addition, professional procedure revenue accounted for an additional $60,015 with facility revenue adding an additional $504,949., Conclusions: A nurse practitioner-led program of lung cancer screening, incidental pulmonary nodules, and tobacco-cessation services can provide additional revenue opportunities for a Thoracic Surgery and Interventional Pulmonology Division, as well as a health care system. The current national, median annual wage of a nurse practitioner is $98,190, and the cost associated directly to their salary (and benefits) may remain neutral or negative within certain programs. However, the larger economic benefit may be realized within the division and institution. This potential additional revenue appears related to evaluation of newly identified diseases and subsequent evaluations, procedures, and operations., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Rationale: Implementation of lung cancer screening programs is occurring across the United States. Programs vary in approaches to patient identification and shared decision-making. The eligibility of persons referred to screening programs, the outcomes of eligibility determination during shared decision-making, and the potential for the electronic medical record (EMR) to identify eligible individuals have not been well described., Objectives: Our objectives were to assess the eligibility of individuals referred for lung cancer screening and compare information extracted from the EMR to information derived from a shared decision-making conversation for the determination of eligibility for lung cancer screening., Methods: We performed a retrospective analysis of individuals referred to a centralized lung cancer screening program serving a five-hospital health services system in Seattle, Washington between October 2014 and January 2016. Demographics, referral, and outcomes data were collected. A pack-year smoking history derived from the EMR was compared with the pack-year history obtained during a shared decision-making conversation performed by a licensed nurse professional representing the lung cancer screening program., Results: A total of 423 individuals were referred to the program, of whom 59.6% (252 of 423) were eligible. Of those, 88.9% (224 of 252) elected screening. There was 96.2% (230 of 239) discordance in pack-year smoking history between the EMR and the shared decision-making conversation. The EMR underreported pack-years of smoking for 85.2% (196 of 230) of the participants, with a median difference of 29.2 pack-years. If identification of eligible individuals relied solely on the accuracy of the pack-year smoking history recorded in the EMR, 53.6% (128 of 239) would have failed to meet the 30-pack-year threshold for screening., Conclusions: Many individuals referred for lung cancer screening may be ineligible. Overreliance on the EMR for identification of individuals at risk may lead to missed opportunities for appropriate lung cancer screening.

Purpose of Review: Pleural infection remains a common problem with significant associated morbidity and mortality. The current treatment paradigm for pleural infection appears to be shifting as more recent data have suggested that the use of intrapleural fibrinolytic therapy (IPFT) may be adequate for treatment, potentially avoiding the need for surgical intervention in a significant number of patients., Recent Findings: The previous Multicenter Intrapleural Sepsis Trial demonstrated improved outcomes when utilizing combined IPFT, however, more recently alterations in this dosing regimen have been explored. Successful retrospective studies have examined the role of extended dosing (more than six sequential doses), concurrent dosing (instilling both medications together as opposed to separate medication dwell times), and daily dosing of intrapleural medications., Summary: Although the use of IPFT is likely shifting the management of pleural infection to less surgical intervention, the optimal dosing strategy of intrapleural therapy remains undefined. Within the last few years more data on variations of IPFT have emerged. This data remains of lower quality because of its retrospective nature and future prospective evaluation is required to further define the optimal dosing regimen for IPFT in complicated pleural space infections.

Background: Pleural effusions are considered rare in cystic fibrosis (CF) patients. There is a paucity of available information in the literature concerning the nature and significance of pleural effusions in non-transplanted CF patients., Methods: We conducted a multicenter retrospective evaluation of non-transplanted adult CF patients. Given the small sample size, only descriptive statistics were performed., Results: A total of 17 CF patients with pleural effusion were identified, of whom 9 patients underwent thoracentesis. The crude incidence of pleural effusion was 43 per 10,000 person-years in hospitalized CF patients at large CF centers. All sampled effusions were inflammatory in nature. All samples submitted for culture grew at least one organism., Conclusion: Pleural effusions are rare in adult non-transplanted CF patients. These fluid collections appear to be quite inflammatory with a higher rate of empyema than in the general population., (Copyright © 2016 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.)