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Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a relatively safe and minimally invasive procedure frequently used to investigate mediastinal lymphadenopathy of unknown etiology. Due to its safety in comparison to mediastinoscopy, which is the diagnostic gold standard, EBUS-TBNA can be used as the first-line diagnostic modality for approaching mediastinal lymphadenopathy in suspected sarcoidosis. In this study, we evaluated the diagnostic yield and safety of EBUS-TBNA for sarcoidosis at our institution. Methods: A retrospective review was performed for all patients who presented with mediastinal lymphadenopathy and underwent EBUS-TBNA for presumed sarcoidosis for a three-year period and subsequently diagnosed with sarcoidosis. Twenty-five patients were included, and parameters such as nodal station sampled, radiographic stage, adverse events, alternative diagnosis method, and symptoms were recorded. Results: Thirteen of 25 patients had non-caseating granulomas on EBUS-TBNA with a diagnostic yield of 52%. Of 12 patients not diagnosed via EBUS-TBNA, a diagnosis was made in four patients (33%) via transbronchial lung biopsy, in three (25%) via mediastinoscopy, in one (8%) via video-assisted thoracoscopic surgery, in three (25%) with an elevated bronchoalveolar lavage (BAL) CD4/CD8 ratio and response to therapy, and in one (8%) via muscle biopsy. The average BAL CD4/CD8 ratio was 5.4 for all patients with sarcoidosis. All patients tolerated the procedure without major complications. Conclusion: EBUS-TBNA is a useful and minimally invasive tool for the diagnosis of sarcoidosis. It should be used as the first-line diagnostic study in suspected sarcoidosis if mediastinal lymphadenopathy is present.

Extracorporeal photopheresis (ECP) is a commonly used treatment for severe graft-versus-host-disease (GVHD). We sought to evaluate the effects of ECP over a prolonged period on forced expiratory volume in 1 s (FEV1) in patients with pulmonary GVHD. We identified eight patients who developed new airflow obstruction following allogeneic stem cell transplantation and a substantial decline in FEV1 despite receiving corticosteroids and standard therapy for pulmonary GVHD. Those eight patients were treated with ECP for a period of 1 year, with a primary endpoint of FEV1 change during this treatment period. Over the first 3 months of ECP, there was no further decline in FEV1 in seven of the eight patients. However, over the 1 year period, only two of the eight patients had stability in FEV1. The rate of FEV1 decline was substantially less once ECP was initiated, though the median FEV1 continued to decline over 1 year of therapy. All patients survived through the first year of ECP therapy. There was a significant decrease in the median dose of prednisone per patient throughout the 12 months of ECP treatment. ECP shows promise in slowing rate of decline of FEV1 in pulmonary GVHD, though the effects may not be long lived. J. Clin. Apheresis 31:347-352, 2016. © 2015 Wiley Periodicals, Inc.

Extracorporeal photopheresis (ECP) is a commonly used treatment for severe graft-versus-host-disease (GVHD). We sought to evaluate the effects of ECP over a prolonged period on forced expiratory volume in 1 s (FEV1) in patients with pulmonary GVHD. We identified eight patients who developed new airflow obstruction following allogeneic stem cell transplantation and a substantial decline in FEV1 despite receiving corticosteroids and standard therapy for pulmonary GVHD. Those eight patients were treated with ECP for a period of 1 year, with a primary endpoint of FEV1 change during this treatment period. Over the first 3 months of ECP, there was no further decline in FEV1 in seven of the eight patients. However, over the 1 year period, only two of the eight patients had stability in FEV1. The rate of FEV1 decline was substantially less once ECP was initiated, though the median FEV1 continued to decline over 1 year of therapy. All patients survived through the first year of ECP therapy. There was a significant decrease in the median dose of prednisone per patient throughout the 12 months of ECP treatment. ECP shows promise in slowing rate of decline of FEV1 in pulmonary GVHD, though the effects may not be long lived. J. Clin. Apheresis 31:347-352, 2016. © 2015 Wiley Periodicals, Inc.

Purpose: To determine if the multiplex real-time polymerase chain reaction respiratory viral panel (RVP) provides the same results when performed on nasal wash versus bronchoalveolar lavage from the same patient within 5 days of each other. Methods: A retrospective chart review was performed on all adult immunocompromised patients who underwent bronchoalveolar lavage (BAL) with a respiratory viral panel (RVP) obtained from the BAL fluid from February 2011 to July 2012. All patients who also had a nasal wash RVP performed within 5 days of the BAL assay were included in this study. Results: There was exact concordance between BAL and NPW specimens in 45 of 58 patients: 26 cases in which both specimens were negative and 19 cases in which the exact same viruses were present in each specimen. In 8 cases, a virus was detected in BAL fluid that was not detected in NPW fluid; in 5 cases, a virus was found in NPW fluid but not BAL. Conclusions: There was good correlation between the two assays when performed within 5 days of each other from the 2 separate specimen sources. For optimal diagnostic detection, it may be useful to repeat the assay in both locations when clinically indicated.

Diagnosis of invasive pulmonary aspergillosis (IPA) is a challenging process in immunocompromised patients. Galactomannan (GM) antigen detection in bronchoalveolar lavage (BAL) fluid is a method to detect IPA with improved sensitivity over conventional studies. We sought to determine the diagnostic yield of BAL GM assay in a diverse population of immunocompromised patients. A retrospective review of 150 fiberoptic bronchoscopy (FOB) with BAL for newly diagnosed pulmonary infiltrate in immunocompromised patients was performed. Patient information, procedural details and laboratory studies were collected. BAL and serum samples were evaluated for GM using enzyme-linked immunoassay. Of 150 separate FOB with BAL, BAL GM was obtained in 143 samples. There were 31 positive BAL GM assays. In those 31 positive tests, 13 were confirmed as IPA, giving a positive predictive value of 41.9%. There was one false negative BAL GM. Of the 18 false positive BAL GM, 4 were receiving piperacillin-tazobactam and 11 were receiving an alternative beta-lactam antibiotic. BAL GM assay shows excellent sensitivity for diagnosing IPA. There was a significant number of false positive BAL GM assays and several of those patients were receiving beta-lactam antibiotics at the time of bronchoscopy.

PURPOSE: Sepsis is a common cause of mortality nationwide. To improve the identification and care of septic patients at our institution, we have provided bundled care, adopting a sepsis bundle based on the Surviving Sepsis Campaign (SSC) guidelines. We hypothesized that we could successfully track the appropriate identification of patients with severe sepsis, as well as their overall mortality, using our hospital discharge database. METHODS: Our hospital discharge database was prospectively queried over 6 fiscal years, beginning July 1 and ending June 30, annually, during 2005-2010. This period coincided with adoption of the SSC database and care bundles. An annual estimate of the number of severe sepsis cases in our institution throughout this period was made using a method derived from Angus, et al. Physician-diagnosed severe sepsis was identified by ICD-9 codes 995.92, 785.52. Additionally, the database was queried for all-cause mortality of these patients. RESULTS: In FY 2005, only 171 of 426 patients identified to have severe sepsis by the modified Angus method were given an ICD-9 diagnosis of severe sepsis or septic shock (40%). This grew to 958 out of 1,205 (80%) by FY 2010. Simultaneously, the all-cause in-hospital mortality rate of patients diagnosed with severe sepsis fell from 49% in FY 2005 to 25% in FY 2010. The mortality index (observed mortality/expected mortality) fell from 1.56 in FY 2005 to 0.88 in FY 2010. Average LOS declined from 24.4 days in FY 2005 to 15.9 days in FY 2010. Severe sepsis as a recognized contribution to overall hospital mortality rose from 18.5% in FY 2005 to 48.4% in FY 2010. CONCLUSIONS: The comparison of the modified Angus method with coded discharges for severe sepsis and septic shock demonstrated improved recognition of severe sepsis. Enhanced recognition, combined with systematic improvements in patient care, effectively reduced the mortality of severe sepsis by approximately 50% over a five-year period. CLINICAL IMPLICATIONS: The hospital discharge database is an effective tool for measuring the outcomes of performance improvement efforts in severe sepsis. DISCLOSURE: The following authors have nothing to disclose: Lucas Pitts, Michael Moncure, Chad Cannon, Steven Simpson No Product/Research Disclosure Information