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Rationale: Current guidelines recommend patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia receive empirical antibiotics for suspected bacterial superinfection on the basis of weak evidence. Rates of ventilator-associated pneumonia (VAP) in clinical trials of patients with SARS-CoV-2 pneumonia are unexpectedly low. Objectives: We conducted an observational single-center study to determine the prevalence and etiology of bacterial superinfection at the time of initial intubation and the incidence and etiology of subsequent bacterial VAP in patients with severe SARS-CoV-2 pneumonia. Methods: Bronchoscopic BAL fluid samples from all patients with SARS-CoV-2 pneumonia requiring mechanical ventilation were analyzed using quantitative cultures and a multiplex PCR panel. Actual antibiotic use was compared with guideline-recommended therapy. Measurements and Main Results: We analyzed 386 BAL samples from 179 patients with SARS-CoV-2 pneumonia requiring mechanical ventilation. Bacterial superinfection within 48 hours of intubation was detected in 21% of patients. Seventy-two patients (44.4%) developed at least one VAP episode (VAP incidence rate = 45.2/1,000 ventilator days); 15 (20.8%) initial VAPs were caused by difficult-to-treat pathogens. The clinical criteria did not distinguish between patients with or without bacterial superinfection. BAL-based management was associated with significantly reduced antibiotic use compared with guideline recommendations. Conclusions: In patients with SARS-CoV-2 pneumonia requiring mechanical ventilation, bacterial superinfection at the time of intubation occurs in

Background: The coronavirus disease 2019 (COVID-19) pandemic raised concern for exposure to healthcare providers through aerosol generating procedures, such as bronchoalveolar lavage (BAL). Current society guidelines recommended limiting use of BAL to reduce operators' risk for infection, yet data on the infection rate for providers after BAL is sparse. Since March 2020, our institution used a modified protocol to perform over 450 BALs on intubated COVID-19 patients. We therefore sought to describe the subsequent infectious risks to providers associated with BAL. Methods: Fifty-two pulmonary and critical care providers (faculty and fellows) at our tertiary-care, urban medical center were surveyed. Survey participants were asked to provide the number of BALs on COVID-19 patients they performed, the number of weeks they cared for intensive care unit (ICU) patients with COVID-19, and the results of any SARS-CoV-2 testing that they received. Participants were asked to assess the difficulty of BAL on intubated COVID-19 patients as compared to routine ICU BAL using a numeric perceived difficulty score ranging from 1 (easier) to 10 (harder). Results: We received forty-seven responses from fifty-two surveyed (90% response rate), with 2 declining to participate. Many respondents (19/45, 42%) spent >5 weeks on an ICU service with COVID-19 patients. The number of BALs performed by providers ranged from 0 to >60. Sixteen of the 35 providers (46%) who performed BALs underwent at least one nasopharyngeal (NP) swab to test for SARS-CoV-2, but none were positive. Twenty-seven of the 35 providers (77%) who performed BALs underwent SARS-CoV-2 serology testing, and only one (3.7%) was positive. Respondents indicated occasionally not being able to follow aerosol-minimizing steps but overall felt BALs in COVID-19 patients was only slightly more difficult than routine ICU BAL. Discussion: At a high-volume center having performed >450 BALs on intubated COVID-19 patients with aerosol-limiting precautions, our survey of bronchoscopists found no positive NP SARS-CoV-2 tests and only one positive antibody test result. While the optimal role for COVID-19 BAL remains to be determined, these data suggest that BAL can be safely performed in intubated COVID-19 patients if experienced providers take precautions to limit aerosol generation and wear personal protective equipment.

Some patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) develop severe pneumonia and acute respiratory distress syndrome1 (ARDS). Distinct clinical features in these patients have led to speculation that the immune response to virus in the SARS-CoV-2-infected alveolus differs from that in other types of pneumonia2. Here we investigate SARS-CoV-2 pathobiology by characterizing the immune response in the alveoli of patients infected with the virus. We collected bronchoalveolar lavage fluid samples from 88 patients with SARS-CoV-2-induced respiratory failure and 211 patients with known or suspected pneumonia from other pathogens, and analysed them using flow cytometry and bulk transcriptomic profiling. We performed single-cell RNA sequencing on 10 bronchoalveolar lavage fluid samples collected from patients with severe coronavirus disease 2019 (COVID-19) within 48 h of intubation. In the majority of patients with SARS-CoV-2 infection, the alveolar space was persistently enriched in T cells and monocytes. Bulk and single-cell transcriptomic profiling suggested that SARS-CoV-2 infects alveolar macrophages, which in turn respond by producing T cell chemoattractants. These T cells produce interferon-γ to induce inflammatory cytokine release from alveolar macrophages and further promote T cell activation. Collectively, our results suggest that SARS-CoV-2 causes a slowly unfolding, spatially limited alveolitis in which alveolar macrophages containing SARS-CoV-2 and T cells form a positive feedback loop that drives persistent alveolar inflammation. Analysis of bronchoalveolar lavage fluid samples from patients with SARS-CoV-2-induced respiratory failure suggests that SARS-CoV-2 infects alveolar macrophages to cause release of T cell chemoattractants, thereby inducing local inflammatory cytokine release and further T cell activation, ultimately resulting in a positive feedback loop that drives alveolar inflammation.

T1 Figure 1ConclusionsOverall, this largest paediatric single cell COVID-19 study to date showed significant differences in response to SARS-CoV-2 between children and adults, reflecting the changes of the immune landscape over developmental time, which in children are dominated by naive and innate responses.

While a substantial proportion of adults infected with SARS-CoV-2 progress to develop severe disease, children rarely manifest respiratory complications. Therefore, understanding differences in the local and systemic response to SARS-CoV-2 infection between children and adults may provide important clues about the pathogenesis of SARS-CoV-2 infection. To address this, we first generated a healthy reference multi-omics single cell data set from children (n=30) in whom we have profiled triple matched samples: nasal and tracheal brushings and PBMCs, where we track the developmental changes for 42 airway and 31 blood cell populations from infancy, through childhood to adolescence. This has revealed the presence of naive B and T lymphocytes in neonates and infants with a unique gene expression signature bearing hallmarks of innate immunity. We then contrast the healthy reference with equivalent data from severe paediatric and adult COVID-19 patients (total n=27), from the same three types of samples: upper and lower airways and blood. We found striking differences: children with COVID-19 as opposed to adults had a higher proportion of innate lymphoid and non-clonally expanded naive T cells in peripheral blood, and a limited interferon-response signature. In the airway epithelium, we found the highest viral load in goblet and ciliated cells and describe a novel inflammatory epithelial cell population. These cells represent a transitional regenerative state between secretory and ciliated cells; they were found in healthy children and were enriched in paediatric and adult COVID-19 patients. Epithelial cells display an antiviral and neutrophil-recruiting gene signature that is weaker in severe paediatricversusadult COVID-19. Our matched blood and airway samples allowed us to study the spatial dynamics of infection. Lastly, we provide a user-friendly interface for this data1as a highly granular reference for the study of immune responses in airways and blood in children.

BackgroundSARS-CoV-2 can cause severe respiratory failure leading to prolonged mechanical ventilation. Data are just emerging about the practice and outcomes of tracheostomy in these patients. We reviewed our experience with tracheostomies for SARS-CoV-2 at our tertiary-care, urban teaching hospital.MethodsWe reviewed the demographics, comorbidities, timing of mechanical ventilation, tracheostomy, and ICU and hospital lengths-of-stay (LOS) in SARS-CoV-2 patients who received tracheostomies. Early tracheostomy was considered ResultsFrom March 2020 to January 2021, our center had 370 patients intubated for SARS-CoV-2, and 59 (16%) had percutaneous bedside tracheostomy. Median time from intubation to tracheostomy was 19 (IQR 17 – 24) days. Demographics and comorbidities were similar between early and late tracheostomy, but early tracheostomy was associated with shorter ICU LOS and a trend towards shorter ventilation. To date, 34 (58%) of patients have been decannulated, 17 (29%) before hospital discharge; median time to decannulation was 24 (IQR 19-38) days. Decannulated patients were younger (56 vs 69 years), and in regression analysis, pneumothorax was associated was associated with lower decannulation rates (OR 0.05, 95CI 0.01 – 0.37). No providers developed symptoms or tested positive for SARS-CoV-2.ConclusionsTracheostomy is a safe and reasonable procedure for patients with prolonged SARS-CoV-2 respiratory failure. We feel that tracheostomy enhances care for SARS-CoV-2 since early tracheostomy appears associated with shorter duration of critical care, and decannulation rates appear high for survivors.

BackgroundSevere community-acquired pneumonia secondary to SARS-CoV-2 is a leading cause of death. Current guidelines recommend patients with SARS-CoV-2 pneumonia receive empirical antibiotic therapy for suspected bacterial superinfection, but little evidence supports these recommendations.MethodsWe obtained bronchoscopic bronchoalveolar lavage (BAL) samples from patients with SARS-CoV-2 pneumonia requiring mechanical ventilation. We analyzed BAL samples with multiplex PCR and quantitative culture to determine the prevalence of superinfecting pathogens at the time of intubation and identify episodes of ventilator-associated pneumonia (VAP) over the course of mechanical ventilation. We compared antibiotic use with guideline-recommended care.ResultsThe 179 ventilated patients with severe SARS-CoV-2 pneumonia discharged from our hospital by June 30, 2020 were analyzed. 162 (90.5%) patients had at least one BAL procedure; 133 (74.3%) within 48 hours after intubation and 112 (62.6%) had at least one subsequent BAL during their hospitalization. A superinfecting pathogen was identified within 48 hours of intubation in 28/133 (21%) patients, most commonly methicillin-sensitive Staphylococcus aureus or Streptococcus species (21/28, 75%). BAL-based treatment reduced antibiotic use compared with guideline-recommended care. 72 patients (44.4%) developed at least one VAP episode. Only 15/72 (20.8%) of initial VAPs were attributable to multidrug-resistant pathogens. The incidence rate of VAP was 45.2/1000 ventilator days.ConclusionsWith use of sensitive diagnostic tools, bacterial superinfection at the time of intubation is infrequent in patients with severe SARS-CoV-2 pneumonia. Treatment based on current guidelines would result in substantial antibiotic overuse. The incidence rate of VAP in ventilated patients with SARS-CoV-2 pneumonia are higher than historically reported.

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic raised concern for exposure to healthcare providers through aerosol generating procedures, such as bronchoalveolar lavage (BAL). Current society guidelines recommended limiting use of BAL to reduce operators’ risk for infection, yet data on the infection rate for providers after BAL is sparse. Since March 2020, our institution used a modified protocol to perform over 450 BALs on intubated COVID-19 patients. We therefore sought to describe the subsequent infectious risks to providers associated with BAL.MethodsFifty-two pulmonary and critical care providers (faculty and fellows) at our tertiary-care, urban medical center were surveyed. Survey participants were asked to provide the number of BALs on COVID-19 patients they performed, the number of weeks they cared for intensive care unit (ICU) patients with COVID-19, and the results of any SARS-CoV-2 testing that they received. Participants were asked to assess the difficulty of BAL on intubated COVID-19 patients as compared to routine ICU BAL using a numeric perceived difficulty score ranging from 1 (easier) to 10 (harder).ResultsWe received forty-seven responses from fifty-two surveyed (90% response rate), with 2 declining to participate. Many respondents (19/45, 42%) spent >5 weeks on an ICU service with COVID-19 patients. The number of BALs performed by providers ranged from 0 to >60. Sixteen of the 35 providers (46%) who performed BALs underwent at least one nasopharyngeal (NP) swab to test for SARS-CoV-2, but none were positive. Twenty-seven of the 35 providers (77%) who performed BALs underwent SARS- CoV-2 serology testing, and only one (3.7%) was positive. Respondents indicated occasionally not being able to follow aerosol-minimizing steps but overall felt BALs in COVID-19 patients was only slightly more difficult than routine bronchoscopy.DiscussionAt a high-volume center having performed >450 BALs on intubated COVID-19 patients with aerosol-limiting precautions, our survey of bronchoscopists found no positive NP SARS-CoV-2 tests and only one positive antibody test result. While the optimal role for COVID-19 BAL remains to be determined, these data suggest that BAL can be safely performed in intubated COVID-19 patients if experienced providers take precautions to limit aerosol generation and wear personal protective equipment.

Some patients infected with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) develop severe pneumonia and the acute respiratory distress syndrome (ARDS) [1]. Distinct clinical features in these patients have led to speculation that the immune response to virus in the SARS-CoV-2-infected alveolus differs from other types of pneumonia [2]. We collected bronchoalveolar lavage fluid samples from 86 patients with SARS-CoV-2-induced respiratory failure and 252 patients with known or suspected pneumonia from other pathogens and subjected them to flow cytometry and bulk transcriptomic profiling. We performed single cell RNA-Seq in 5 bronchoalveolar lavage fluid samples collected from patients with severe COVID-19 within 48 hours of intubation. In the majority of patients with SARS-CoV-2 infection at the onset of mechanical ventilation, the alveolar space is persistently enriched in alveolar macrophages and T cells without neutrophilia. Bulk and single cell transcriptomic profiling suggest SARS-CoV-2 infects alveolar macrophages that respond by recruiting T cells. These T cells release interferon-gamma to induce inflammatory cytokine release from alveolar macrophages and further promote T cell recruitment. Our results suggest SARS-CoV-2 causes a slowly unfolding, spatially-limited alveolitis in which alveolar macrophages harboring SARS-CoV-2 transcripts and T cells form a positive feedback loop that drives progressive alveolar inflammation.This manuscript is accompanied by an online resource: https://www.nupulmonary.org/covid-19/One sentence summarySARS-CoV-2-infected alveolar macrophages form positive feedback loops with T cells in patients with severe COVID-19.

African Americans were underrepresented in lung cancer screening (LCS) trials, despite having higher lung cancer incidence and worse outcomes compared with Caucasians. There is concern that the 30-pack-year threshold excludes some African Americans who may benefit from LCS.LCS in an underserved health care system was reviewed. Providers attested that patients met LCS criteria, including 30-pack-year history, but patients also self-reported smoking histories. Self-reported data were used to identify patients with30-pack-year histories.Over 2 years, 784 patients self-reported sufficient data to calculate pack-years. The majority were men (57.5%), and 66.2% were African Americans. Median total years smoked was 40 (interquartile range, 30-45 years), and median pack-years was 25 (interquartile range, 15-40 pack-years). African Americans were more likely to report30 pack-years compared with other races (P.001). The overall incidence of lung cancer was 2.0%, and incidence was similar for those with ≥30 or30 pack-years (2.1% versus 2.0%; odds ratio, 0.94; 95% confidence interval, 0.35-2.53; P = .902). Race was not associated with lung cancer diagnosis, but African Americans were the only race to have lung cancer if pack-years were30. The incidence of cancer in African Americans was similar in those who reported ≥30 or30 pack-years (2.2% versus 2.7%; odds ratio, 1.21; 95% confidence interval, 0.39-3.75; P = .740), and the 30-pack-year threshold was not associated with lung cancer diagnosis.This is the first review of LCS in African Americans who self-reported30 pack-years. Although retrospective, these data raise concern that the 30-pack-year threshold may not be an appropriate LCS criterion in African Americans.

Whitebark pine (Pinus albicaulis. Engelm.) is vulnerable to a number of threats including an introduced pathogen (Cronartium ribicola J.C. Fisch.), epidemic levels of native mountain pine beetle (Dendroctonus ponderosae Hopkins), fire suppression, and climate change. To describe the structure of whitebark pine populations in two national parks in the southern Cascades (Crater Lake, Oregon, USA (CRLA) and Lassen Volcanic, California, USA (LAVO) National Parks), we surveyed trees in 30 &times, 50 &times, 50 m plots in both parks. We used these plots to describe the extent of white pine blister rust (the disease caused by Cronartium ribicola), mountain pine beetle occurrence, and to elucidate factors influencing the presence of pests and pathogens, cone production, and canopy kill. In each plot, we recorded data related to tree health, including symptoms of blister rust and mountain pine beetle, and reproductive vigor (cone production). In both parks, encroachment from other species, particularly mountain hemlock (Tsuga mertensiana (Bong.) Carri&egrave, re), was negatively associated with cone production. In CRLA, water stress was a good predictor of blister rust infection and cone production. For CRLA and LAVO, the presence of mountain pine beetle and blister rust was associated with higher canopy kill for whitebark pine. Lastly, we found evidence for a pest-pathogen interaction, mountain pine beetle attack was greater for trees that showed symptoms of blister rust infection in CRLA. Our results indicate that whitebark pine populations in the southern Cascade Range are experiencing moderate levels of blister rust infection compared with other sites across the species range, and that competition from shade-tolerant species may result in an additional threat to whitebark pine in both parks. We present our findings in the context of park management and situate them in range-wide and regional conservation strategies aimed at the protection and restoration of a declining species.

Pulmonary embolism (PE) remains a significant cause of hospital admission and health-care costs. Estimates of PE incidence came from the 1990s, and data are limited to describe trends in hospital admissions for PE over the past decade.We analyzed Nationwide Inpatient Sample data from 1993 to 2012 to identify patients admitted with PE. We included admissions with International Classification of Diseases, 9th revision, codes listing PE as the principal diagnosis as well as admissions with PE listed secondary to principal diagnoses of respiratory failure or DVT. Massive PE was defined by mechanical ventilation, vasopressors, or nonseptic shock. Outcomes included hospital lengths of stay, adjusted charges, and all-cause hospital mortality. Linear regression was used to analyze changes over time.Admissions for PE increased from 23 per 100,000 in 1993 to 65 per 100,000 in 2012 (P .001). The percent of admissions meeting criteria for massive PE decreased (5.3% to 4.4%, P = .002), but the absolute number of admissions for massive PE increased (from 1.5 to 2.8 per 100,000, P .001). Median length of stay decreased from 8 (interquartile range [IQR], 6-11) to 4 (IQR, 3-6) days (P .001). Adjusted hospital charges increased from $16,475 (IQR, $10,748-$26,211) in 1993 to $25,728 (IQR, $15,505-$44,493) in 2012 (P .001). All-cause hospital mortality decreased from 7.1% to 3.2% (P .001), but population-adjusted deaths during admission for PE increased from 1.6 to 2.1 per 100,000 (P .001).Total admissions and hospital charges for PE have increased over the past two decades. However, the population-adjusted admission rate has increased disproportionately to the incidence of patients with severe PE. We hypothesize that these findings reflect a concerning national movement toward more admissions of less severe PE.

Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disease resulting in respiratory failure and death. Use of noninvasive ventilation (NIV) improves survival. However, use of volume-assured pressure support (VAPS) has not been extensively studied in ALS.To explore the clinical usefulness of a detailed evaluation of device-recorded NIV data in the management of chronic respiratory failure in ALS, and to determine whether there are differences in efficacy between patients using VAPS or PS.We performed a retrospective chart review of 271 patients with ALS using either PS or VAPS, along with an evaluation of device-recorded data to explore differences in attainment of goal tidal volumes (Vt) and ratio of respiratory rate to tidal volume (f/Vt), in addition to triggering and cycling ability.Two hundred and fifteen patients were using PS, while 56 were using VAPS. There were no significant differences in demographic data, symptoms, pulmonary function, or patient compliance. Compared with VAPS, achieved Vt was significantly lower for PS while f/Vt was significantly higher. Percent spontaneous triggering was relatively preserved in both cohorts, whereas percent spontaneous cycling was considerably decreased in both. Furthermore, there was no association found between spontaneous triggering or cycling, and pulmonary function, indicating the presence of low spontaneous breath cycling or triggering ability is difficult to predict.Examination of device data for exhaled tidal volumes and f/Vt may be of use in evaluating efficacy of NIV in ALS. VAPS provides more reliable goal Vt than does PS, and is associated with decreased f/Vt. Spontaneous cycling is decreased in ALS despite preservation of triggering ability. Although a set backup rate may address decreased triggering, perhaps more importantly, setting a sufficient fixed inspiratory time would address the issue of decreased cycling.

Prompt diagnosis and treatment of acute pulmonary embolism (PE) is essential to reduce mortality. Risk factors for PE are well known, but factors associated with delayed diagnosis are less clear.Our objective was to identify clinical factors associated with delayed diagnosis of patients with acute PE presenting to a tertiary-care emergency department (ED).We studied 400 consecutive adults who presented to our ED with acute, symptomatic PE. All patients were diagnosed by computed tomography (CT) angiography. Early diagnosis was defined as CT diagnosis12h from ED arrival, and delayed diagnosis as CT diagnosis12h. Univariate and multiple logistic regression models were used to identify factors associated with delayed diagnosis. Odds ratios with 95% confidence intervals are reported.The median time from arrival to diagnosis was 2.4h (interquartile range 1.4-7.6), and 73 (18.3%) patients had delayed diagnosis. Patients aged65 years and those with coronary artery disease or congestive heart failure had longer times from ED arrival to CT diagnosis, whereas patients with recent immobility had shorter times. Patients diagnosed12h were older and had higher rates of morbid obesity and coronary artery disease, whereas patients diagnosed12h had higher rates of tachycardia. In multiple regression modeling, tachycardia and recent immobility remained associated with early diagnosis, whereas morbid obesity remained associated with delayed diagnosis.Older patients with cardiovascular comorbidities had longer times from ED arrival to CT diagnosis. Our data suggest that these patients represent more of a diagnostic challenge than those presenting with traditional risk factors for PE, such as tachycardia and recent immobilization. Physicians should consider these factors to diagnosis acute PE promptly in the ED.

Background: Medical students and practitioners learn and use a vocabulary originating almost entirely from classical Latin and Greek languages. Previous generations required Latin or Greek prior to medical school, but the current generation does not have such requirements. Anecdotal evidence suggests that understanding Latin or Greek helps students to learn and practitioners to recall otherwise foreign terminology. This study evaluated students' familiarity with Latin and Greek etymologies before and after a gross anatomy course that incorporated etymologies into its curriculum. Methods: First-year medical students at Mayo Clinic College of Medicine were taught Latin and Greek etymologies through lectures and handouts during their gross anatomy course. They took a pretest and a posttest before and after the course to assess their understanding of etymologies. In addition, students from all four years of medical school, residents, and staff physicians also took a general etymology quiz to assess their understanding of etymologies. Results: After their gross anatomy course emphasizing etymologies, first-year students scored higher on the posttest than they did on the pretest. First-year students also reported that learning etymologies enhanced anatomy learning, made the experience more enjoyable, and proved to be less difficult than they thought it would be prior to the course. Medical students, residents, and staff physicians scored almost equally on the general etymology quiz and almost equally reported that etymologies enhanced learning and recalling terminology. Medical students, residents, and staff physicians almost equally endorsed incorporating etymologies into medical education. Conclusions: This study provides novel scientific evidence that a basic understanding of Latin and Greek etymologies enhances performance and comfort when learning and using medical terminology. Clin. Anat. 20:332–337, 2007. © 2006 Wiley-Liss, Inc.

Art and anatomy have been closely related since the Renaissance, when artists studied the human body to gain more perfect perspectives, and anatomists began illustrating their texts. As the two fields became increasingly intertwined, the distinctions between artistic drawings and scientific illustrations of the human body's form and function became increasingly blurred. Early Renaissance anatomists were more artistic than scientific with their images, but Hieronymus Fabricius ab Acquapendente (1533–1619) provided a crucial turning point in the evolution of anatomic illustration. His new and strict focus upon scientific illustration developed in the context of previous anatomists' work and theories, but his is a critical and previously untold story in the history of medicine. Clin. Anat. 19:382–388, 2006. © 2006 Wiley-Liss, Inc.

The original article to which this Erratum refers was published in Clinical Anatomy 17:540–543Clinical Anatomy(2004) 17(7) 540–543

The Nationwide Inpatient Sample aggregated data from approximately 20% of US hospital admissions from 1993 to 2011. Prior literature found that pneumonia admissions decreased following the introduction of the pneumococcal vaccine in 2000.1 The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes provide information regarding pneumonia pathogens, but no studies, to our knowledge, have used these codes to analyze longitudinal trends in the pathogens documented during hospitalizations for pneumonia.

Purpose Visual inspection (VI) of bubbles in the chest drainage unit does not differentiate a true leak of alveolopleural fistula (APF) from a false leak. We hypothesized that detection of elevated levels of carbon dioxide, increase in oxygen content, or both, in pleural gas upon the administration of supplemental oxygen would accurately identify APF. Description Prospective study comparing pleural gas analysis (GA) with VI to detect APF after surgical lobectomy (n = 50). Evaluation APF was found in 22 (44%) patients at the time of analysis. VI revealed air bubbles in 31 (62%) patients, indicating the presence of APF, of whom 12 (38.7%) were false leaks. VI failed to identify APF in 3 (6%) patients that resulted in post–tube removal pneumothorax. By contrast, GA accurately demonstrated APF in 21 patients, with only one false negative and no false positives. GA demonstrated better sensitivity (95.5% vs 86.4%), specificity (100% vs 57.1%), positive predictive value (100% vs 61.3%), and negative predictive value (96.6% vs 84.2%) compared to VI. Conclusions Pleural gas analysis is an effective technique to detect APF and can facilitate timely and safe chest tube removal.

Acute pulmonary embolism (PE) is a common, multidisciplinary disease with substantial associated morbidity, mortality and healthcare expense. In this article we present a succinct review of diagnostic tools, risk stratification and medical therapies for cardiovascular care of patients with acute PE. While pulmonary angiography remains the 'gold standard' for diagnosis, a host of diagnostic modalities, interpreted in the setting of clinical probability, are available for patient assessment, including ECG, chest radiography, D-dimer, lower-extremity venous ultrasound, ventilation-perfusion scans, computed tomography and magnetic resonance angiography, and echocardiography, each with associated value. Diagnostic algorithms incorporate multiple tools in order to obtain a more comprehensive evaluation. Therapeutic anticoagulation remains the mainstay of therapy in PE. In massive PE, utilization of thrombolysis is reasonable in the absence of contraindications. Submassive PE, characterized by right ventricular dysfunction as assessed by echocardiography and ECG, is associated with higher mortality. Use of thrombolysis in submassive PE remains controversial. Catheter-directed therapies are emerging as an added approach to acute PE and have the potential to improve outcomes in PE. Use of inferior vena cava filters should be pursued in a select patient population as they serve to reduce recurrent acute PE; however, they are associated with more frequent deep venous thrombosis and provide no mortality benefit. In risk-stratified hemodynamically stable patients, an outpatient management strategy inclusive of therapeutic anticoagulation and careful clinical follow-up may be appropriate.

Acute pulmonary embolism (PE) may be rapidly fatal if not diagnosed and treated. IV heparin reduces mortality and recurrence of PE, but the relationship between survival and timing of anticoagulation has not been extensively studied.We studied 400 consecutive patients in the ED diagnosed with acute PE by CT scan angiography and treated in the hospital with IV unfractionated heparin from 2002 to 2005. Patients received heparin either in the ED or after admission. Time from ED arrival to therapeutic activated partial thromboplastin time (aPTT) was calculated. Outcomes included in-hospital and 30-day mortality, hospital and ICU lengths of stay, hemorrhagic events on heparin, and recurrent venous thromboembolism within 90 days.In-hospital and 30-day mortality rates were 3.0% and 7.7%, respectively. Patients who received heparin in the ED had lower in-hospital (1.4% vs 6.7%; P = .009) and 30-day (4.4% vs 15.3%; P.001) mortality rates as compared with patients given heparin after admission. Patients who achieved a therapeutic aPTT within 24 h had lower in-hospital (1.5% vs 5.6%; P = .093) and 30-day (5.6% vs 14.8%; P = .037) mortality rates as compared with patients who achieved a therapeutic aPTT after 24 h. In multiple logistic regression models, receiving heparin in the ED remained predictive of reduced mortality, and ICU admission remained predictive of increased mortality.We report an association between early anticoagulation and reduced mortality for patients with acute PE. We advocate further study with regard to comorbidities to assess the usefulness of modifications to hospital protocols.

Objective To examine the existing evidence on gender differences in the prevalence, treatment, and quality of life of patients with chronic rhinosinusitis (CRS). Methods Review of the literature and expert opinion. Results From a sociologic standpoint, women have historically been considered more likely to report symptoms, seek medical care, and give poorer self-evaluation of health, which may bias data toward increased prevalence and a greater effect of CRS on quality of life in women. However, the influence of gender seems to be restricted primarily to the evaluation of general quality of life, whereas the disease-specific health-related quality of life is not different between genders. Furthermore, migraine headaches, which are more common among women, may be misdiagnosed as CRS, which contributes to gender differences in the prevalence of CRS. The degree to which reported differences in prevalence and health utilization represent biologic or physiologic differences between genders is not known; however, differences in anatomic size, tobacco susceptibility, and hormonal factors have been speculated to increase the overall susceptibility to CRS in women compared with men. Conclusions Focused research that examines the effect of gender on the development, treatment, and outcomes of CRS is warranted.

Medical students and practitioners learn and use a vocabulary originating almost entirely from classical Latin and Greek languages. Previous generations required Latin or Greek prior to medical school, but the current generation does not have such requirements. Anecdotal evidence suggests that understanding Latin or Greek helps students to learn and practitioners to recall otherwise foreign terminology. This study evaluated students' familiarity with Latin and Greek etymologies before and after a gross anatomy course that incorporated etymologies into its curriculum.First-year medical students at Mayo Clinic College of Medicine were taught Latin and Greek etymologies through lectures and handouts during their gross anatomy course. They took a pretest and a posttest before and after the course to assess their understanding of etymologies. In addition, students from all four years of medical school, residents, and staff physicians also took a general etymology quiz to assess their understanding of etymologies.After their gross anatomy course emphasizing etymologies, first-year students scored higher on the posttest than they did on the pretest. First-year students also reported that learning etymologies enhanced anatomy learning, made the experience more enjoyable, and proved to be less difficult than they thought it would be prior to the course. Medical students, residents, and staff physicians scored almost equally on the general etymology quiz and almost equally reported that etymologies enhanced learning and recalling terminology. Medical students, residents, and staff physicians almost equally endorsed incorporating etymologies into medical education.This study provides novel scientific evidence that a basic understanding of Latin and Greek etymologies enhances performance and comfort when learning and using medical terminology.