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Background Staging guidelines for lung cancer recommend endobronchial ultrasound (EBUS) and systematic biopsy of at least three mediastinal lymph node (LN) stations for accurate staging. A four-point ultrasonographic score (Canada Lymph Node Score [CLNS]) was developed to determine the probability of malignancy in each LN. A LN with a CLNS of Research Question Do LNs considered triple normal on CT scanning, PET scanning, and CLNS evaluation require routine biopsy? Study Design and Methods LNs were evaluated for ultrasonographic features at the time of EBUS and the CLNS was applied. Triple-normal LNs were defined as cN0 on CT scanning (short axis, Results In total, 143 LNs from 57 cN0 patients were assessed. Triple-normal LNs showed a specificity and NPV of 60% (95% CI, 51.2%-68.3%) and 93.1% (95% CI, 85.6%-97.4%), respectively. After pathologic assessment, only 5.6% (n = 8/143) of triple-normal nodes were proven to be malignant. Interpretation At the time of staging for lung cancer, combining CT scanning, PET scanning, and CLNS criteria can identify triple-normal LNs that have a high NPV for malignancy. This raises the question of whether triple-normal LNs require routine sampling during EBUS and transbronchial needle aspiration. A prospective trial is required to confirm these findings.

Staging guidelines for lung cancer recommend endobronchial ultrasound (EBUS) and systematic biopsy of at least three mediastinal lymph node (LN) stations for accurate staging. A four-point ultrasonographic score (Canada Lymph Node Score [CLNS]) was developed to determine the probability of malignancy in each LN. A LN with a CLNS of 2 is considered low probability for malignancy. We hypothesized that, in patients with cN0 non-small cell lung cancer, LNs with CLNS of 2 may not require routine biopsy because they represent true node-negative disease.Do LNs considered triple normal on CT scanning, PET scanning, and CLNS evaluation require routine biopsy?LNs were evaluated for ultrasonographic features at the time of EBUS and the CLNS was applied. Triple-normal LNs were defined as cN0 on CT scanning (short axis, 1 cm), PET scanning (no hypermetabolic activity), and EBUS (CLNS, 2). Specificity and negative predictive value (NPV) were calculated against the gold standard pathologic diagnosis from surgically excised specimens.In total, 143 LNs from 57 cN0 patients were assessed. Triple-normal LNs showed a specificity and NPV of 60% (95% CI, 51.2%-68.3%) and 93.1% (95% CI, 85.6%-97.4%), respectively. After pathologic assessment, only 5.6% (n = 8/143) of triple-normal nodes were proven to be malignant.At the time of staging for lung cancer, combining CT scanning, PET scanning, and CLNS criteria can identify triple-normal LNs that have a high NPV for malignancy. This raises the question of whether triple-normal LNs require routine sampling during EBUS and transbronchial needle aspiration. A prospective trial is required to confirm these findings.

Background Guidelines recommend lung cancer screening (LCS), and it is currently being adopted nationwide. The American College of Chest Physicians advises inclusion of specific programmatic components to ensure high-quality screening. However, little is known about how LCS has been implemented in practice. We sought to evaluate the experience of early-adopting programs, characterize barriers faced, and identify strategies to achieve successful implementation. Methods We performed qualitative evaluations of LCS implementation at three Veterans Administration facilities, conducting semistructured interviews with key staff (n = 29). Guided by the Promoting Action on Research Implementation in Health Services framework, we analyzed transcripts using principals of grounded theory. Results Programs successfully incorporated most recommended elements of LCS, although varying in approaches to patient selection, tobacco treatment, and quality audits. Barriers to implementation included managing workload to ensure appropriate evaluation of pulmonary nodules detected by screening and difficulty obtaining primary care "buy-in." To manage workload, programs used nurse coordinators to actively maintain screening registries, held multidisciplinary conferences that generated explicit management recommendations, and rolled out implementation in a staged fashion. Successful strategies to engage primary care providers included educational sessions, audit and feedback of local outcomes, and assisting with and assigning clear responsibility for nodule evaluation. Capitalizing on pre-existing relationships and including a designated program champion helped facilitate intradisciplinary communication. Conclusions Lung cancer screening implementation is a complex undertaking requiring coordination at many levels. The insight gained from evaluation of these early-adopting programs may inform subsequent design and implementation of LCS programs.

Guidelines recommend lung cancer screening (LCS), and it is currently being adopted nationwide. The American College of Chest Physicians advises inclusion of specific programmatic components to ensure high-quality screening. However, little is known about how LCS has been implemented in practice. We sought to evaluate the experience of early-adopting programs, characterize barriers faced, and identify strategies to achieve successful implementation.We performed qualitative evaluations of LCS implementation at three Veterans Administration facilities, conducting semistructured interviews with key staff (n = 29). Guided by the Promoting Action on Research Implementation in Health Services framework, we analyzed transcripts using principals of grounded theory.Programs successfully incorporated most recommended elements of LCS, although varying in approaches to patient selection, tobacco treatment, and quality audits. Barriers to implementation included managing workload to ensure appropriate evaluation of pulmonary nodules detected by screening and difficulty obtaining primary care "buy-in." To manage workload, programs used nurse coordinators to actively maintain screening registries, held multidisciplinary conferences that generated explicit management recommendations, and rolled out implementation in a staged fashion. Successful strategies to engage primary care providers included educational sessions, audit and feedback of local outcomes, and assisting with and assigning clear responsibility for nodule evaluation. Capitalizing on pre-existing relationships and including a designated program champion helped facilitate intradisciplinary communication.Lung cancer screening implementation is a complex undertaking requiring coordination at many levels. The insight gained from evaluation of these early-adopting programs may inform subsequent design and implementation of LCS programs.

Introduction Interest in databases is growing to allow for outcomes research, assess health-care quality, and determine best practices and resource allocation, and they are increasingly considered as a tool to potentially tie reimbursement to outcome parameters. Little is known about resource use and risk-adjusted morbidity and mortality after therapeutic bronchoscopic interventions. Methods Data were extracted and reviewed from an ongoing prospective, multi-institutional outcomes database for therapeutic bronchoscopic interventions. All consecutive patients are entered into this database, and information on demographics, indications, procedures and anesthesia, comorbidities and general health status, urgency of intervention, morbidity and mortality to 30 days, increase in levels of care, and procedural resources is documented. Results From December 2005 to May 2007, 554 therapeutic procedures were performed in four hospitals. Most procedures were done under general anesthesia (n = 362) and rigid bronchoscopy (n = 483), and the most common intervention was airway stent placement (n = 258). Forty-two percent of procedures were done urgently or emergently. Complications were common (19.8%), and 30-day mortality was 7.8%, correlating with underlying health status and urgency of intervention. Discussion Prospective and ongoing data analysis for bronchoscopic procedures is feasible and valuable. Risk-adjusted and disease-specific outcomes can be documented and potentially used for quality assessment, benchmarking, and quality improvement initiatives. Appropriate use of resources and effect of interventions can be documented. Extending the number of participating centers as well as inclusion of quality of life tools and technical success are the next steps.

Study objectives The left anterior descending artery (LADA), particularly when the proximal segment of the vessel is involved, is a challenging area for percutaneous coronary interventions (PCIs); therefore, coronary artery bypass grafting is often considered and sometimes performed even in patients with single-vessel disease involving the LADA. This study compares mid-term results of LADA revascularization with a drug-eluting stent (DES), with off-pump coronary artery bypass grafting (OPCAB) in patients with single-vessel or multivessel coronary artery disease (CAD) Design Matched-groups, retrospective cohort comparison between the DES and OPCAB Patients From June 2002 to December 2003, 354 patients underwent myocardial revascularization of the LADA by OPCAB, and 168 by DES. After matching for age, sex, and extent of CAD, two groups (116 patients each) were used to compare the two revascularization modalities. The groups were similar; however, an ejection fraction of Results The average number of coronary vessels treated per patient in the two groups was similar (OPCAB, 1.97; DES, 1.6; p = 0.581). The 30-day mortality rate was 0.9% in the OPCAB group and 0% in the DES group (p = 0.329). The mean duration of follow-up was 12 months. There was one late death in each group. Angina returned in 31% of patients in the DES group and in 11.2% of the patients in the OPCAB group (p = 0.001). There were 12 reinterventions in the DES group compared to three reinterventions in the surgical group (p = 0.020). The only independent predictor (Cox proportional hazards regression model) of the return of angina (risk ratio [RR], 3.36; 95% confidence interval [CI], 1.57 to 7.14) and reintervention (RR, 3.9; 95% CI, 1.34 to 11.24) was assignment to the DES group Conclusions The mid-term clinical outcome of OPCAB in patients with CAD, including multivessel disease, was better than that for PCIs with only one DES used in patients with similar extents of CAD

Study objectives Cardiac output (CO) is measured but sparingly due to limitations in its measurement technique ( ie , right-heart catheterization). Yet, in recent years it has been suggested that CO may be of value in the diagnosis, risk stratification, and treatment titration of cardiac patients, especially those with congestive heart failure (CHF). We examine the use of a new noninvasive, continuous whole-body bioimpedance system (NICaS; NI Medical; Hod-Hasharon, Israel) for measuring CO. The aim of the present study was to test the validity of this noninvasive cardiac output system/monitor (NICO) in a cohort of cardiac patients. Design Prospective, double-blind comparison of the NICO and thermodilution CO determinations. Patients We enrolled 122 patients in three different groups: during cardiac catheterization (n = 40); before, during, and after coronary bypass surgery (n = 51); and while being treated for acute congestive heart failure (CHF) exacerbation (n = 31). Measurements and intervention In all patients, CO measurements were obtained by two independent blinded operators. CO was measured by both techniques three times, and an average was determined for each time point. CO was measured at one time point in patients undergoing coronary catheterization; before, during, and after bypass surgery in patients undergoing coronary bypass surgery; and before and during vasodilator treatment in patients treated for acute heart failure. Results Overall, 418 paired CO measurements were obtained. The overall correlation between the NICO cardiac index (CI) and the thermodilution CI was r = 0.886, with a small bias (0.0009 ± 0.684 L) [mean ± 2 SD], and this finding was consistent within each group of patients. Thermodilution readings were 15% higher than NICO when CI was 2 , and 5% lower than NICO when CI was > 3 L/min/m 2 . The NICO has also accurately detected CI changes during coronary bypass operation and vasodilator administration for acute CHF. Conclusion The results of the present study indicate that whole-body bioimpedance CO measurements obtained by the NICO are accurate in rapid, noninvasive measurement and the follow-up of CO in a wide range of cardiac clinical situations.

Study objective: To prospectively address the question whether the assessment of valvular hemodynamics and myocardial function during low-dose dobutamine infusion can guide decision making in patients with aortic stenosis and left ventricular (LV) dysfunction. Patients and measurements: Twenty-four patients with aortic stenosis and LV dysfunction (mean ejection fraction, 28%; New York Heart Association class, II to IV) were studied by dobutamine echocardiography assessing mean pressure gradient, aortic valve area, and aortic valve resistance. Patients were prospectively divided into severe and nonsevere aortic stenosis groups according to the response of the valve area to the augmentation of systolic flow. The clinical decision was considered to be concordant with the results of dobutamine echocardiography, when patients with severe aortic stenosis and preserved contractile function were referred by a specialist for aortic valve replacement and when patients with nonsevere aortic stenosis were not. Patients were observed for up to 3 years. Results: All eight patients with severe aortic stenosis who were referred for surgery survived and had good cardiovascular outcomes, and six of eight patients who were not initially referred for surgery had poor outcomes, including heart failure and sudden cardiac death. The eight patients with nonsevere aortic stenosis did comparatively well without valve replacement. Cardiac death or pulmonary edema occurred in 4 of 16 patients (25%) when the clinical decision was concordant with the results of the dobutamine echocardiogram and occurred in 6 of 8 patients (75%) when the clinical decision was discordant (p 5 0.019 [x 2 test]). Conclusion: Patients with aortic stenosis, LV dysfunction, and relatively low gradients have better outcomes when management decisions are based on the results of dobutamine echocardiograms. Those patients identified as having severe aortic stenosis and preserved contractile reserve by dobutamine echocardiography should undergo surgery, while patients identified as having nonsevere aortic stenosis can be managed conservatively. (CHEST 2001; 119:1766‐1777)

Objective Clinical observation has identified cases inwhich the negative pressures exerted on patient chest drains haveappeared to far exceed the level of suction intended. This study wasdesigned to test whether the use of high rates of airflow in typicalpleural/mediastinal drainage systems exerts excessively high negativepressures on the chest drainage tube. Methods Threepleural drainage systems were tested in vitro atnegative pressure settings ranging, in 5-cm H 2 O increments, from 5 to 35 cm H 2 O. At each negative-pressure setting, each device was tested with three different rates of airflow. Thenegative pressures exerted in the chest drain were measured by watermanometer and were compared with the initial pressure settings. Results When a high rate of airflow was used, allthree systems produced negative pressures that exceeded the pressurelevel initially set; two of the systems exerted negative pressures thatwere approximately double those intended, for all pressuresettings. Conclusions Pleural drainage systemsmay exert excessive and potentially dangerous high negative pressuresif high airflow is utilized. The risk to patients will be minimized ifthe airflow through the pressure-regulating chamber of the drainagesystem is adjusted to produce slow, consistent bubbling. High rates ofbubbling and turbulence in the water column indicate that the negativepressure level may be excessively high, particularly for patients whodo not have air leakage.