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Rapid on-site evaluation (ROSE) performed during endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) has shown significant value. However, ROSE may not be available for some pulmonary centers. Performing ROSE can be challenging and stressful due to time constrains for preparing, staining and reviewing the cytology slides between passes.A retrospective cytology report review of EBUS-FNA procedures performed between October 2014 and May 2019 revealed 516 cases that were included in the study. The number of passes for each procedure was documented. The adequacy rates were assessed at 4 different study points; ≤3 passes, ≤5 passes, at odd passes only, and the even passes only. The study groups results were compared to the overall ROSE and the final cytology adequacy.The overall ROSE interpretation was adequate in 370 (71.7%) and inadequate in 146 (28.3%). After reviewing the Papanicolaou stained slides and cell blocks, the final cytology results were adequate in 473 (91.7%) and inadequate in 43 (8.3%) of the cases. The number of passes per procedure ranged from 1 to 17. Our results showed that ROSE evaluation of the first 5 passes during the EBUS-FNA procedure could achieve the similar adequacy rate compared to the overall ROSE evaluation of all the passes.To achieve the most benefits of ROSE and to reduce the procedure time for EBUS-FNA, we recommend performing ROSE for ≤5 passes depending on the adequacy, and save all additional passes for cell blocks preparation if more than 5 passes are attempted.

Early tracheostomy (fewer than eight days after intubation) is associated with shorter length of stay in the intensive care unit and shorter duration of mechanical ventilation. Studies assessing the association between early tracheostomy and incidence of delirium, however, are lacking. This investigation sought to fill this gap.Retrospective cross-sectional study.Multi-institutional acute care facilities in the United States.Data were derived from the National Inpatient Sample data from 2010 to 2014. Included patients were 65 or older and underwent both intubation and tracheostomy during the hospitalization. The authors excluded patients who underwent multiple intubations or tracheostomy procedures.Early tracheostomy versus non-early tracheostomy.In total, 23,310 patients were included, of whom 24.8% underwent early tracheostomy. From multivariate logistic regression, early tracheostomy was associated with lower odds of having a delirium diagnosis (odds ratio [OR] 0.77, p0.00001) across all admission classifications. Upon subgroup analysis, early tracheostomy was associated significantly with lower odds of having delirium for patients admitted with medical (OR 0.74, p0.00001) and nonsurgical injury admissions (OR 0.74, p = 0.00116).Early tracheostomy was associated significantly with lower odds of delirium among all patients studied. This association held true across medical and nonsurgical subgroups.

Since March 2019, E-cigarette or Vaping product associated lung injury (EVALI) has become an ongoing epidemic with more 2600 cases reported in the span of a few months in the United States. EVALI is defined as acute lung injury that develops secondary to the use of e-cigarettes or vaping products within the previous 90 days after exlusion of other possible inciting factors. Vitamin E acetate is believed to play a significant role in its pathogenesis. Treatment involves use of corticosteroids and further avoidance of these products. We describe a case series of 8 patients with EVALI, their clinical course and outcomes. All patients showed an excellent response to corticosteroids. In our experience, prognosis of EVALI is excellent, with complete resolution of symptoms in patients who followed up at 8 weeks.

An accurate assessment of the mediastinal lymph node status is essential in the staging and treatment planning of potentially resectable non-small-cell lung cancer.We performed this meta-analysis to evaluate the role of endobronchial ultrasound-guided transbronchial needle aspiration in detecting occult mediastinal disease in non-small-cell lung cancer with no radiologic mediastinal involvement.The PubMed, Embase, and Cochrane libraries were searched for studies describing the role of endobronchial ultrasound-guided transbronchial needle aspiration in patients with lung cancer with radiologically negative mediastinum. The individual and pooled sensitivity, prevalence, negative predictive value, and diagnostic odds ratio were calculated using the random effects model. Meta-regression analysis, heterogeneity, and publication bias were also assessed.A total of 13 studies that met the inclusion criteria were included in the meta-analysis. The pooled effect sizes of the different diagnostic parameters were estimated as follows: prevalence, 12.8% (95% confidence interval, 10.4-15.7%); sensitivity, 49.5% (95% confidence interval, 36.4-62.6%); negative predictive value, 93.0% (95% confidence interval, 90.3-95.0%); and log diagnostic odds ratio, 5.069 (95% confidence interval, 4.212-5.925). Significant heterogeneity was noticeable for the sensitivity, disease prevalence, and negative predictive value, but not observed for log diagnostic odds ratio. Publication bias was detected for sensitivity, negative predictive value, and log diagnostic odds ratio but not for prevalence. Bivariate meta-regression analysis showed no significant association between the pooled calculated parameters and the type of anesthesia, imaging used to define negative mediastinum, rapid on-site test usage, and presence of bias by Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. Interestingly, we observed a greater sensitivity, negative predictive value, and log diagnostic odds ratio for studies published before 2010 and for prospective multicenter studies.Among patients with non-small-cell lung cancer with a radiologically normal mediastinum, the prevalence of mediastinal disease is 12.8% and the sensitivity of endobronchial ultrasound-guided transbronchial needle aspiration is 49.5%. Despite the low sensitivity, the resulting negative predictive value of 93.0% for endobronchial ultrasound-guided transbronchial needle aspiration suggests that mediastinal metastasis is uncommon in such patients.

A 43-year-old man with a past medical history of HIV/AIDS presented with a cough, fever and night sweats. He was febrile, with normal heart rate and blood pressure. Initial laboratory testing included a mild leukocytosis. Chest X-ray demonstrated a right perihilar opacity and bilateral pleural effusions. He was admitted for treatment of pneumocystis pneumonia vs tuberculosis. He developed respiratory failure and was transferred to the ICU. He subsequently developed abdominal pain and severe lactic acidosis. CT scan demonstrated pneumatosis. Considering the clinical concern for mesenteric ischemia he was taken to the operating room, where it was noted that he had hepatomegaly and viable bowel. The mesentery demonstrated diffuse lymphadenopathy. Mesenteric lymph nodes were biopsied. He failed to improve clinically and his leukocytosis continued to increase to as high as 102,000, with a blood smear revealing atypical appearing lymphocytes. The patient continued to decline and ultimately died. Autopsy results demonstrated diffuse non-Hodgkin's lymphoma. Only 30 cases of non-Hodgkin's lymphoma have been reported in the literature as causing liver failure. This is the only case that included pneumatosis and lactic acidosis that mimicked mesenteric ischemia. How to cite this article Letourneau PA, Shah SK, Tchakarov A, Tanner AH, Hetz RA, Jani PP, Walker PA, Martinez EJ, Khan SA. Lactic Acidosis, Multiorgan Failure and Pneumatosis: A Rare Presentation of Lymphoma. Panam J Trauma Critical Care Emerg Surg 2013;2(2):94-96.