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Background Radial endobronchial ultrasound (R-EBUS) is an effective technique in the diagnosis of peripheral pulmonary lesions (PPL). However, lesion orientation with regards to the radial probe remains an important factor for effective biopsy. “Within” orientation was associated with significantly higher diagnostic yield. Cryobiopsy is a novel technique in obtaining larger tissue samples with the frozen tip allowing biopsy in a 360° direction, thus potentially achieving more effective biopsy in eccentrically and adjacently orientated lesions. We aimed to evaluate the performance and safety of transbronchial cryobiopsy versus forceps biopsy in eccentrically and adjacently orientated R-EBUS lesions. Methods Retrospective review of R-EBUS transbronchial biopsy for PPL over 17 months. Results 114 R-EBUS scans were included for analysis during the study period. Forceps biopsy was performed in 76 (66.7%) cases and cryobiopsy in 38 (33.3%) cases. Baseline demographics and lesion characteristics did not differ between the two groups. Median (interquartile range) lesion size was 3.48 (2.63–4.51) cm. Overall, 41.2% of lesions were of eccentric orientation and 15.8% adjacent orientation; only 43% were concentric in orientation. Overall diagnostic yield was 67.5% (77 out of 114). Orientation remained an important factor affecting diagnostic yield. Transbronchial cryobiopsy significantly increased the diagnostic yield in eccentrically and adjacently orientated lesions to 75.0% (18 out of 24), compared to 48.8% (20 out of 41) obtained via forceps biopsy (p, Transbronchial cryobiopsy under R-EBUS guidance potentially increases diagnostic yield in eccentric and adjacently orientated peripheral pulmonary lesions. http://bit.ly/2KWtkGq

Introduction: Obstructive sleep apnea (OSA) is a known risk factor for cardiovascular mortality and morbidity. Patients with OSA can present with clinical syndromes of heart failure, but most of them have preserved left ventricular ejection fraction (HFpEF). In Malaysia, data regarding left ventricular (LV) diastolic dysfunction among OSA patients is limited. Objective: To determine the prevalence of LV diastolic dysfunction and factors associated with LV diastolic dysfunction among OSA patients on positive airway pressure (PAP) treatment. Method: Cross-sectional study analyzing 47 patients with OSA on PAP treatment at Sarawak General Hospital. All patients underwent transthoracic echocardiography (TTE) and serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) level was measured. Results: The mean age was 52.2±14.24 years, mean body mass index (BMI) 39.80±89.7 kg/m2, and mean apnea hypopnea index (AHI) 60.7±29.1. The mean LVEF was 66.2±8.0% and 15.6% had LV diastolic dysfunction. Most patients (14.9%) had grade II and 2.1% with grade III LV diastolic dysfunction. Among the patients with LV diastolic dysfunction, NT-proBNP was significantly elevated (>125pg/ml) in 87.5% of patients (p 125pg/ml had positive predictive value, negative predictive value, sensitivity and specificity of 70%, 97.3%, 87.5% and 92.3% respectively to diagnose LV diastolic dysfunction. Conclusion: The prevalence of LV diastolic dysnfunction in OSA patients was 15.6%. Elevated NT-proBNP level (>125 pg/ml) was a useful biomarker in the diagnosis of LV diastolic dysfunction among OSA patients.

A 38-year-old previously fit smoker of 10 pack-years presented with 1 month of progressive worsening exertional dyspnoea. He had no cough, chest pain nor constitutional symptoms. Auscultation of the chest revealed widespread crepitations. Oxygen saturation was 96% on room air, desaturating to 88% after mild exertion. Chest radiograph showed diffuse nodular interstitial infiltrates with significant peribronchial cuffing. CT thorax revealed multiple Cheerio signs of varying sizes and wall thickness, distributed evenly bilaterally (figure 1). There was significant interlobular septal thickening with thickened peribronchovascular bundles, and a thick-walled cavitation in the left lower lobe. Flexible bronchoscopy was performed under fluoroscopy via endotracheal tube. Radial endobronchial ultrasound (R-EBUS) examination at all visible subsegmental branches of the lateral segment of the right lower lobe demonstrated multiple scattered hyperechoic linear arcs and dots, representing patent airspaces (figure 2A,B, arrow). Transbronchial lung cryobiopsy was performed uneventfully at the site of the R-EBUS examination. Histopathological examination revealed invasive lung adenocarcinoma with predominantly micropapillary and …

A 45-year-old man with no known chronic medical illness presented with insidious onset of exertional dyspnoea and left pleuritic chest pain. He was pale on physical examination and left chest percussion note was dull. Otherwise, he had no telangiectasia, cyanosis or finger clubbing. No family history of telangiectasia or bleeding episodes were reported, he also denied any history of epistaxis or haemoptysis. Chest roentograph on admission demonstrated left pleural effusion. Transthoracic ultrasound showed a large thin-walled elongated hypoechoic nodule surrounded by collapsed lung and loculated hyperechoic pleural fluid (figure 1A, arrow). Colour Doppler ultrasound established turbulent flow within the nodule (figure 1B, arrow) which raised the suspicion of pulmonary arteriovenous malformation (PAVM). His haemoglobin level was 5.5 g/dL. Urgent CT thorax revealed multiple PAVMs with the largest at the left lower lobe, arising …

Chylothorax is defined as the presence of chyle in the pleural cavity. Central vein thrombosis is an under-recognized cause of chylothorax in the adult population and is commonly related to central venous catheterization. Case 1 illustrates a patient with AIDS and disseminated tuberculosis with left chylothorax and central vein thrombosis after a month of antituberculosis therapy. Case 2 was a patient with advanced seminoma who presented with left chylothorax and central vein thrombosis while on chemotherapy. Chylothorax resolved with anticoagulation for both cases. Case 3 was a lymphoma patient with central vein thrombosis who developed chylothorax during chemotherapy. Chylothorax resolved with the continuation of anticoagulation and did not recur despite his progressive underlying lymphoma. There was no central venous catheterization in any of these three cases. These cases illustrate the unique association of central vein thrombosis and chylothorax and the importance of anticoagulation in its management.