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Background: Healthcare workers (HCWs) are at high risk of exposure to SARS-CoV-2. Cross-sectional studies have provided variable rates of seroprevalence in HCWs. Longitudinal assessments of the serological response to Covid-19 among HCWs are crucial to understanding the risk of infection and changes in antibody titers over time. We aimed to investigate seroprevalence and risk factors associated with seroconversion in a prospective cohort of HCWs during the peak of the first wave of the Covid-19 pandemic., Methods: We conducted a longitudinal study among 446 front-line HCWsin a tertiary-care hospital in Chile from April to July 2020. IgG was determined monthly using two different ELISAs in serum samples of HCWs, during the three-month period. In each visit, demographic data, symptoms, risk factors, and exposure risks were also assessed., Results: The overall seroprevalence at the end of the study period was 24% (95% CI20.2-28.3), with 43% of seropositive HCWs reporting no prior symptoms. Seroconversion rates significantly differed over the study period, from 2.1% to as high as 8.8% at the peak of the epidemic. There were no statistically significant differences observed between HCWs in direct clinical care of patients with Covid-19 and those working in low risk areas. Antibody titers appeared to wane over time., Conclusions: HCWs were severely affected with a high rate of seroconversion that appeared to mirror the local epidemiological situation. A significant amount of participants underwent an asymptomatic infection, highlighting the need for improved surveillance policies. Antibody titers appear to wane over time; further studies to understand this finding's impact on the risk of reinfection are warranted.

Background: Understanding the characteristics of the Covid-19 pandemic in different geographical regions, ethnic and socioeconomic settings are of emerging importance. This study presents the demographic and clinical features of SARS-CoV-2 infected patients in a large private healthcare center in Santiago, Chile, during the first month of the pandemic., Methods: We analyzed the demographics, laboratory and clinical characteristics including severity and outcome of all patients diagnosed with Covid-19 during the first month of the pandemic. SARS-2-CoV infection was confirmed by RT-PCR in nosopharyngeal samples. The primary outcome was a composite of ICU admission or all-cause, in-hospital mortality. Clinical and laboratory parameters of hospitalized patients were analyzed regarding their association with the primary outcome., Results: From March 3 to April 4, 2020, 3679 individuals were tested for SARS-CoV-2 in our hospital. Of those, 381 had Covid-19 and were included into this analysis. Most patients (99.2%) were Chileans, 12% returning from recent travel. The median age was 39 years (IQR 31-49) and 52% were female. A total of 88 patients (23.1%) were hospitalized; 18 (3.7%) required ICU and/or died. The overall mortality was 0.7%. Increased body mass index (BMI) and elevated C-reactive protein (CRP) were independently associated with ICU care or death., Conclusion: During the first weeks of the pandemic in Chile, most Covid-19 patients were young, with low rates of hospitalization, ICU requirement, and fatality. BMI and CRP on admission were predictors for severity. Our data provide important information on the clinical course and outcome of Covid-19 in a Latin American setting.

Background: Thoracentesis using suction is perceived to have increased risk of complications, including pneumothorax and re-expansion pulmonary oedema (REPO). Current guidelines recommend limiting drainage to 1.5 L to avoid REPO. Our purpose was to examine the incidence of complications with symptom-limited drainage of pleural fluid using suction and identify risk factors for REPO., Methods: A retrospective cohort study of all adult patients who underwent symptom-limited thoracentesis using suction at our institution between January 1, 2004 and August 31, 2018 was performed, and a total of 10 344 thoracenteses were included., Results: Pleural fluid ≥1.5 L was removed in 19% of the procedures. Thoracentesis was stopped due to chest discomfort (39%), complete drainage of fluid (37%) and persistent cough (13%). Pneumothorax based on chest radiography was detected in 3.98%, but only 0.28% required intervention. The incidence of REPO was 0.08%. The incidence of REPO increased with Eastern Cooperative Oncology Group performance status (ECOG PS) ≥3 compounded with ≥1.5 L (0.04-0.54%; 95% CI 0.13-2.06 L). Thoracentesis in those with ipsilateral mediastinal shift did not increase complications, but less fluid was removed (p<0.01)., Conclusions: Symptom-limited thoracentesis using suction is safe even with large volumes. Pneumothorax requiring intervention and REPO are both rare. There were no increased procedural complications in those with ipsilateral mediastinal shift. REPO increased with poor ECOG PS and drainage ≥1.5 L. Symptom-limited drainage using suction without pleural manometry is safe., Competing Interests: Conflict of interest: A.E.S. Sagar has nothing to disclose. Conflict of interest: M.F. Landaeta has nothing to disclose. Conflict of interest: A.M. Adrianza has nothing to disclose. Conflict of interest: G.L. Aldana has nothing to disclose. Conflict of interest: L. Pozo has nothing to disclose. Conflict of interest: A. Armas-Villalba has nothing to disclose. Conflict of interest: C.C. Toquica has nothing to disclose. Conflict of interest: A.J. Larson has nothing to disclose. Conflict of interest: M.R. Vial has nothing to disclose. Conflict of interest: H.B. Grosu has nothing to disclose. Conflict of interest: D.E. Ost has nothing to disclose. Conflict of interest: G.A. Eapen has nothing to disclose. Conflict of interest: A. Sheshadri has nothing to disclose. Conflict of interest: R.C. Morice has nothing to disclose. Conflict of interest: V.R. Shannon has nothing to disclose. Conflict of interest: L. Bashoura has nothing to disclose. Conflict of interest: D.D. Balachandran has nothing to disclose. Conflict of interest: F.A. Almeida has nothing to disclose. Conflict of interest: M.H. Uzbeck has nothing to disclose. Conflict of interest: R.F. Casal has nothing to disclose. Conflict of interest: S.A. Faiz has nothing to disclose. Conflict of interest: C.A. Jimenez has nothing to disclose., (Copyright ©ERS 2020.)

Background: Pulmonary carcinoids, which are well-differentiated lung neuroendocrine carcinomas, account for only 1-2 % of primary lung malignancies. Although fluorodeoxyglucose positron-emission tomography/computed tomography performs poorly in the identification of mediastinal lymph node metastases, particularly for pulmonary carcinoids, endobronchial ultrasound-guided (EBUS) transbronchial needle aspiration (TBNA) may be a useful means of preoperative nodal assessment in patients with these conditions. However, the diagnostic performance of EBUS TBNA is unknown. This study was designed to determine the sensitivity of EBUS for mediastinal staging in patients with typical carcinoid., Study Design and Methods: A retrospective review of all patients with carcinoids who underwent EBUS TBNA and/or surgical resection with lymphadenectomy at The University of Texas MD Anderson Cancer Center was performed. The sensitivity of EBUS -TBNA in diagnosis of mediastinal lymph node metastases was determined., Results: Of the 212 patients with pulmonary carcinoids we identified, 137 had surgery with no preoperative EBUS TBNA, 68 had EBUS TBNA followed by surgery, and 7 had EBUS TBNA only. The sensitivity rate for EBUS TBNA in diagnosis of mediastinal lymph node metastases was 77.78 % overall (95 % CI, 57.7-91.3%) and it was 87.5 % (95 % CI, 67.6-97.3%) when we considered only patients with EBUS TBNA-accessible lymph nodes., Discussion: The sensitivity of EBUS TBNA for diagnosis of mediastinal lymph node metastases of pulmonary carcinoids was slightly lower than that reported previously for non-small cell lung cancer. Preoperative EBUS TBNA identified nodal metastases not previously identified by imaging., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: The behavior of pleural fluid cytokine (PFCs) levels and their association with pleurodesis after indwelling pleural catheter (IPC) placement is unknown., Objective: A prospective exploratory study was conducted to obtain preliminary data on PFC levels after IPC placement., Methods: The PFC panel consisted of 4 cytokines [interleukin -8 (IL-8), vascular endothelial growth factor, total (but not activated) transforming growth factor betas, and basic fibroblast growth factor], measured across 5 time points (T0: insertion; T1: 24 to 48 h; T2: 72 to 96 h; T3: 1 wk; and T4: 2 wk). Profile plots were used to identify patterns of change of PFC levels. Correlation matrices for each PFC over time were computed, and area under the curve (AUC) categories were used to compare the cumulative incidence of IPC removal. Auto pleurodesis was defined as elective catheter removal because of decreased drainage within 90 days of insertion., Results: A total of 22 patients provided complete data. Except for IL-8, the majority of PFCs demonstrated strong positive correlations across measurement time points. Patients with high AUCs for IL-8, basic fibroblast growth factor, and vascular endothelial growth factor had a higher cumulative incidence of IPC removal by 90 days than did patients with low AUCs., Conclusion: This is the first study to evaluate longitudinal changes of pleural cytokine levels with respect to the likelihood of IPC removal and provide early evidence that the cytokine profile may be associated with the outcome of pleurodesis induced by IPCs. However, this is an exploratory study and further studies are needed to assess if these findings can be validated in further studies.

Background: Malignancy-associated secondary spontaneous pneumothorax (MSSP) poses significant challenges due to limited survival. By assessing risk factors associated with a MSSP recurrence, there is potential to identify patients who could benefit from early intervention intended to prevent recurrence., Methods: We performed a retrospective cohort study of patients with MSSP. The primary outcome was time to MSSP recurrence. We used a competing risk model to identify risk factors associated with MSSP recurrence., Results: A total of 2,532 patients were diagnosed with pneumothorax, with 114 having MSSP but only 96 were evaluable for the time-to-recurrence analysis. Of the 96 patients, 9 (9.4%) patients experienced recurrent MSSP, and 58 (60.4%) patients died during the study's follow-up period. The estimated cumulative incidence (CI) of MSSP considering death as a competing risk was 10.1% at 15 months. The univariable model identified the following covariates as associated with MSSP recurrence: mediastinal shift (HR 12.30, 95% CI: 3.44-43.91, P<0.001), distance from lung apex to thoracic cupola (HR 1.02, 95% CI: 1.00-1.03, P=0.003), and distance between visceral and chest wall at the hilum (HR 1.02, 95% CI: 1.00-1.03, P=0.026)., Conclusions: Although the incidence of MSSP recurrence was found to be low, clinical factors such as sarcoma, the associated mediastinal shift, greater distance from lung apex to thoracic cupola, greater distance between visceral and chest wall at the hilum were found to be risk factors for MSSP recurrence., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: The tyrosine kinase inhibitor pazopanib is used for treatment of sarcoma. Recent studies have suggested that the use of pazopanib may lead to the development of pneumothorax, an unexpected adverse effect in patients with sarcoma metastatic to the chest., Methods: We conducted a retrospective case control study of patients with sarcoma with metastases to the chest with pneumothorax (cases) and without pneumothorax (controls). The control population was selected from tumor registry in a 1:4 (cases to controls) ratio. The primary outcome of interest was the association between pazopanib and pneumothorax risk in patients with sarcoma metastatic to the chest. Secondary objective was to evaluate risk factors for pneumothorax., Results: We identified 41 cases and 164 controls. Using purposeful selection method the odds of developing pneumothorax while being on pazopanib was not significant in univariate (p = .06) and multivariable analysis (p = .342). On univariate analysis risk factors of pneumothorax in patients with sarcoma were age, male sex, African American race, the presence of cavitary lung nodules/masses, and the presence of pleural-based nodules/masses. On multivariate analysis, only the presence of cavitary lung nodules/masses (P < .001) and the presence of pleural-based nodules/masses (P < .001) remained as risk factors for developing pneumothorax., Conclusion: Pazopanib does not increase the risk of pneumothorax in patients with sarcoma and evidence of metastatic disease to the chest. Presence of cavitary lung nodules/masses and the presence of pleural-based nodules/masses were found to be risk factors for pneumothorax.

Endobronchial ultrasound-guided transbronchial needle biopsy (EBUS-TBNA) has proven to be an effective and minimally invasive tool to diagnose and stage lung cancer. However, its use for the diagnosis of rare mediastinal and lung pathologies has been rarely described. Hereby we describe a retrospective chart review of our EBUS-TBNA database for unusual diagnosis made between July 2012 and October 2016. Those conditions considered unusual for EBUS-TBNA diagnosis were identified and their medical records reviewed., (Copyright © 2018 Sociedade Portuguesa de Pneumologia. Published by Elsevier España, S.L.U. All rights reserved.)

Competing Interests: Competing interests: None declared.

Transdifferentiation from non-small cell lung cancer (NSCLC) to small cell lung cancer (SCLC) has been reported mostly in adenocarcinomas and has been described as a cause of acquired tyrosine kinase inhibitor (TKI) resistance. However, transdifferentiation has also been described in patients with different histologic characteristics and patients not exposed to TKIs and with no epidermal growth factor receptor (EGFR) mutation (the target of TKIs). To this date transdifferentiation remains poorly understood. We conducted a retrospective case series of patients who had biopsy-proven SCLC within 2 years after a diagnosis of NSCLC or in the same location as the known primary NSCLC. We found that 0.2% of lung cancer patients at our institution experienced transdifferentiation. Among these, 30 had adenocarcinoma and 16 had squamous cell carcinoma. In 27 of the 30 patients with adenocarcinoma (90%), SCLC was found in the same location as the known primary. In 14 of the 30 patients (47%), SCLC occurred within 2 years after the NSCLC diagnosis. In 12 of the 16 patients with squamous cell carcinoma (75%), SCLC was found in the same location as the known primary. In 8 of these 16 patients (50%), SCLC occurred within 2 years after the NSCLC diagnosis. Few patients with adenocarcinoma and none with squamous cell carcinoma were treated with TKIs or had an EGFR mutation. In conclusion the findings in the current study suggest that the discovery of SCLC histology after treatment of NSCLC may be more common than thought suggesting that further study is warranted to evaluate the phenomenon of transdifferentiation., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background and Objective: Pleuroscopy is the test of choice for patients with suspected malignant pleural effusion and negative cytology. Biopsies negative for malignancy are frequently attributed to non-specific pleuritis, which poses a dilemma in patients with a known active malignancy, raising concern for a false-negative result. Our primary objective was to determine the outcomes of patients with active malignancy who had a non-malignant diagnosis on pleuroscopy., Methods: Retrospective review of all pleuroscopy cases from January 2005 to January 2015 at our institution was conducted. Biopsies were categorized by histopathology as malignant, eosinophilic or non-specific pleuritis. Malignant histopathology was considered a true positive. Eosinophilic or non-specific pleuritis was categorized as malignant, if malignancy was later identified during follow-up, or chemotherapy induced, possible radiation induced, other paramalignant, other benign or idiopathic., Results: Of the 199 pleuroscopy cases reviewed, 172 (86%) had a history of active malignancy. On histopathology, 73 (42%) had malignancy, 9 (5%) had eosinophilic pleuritis and 90 (52%) had non-specific pleuritis. Three patients with non-specific pleuritis were diagnosed with malignancy at follow-up. Pleuritis in 24 patients was chemotherapy induced, 27 were possibly radiation induced, 11 were other paramalignant and 3 were other benign. Idiopathic pleuritis was diagnosed in 31 patients. Patients were monitored for a mean of 23 ± 11 months., Conclusion: The prevalence of malignant pleural disease was lower than expected for our patient population. Patients with no malignancy on histopathology were most likely to have non-specific pleuritis, a cause for which was identified in a majority of patients after clinical review., (© 2017 Asian Pacific Society of Respirology.)

Background: The optimal approach to sedation for pleuroscopy remains undefined. Propofol is the favored sedative-hypnotic for many proceduralists but has a narrow therapeutic window and the risk for oversedation is high. Propofol-based sedation administered by anesthesiologists and the routine use of end-tidal capnography and bispectral index (BIS) monitoring may attenuate risks of complications., Objectives: The purpose of our study was to evaluate the safety and efficacy of monitored anesthesia care for pleuroscopy., Methods: We conducted a retrospective cohort study of patients who underwent pleuroscopy. The primary outcome of interest was the incidence of anesthesia complications in patients undergoing pleuroscopy. Hypoxia was defined as oxygen saturation of less than 90% for 2 min and hypotension was defined as the need for vasopressors., Results: Of 199 enrolled patients, there were no significant complications attributed directly to anesthesia. Minor complications included hypoxia in 9 patients (4.5%), hypotension in 76 patients (38.2%), and insertion of a nasopharyngeal tube airway in 2 patients (1.0%). There was no significant difference in anesthesia-related complications between those with BIS monitoring and those without. Lower mean oxygen saturations (p = 0.028) and hypoxia (p = 0.021) were found in patients receiving the combination of propofol plus narcotics plus sedatives compared to those receiving propofol only, propofol plus narcotics or propofol plus sedatives., Conclusion: Our study demonstrates that pleuroscopy using propofol with end-tidal capnography monitoring, with or without BIS monitoring, is safe and effective. The combination of propofol with narcotics and sedatives is associated with more hypoxia and lower mean oxygen saturation compared with propofol alone, propofol plus narcotics or propofol plus sedatives., (© 2017 S. Karger AG, Basel.)

Background and Objective: Standard nodal staging of lung cancer consists of positron emission tomography/computed tomography (PET/CT), followed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) if PET/CT shows mediastinal lymphadenopathy. Sensitivity of EBUS-TBNA in patients with N0/N1 disease by PET/CT is unclear and largely based on retrospective studies. We assessed the sensitivity of EBUS-TBNA in this setting., Methods: We enrolled patients with proven or suspected lung cancer staged as N0/N1 by PET/CT and without metastatic disease (M0), who underwent staging EBUS-TBNA. Primary outcome was sensitivity of EBUS-TBNA compared with a composite reference standard of surgical stage or EBUS-TBNA stage if EBUS demonstrated N2/N3 disease., Results: Seventy-five patients were included in the analysis. Mean tumour size was 3.52 cm (±1.63). Fifteen of 75 patients (20%) had N2 disease. EBUS-TBNA identified six while nine were only identified at surgery. Sensitivity of EBUS-TBNA for N2 disease was 40% (95% CI: 16.3-67.7%)., Conclusion: A significant proportion of patients with N0/N1 disease by PET/CT had N2 disease (20%) and EBUS-TBNA identified a substantial fraction of these patients, thus improving diagnostic accuracy compared with PET/CT alone. Sensitivity of EBUS-TBNA however appears lower compared with historical data from patients with larger volume mediastinal disease. Therefore, strategies to improve EBUS-TBNA accuracy in this population should be further explored., (© 2017 Asian Pacific Society of Respirology.)

The standard approach to staging of lung cancer in patients with pleural effusion (clinical M1a) is thoracentesis followed by pleural biopsies if the cytologic analysis is negative. If pleural biopsy findings are negative, endobronchial ultrasound-guided transbronchial needle aspiration is used to complete the staging process and, in some cases, obtain diagnosis. In this case series we report 7 patients in which a combined procedure was performed for staging of known or suspected lung cancer. We found that the combined approach was both feasible and safe in this case series.

Fibroepithelial polyps are benign lesions, frequently found in the skin and genitourinary tract. Airway involvement is rare, and few case reports have been published. Our patient was a 79 y.o. male smoker, who was referred to us with a 3-month history of dry cough. At physical examination, the patient looked well, but a chest CT showed a 6-mm polyp lesion in his trachea. A flexible bronchoscopy confirmed this lesion, and forceps biopsies were performed. Argon plasma coagulation was used to completely resect and treat the lesion. Pathological analysis revealed a fibroepithelial polyp (FP). The aim of this manuscript is to report a case of FP with bronchoscopic management and to review the current literature about this condition.

Rationale: Endobronchial ultrasound (EBUS) has transformed mediastinal staging in lung cancer. A systematic approach, beginning with lymph nodes contralateral to the primary tumor (N3), is considered superior to selective sampling of radiographically abnormal nodes. However, the extent to which this recommendation is followed in practice remains unknown., Objectives: To assess the frequency with which pulmonologists, pulmonary fellows, and interventional pulmonologists endoscopically stage lung cancer appropriately., Methods: Bronchoscopists currently performing EBUS were surveyed about their practice patterns, procedural volume, and self-confidence in EBUS skills; they then performed a proctored simulated staging EBUS. The primary outcome was the proportion of participants who appropriately initiated ultrasonographic evaluation with the N3 nodal stations in a simulated patient undergoing EBUS for mediastinal staging., Results: Sixty physicians (22 interventional pulmonologists, 18 general pulmonologists, and 20 pulmonary fellows) participated in the study. The rates of appropriate staging by study group were 95.5% (21 of 22) for interventional pulmonologists, 44.4% (8 of 18) for general pulmonologists, and 30.0% (6 of 20) for pulmonary fellows (P < 0.001). Increased procedural volume correlated with appropriate staging practices (P < 0.001). Within each group, we assessed the concordance between self-confidence in EBUS and simulation performance. Among interventional pulmonologists, the concordance was 95.4%, followed by 61.1% for general pulmonologists and 40.0% for pulmonary fellows., Conclusions: General pulmonologists and pulmonary fellows were less likely than interventional pulmonologists to perform appropriate EBUS staging. In addition, the lack of concordance between self-confidence and appropriate staging performance among noninterventionists signals a need for improved dissemination of guidelines for EBUS-guided mediastinal staging.

Background: Patients with non-small cell lung cancer (NSCLC) being evaluated for stereotactic ablative body radiotherapy (SABR) are typically staged noninvasively with positron emission tomography/computed tomography (PET/CT). Incorporating endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) into the staging workup of these patients has not been evaluated. Our primary objective was to compare the performance of PET/CT with EBUS-TBNA for intrathoracic nodal assessment among SABR-eligible patients., Methods: This was a retrospective study consisting of two parts. First, we assessed the concordance for nodal metastasis of PET/CT and EBUS-TBNA. Second, we evaluated clinical outcomes among patients who underwent SABR with and without a prior EBUS-TBNA., Results: We identified 246 eligible patients. Compared with PET/CT, EBUS-TBNA led to a stage shift in 48 of 246 patients (19%). Of 174 N0 patients by PET/CT, 6 (3.4%) had nodal metastasis on EBUS-TBNA. Among 72 clinical N1 patients, 36 (50%) were downstaged to N0 after EBUS-TBNA, therefore becoming eligible for SABR. Concordance between PET/CT and EBUS-TBNA for nodal metastasis was 83% (κ = 0.53). Clinical outcomes of patients who underwent SABR with or without a prior EBUS-TBNA did not differ significantly., Conclusions: Concordance of PET/CT and EBUS-TBNA for nodal disease was only moderate. Incorporating EBUS-TBNA into the staging workup was beneficial in identifying occult nodal metastasis that would otherwise be left untreated with SABR and in expanding the pool of potentially SABR-eligible patients., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: To provide evidence-based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research., Methods: A taskforce composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system., Results: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified, of which 226 publications were chosen. The taskforce generated a total of 19 recommendations, 10 positive (1B, 3; 2C, 3; 2D, 4) and 9 negative (1B, 8; 2C, 1). A recommendation was not possible in 6 questions., Conclusions: Percutaneous techniques are associated with a lower risk of infections compared with surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research., Methods: A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system., Results: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions., Conclusion: Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used., (Copyright © 2017 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.)

Rationale: Accurate mediastinal staging is a cornerstone in the management of patients with lung cancer. For patients with radiographically normal mediastinum, current lung cancer guidelines recommend invasive mediastinal staging when tumors are centrally located. However, definitions of central tumors are nonspecific, and there are discrepancies among guidelines (e.g., some use the inner one-third of the hemithorax, whereas others use the inner two-thirds)., Objectives: To describe the definitions of central tumors used by pulmonologists and thoracic surgeons in their practices., Methods: An online questionnaire was e-mailed to members of the American Association for Bronchology and Interventional Pulmonology and members of the Cardiothoracic Surgery Network., Measurements and Main Results: A total of 218 participants completed our survey (12% response rate). Most common definitions for central tumors were: inner one-third of the hemithorax (55%), in contact with hilar structures (29%), and inner two-thirds of the hemithorax (15%). Of note, 29% of participants chose a definition fabricated specifically for this survey and not supported by guidelines. Regarding the method to delineate the thirds of the hemithorax, 182 (84%) participants chose a system of concentric lines arising in the hilum, whereas 31 (14%) chose straight lines in the sagittal plane of the chest. We found strikingly similar responses in members of both societies., Conclusions: A uniform definition of tumor centrality is currently lacking, and should be formulated. Studies using objective measurements that evaluate the ability of these different definitions of central lung tumors to predict N2 disease are needed to construct a clear and evidence-based definition.

Competing Interests: Competing interests: None declared.

Objectives: Fungal empyema thoracis (FET) is a rare life-threatening infection. We sought to describe the clinical characteristics of FET in a large academic cancer center., Methods: We conducted a retrospective chart review of all cancer patients who had a fungal isolate from the pleural fluid culture between 1/2005 and 8/2013., Results: A total of 106 fungal isolates were identified in 97 patients. Yeasts accounted for 62% of the isolates whereas 38% were identified as molds. The most frequent pathogens were Candida spp. (58%) and Aspergillus spp. (12%). All patients with Aspergillus and 83% with Candida met criteria for proven fungal disease. Compared to the Aspergillus group, Candida FET was associated with recent abdominal or thoracic surgical procedures (44% vs. 0%, p = 0.01). Overall, 6-week mortality was high, with no significant differences between Candida and Aspergillus (31% vs. 45%, respectively [p = 0.48]). Only 1 out of 11 patients with uncommon molds died at 6 weeks, despite only 2 of them received appropriate antifungal therapy., Conclusions: Development of FET carries a high mortality in cancer patients. A history of a recent surgical procedure is a risk factor for FET due to Candida. Isolation of uncommon molds is likely to represent a contamination of the pleural fluid., (Copyright © 2016. Published by Elsevier Ltd.)

Background: Tissue plasminogen activator (tPA) has been successfully used to relieve obstruction of dysfunctional devices, including vascular catheters. Intrapleural tPA is used by some centers to restore flow of nondraining indwelling pleural catheters (IPCs) in symptomatic patients with malignant pleural effusions (MPEs). Because few studies have evaluated its safety and effectiveness, we conducted a retrospective cohort study of outcomes after tPA treatment during a 10-year period at our institution., Methods: We studied 97 patients with MPE and a nondraining IPC in the setting of persistent pleural fluid who were treated with intrapleural tPA. The primary outcome was restoration of flow after treatment. Secondary outcomes included complication rates and the need for further pleural interventions. Symptomatic relief was assessed using the Borg perceived scale., Results: We identified 97 patients with MPE and a nondraining IPC who were treated with tPA. Flow was restored after 1 tPA dose in 83 of 97 patients (86%; 95% confidence interval, 77%-92%). Reocclusion after 1 dose was seen in 27 of 83 patients (32%), and 22 (81%) of these patients were treated with a second tPA dose. Among these 22, flow was restored in 16 (72%; 95% confidence interval, 44%-84%). Borg score improvement was only seen in patients who had restored flow (P=0.024). This finding was independent of the size of the effusion upon chest x-ray. There were 5 complications: 2 hemothoraxes and 3 infectious complications., Conclusion: On the basis of our finding of successful flow restoration with few complications, we recommend intrapleural tPA treatment for symptomatic patients with nondraining IPCs in the setting of persistent pleural fluid.

A patient diagnosed with pulmonary embolism had persistent symptoms despite adequate therapy. Tissue sampling with endobronchial ultrasound-guided needle aspiration revealed endovascular metastasis from a prior early-stage colorectal cancer. We describe the challenges in the diagnosis and workup of suspected tumor emboli., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)