<i>Background</i>. An increasing number of pulmonary nodules of unknown nature are detected as a result of screening by CT in high lung cancer risk patients.<i> Objectives</i>. The purposes of this study were to assess the diagnostic yield of electromagnetic navigation bronchoscopy (ENB) combined with transbronchial lung cryobiopsy (TBLC) and to compare it with standard transbronchial biopsy (TBB) in pulmonary nodules of less than 2&#x2009;cm in diameter.<i> Methods</i>. We prospectively included 32 patients (18 men and 14 women, mean age 68 &#xb1; 9 years) with nodules of less than 2&#x2009;cm in diameter and no metastasis at <sup>18</sup>FDG PET-CT. The nodule position was determined by ENB, radial endobronchial ultrasonography miniprobe, and fluoroscopy. Eight samples were obtained, six by TBB and two by TBLC.<i> Results</i>. Nodule diameter averaged 16 &#xb1; 3&#x2009;mm. Twenty-five nodules were malignant and 18 were surgically resected. Surgery was avoided in four patients as the biopsies revealed a benign disease. The samples obtained by TBLC were five times larger than those by TBB. The diagnostic yields of TBLC and TBB were 69&#x25; and 38&#x25;, respectively (<i>p</i>=0.017). Adverse events consisted in 15 mild or moderate bleedings and one pneumothorax.<i> Conclusions</i>. In the setting of peripheral pulmonary lesions of less than 20&#x2009;mm in diameter, ENB-combined TBLC is feasible and safe, provides larger samples, and has higher diagnostic yield than TBB.

Olivier Taton

Benjamin Bondue

Pierre Alain Gevenois

Myriam Remmelink

Dimitri Leduc

Diagnostic Yield of Combined Pulmonary Cryobiopsies and Electromagnetic Navigation in Small Pulmonary Nodules

<i>Background.</i> Flour dust in the respiratory tract affects lung function. Flour dust is a heterogeneous organic substance which can have a tendency to cause respiratory ailments. There is growing consensus on the deleterious effects of flour dust on respiratory symptoms and lung performance of flour mill workers.<i> Methods.</i> The study design was comparative cross-sectional. A total of 54 flour mill workers who work for more than eight-hour shift per day and 54 control subjects matched for sex, age, weight, height, and area of residence were enrolled. Anthropometric measurement was done. Lung function was measured by using a digital portable spirometer (Spiro Pro) based on the ATS guidelines. FVC, FEV<sub>1</sub>, FEV<sub>1</sub>/FVC, PEFR, and FEF<sub>25</sub>% <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-3.29111pt" id="M1" height="5.8541pt" version="1.1" viewBox="-0.0498162 -2.56299 13.4725 5.8541" width="13.4725pt"><g transform="matrix(.0091,0,0,-0.0091,.726,3.132)"><path id="g190-46" d="M300 253H71L57 198H286L300 253Z"/></g><g transform="matrix(.0091,0,0,-0.0091,3.978,3.132)"><path id="g50-56" d="M453 623H65C60 580 56 530 46 472H80C103 538 110 548 175 548H389C310 380 195 168 90 0L98 -12L175 -2C273 206 366 408 462 610L453 623Z"/></g><g transform="matrix(.0091,0,0,-0.0091,8.411,3.132)"><path id="g50-54" d="M158 548H390L417 615L410 623H122L83 318C105 326 143 337 185 337C296 337 350 275 350 188C350 116 308 42 225 42C164 42 122 74 100 93C90 101 82 99 72 92C60 82 51 68 50 59C48 46 52 38 66 24C82 9 125 -12 172 -12C225 -11 292 15 346 59C408 108 437 166 437 226C437 309 371 397 242 397C214 397 170 382 133 369L158 548Z"/></g></svg>% were measured. Productive cough, dry cough, wheeze, and breathlessness were evaluated using BMRC questionnaire guidelines, administered through face-to-face interview.<i> Result.</i> This study showed statistically significant reduction in the mean values of pulmonary function tests in flour mill workers as compared to their matched controls. Reduction of pulmonary function indices in study subjects was significant for FVC (4.25±0.93 vs. 5.30±0.71, p&lt;0.001), FEV<sub>1</sub> (3.46±0.86 vs. 4.50±0.72, p&lt;0.001), PEFR (5.43±2.43 vs. 7.87±2.53, p&lt;0.001), and FEF<sub>25</sub>% <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-3.29111pt" id="M2" height="5.8541pt" version="1.1" viewBox="-0.0498162 -2.56299 13.4725 5.8541" width="13.4725pt"><g transform="matrix(.0091,0,0,-0.0091,.726,3.132)"><use xlink:href="#g190-46"/></g><g transform="matrix(.0091,0,0,-0.0091,3.978,3.132)"><use xlink:href="#g50-56"/></g><g transform="matrix(.0091,0,0,-0.0091,8.411,3.132)"><use xlink:href="#g50-54"/></g></svg>%, (3.87±1.61 vs. 4.60±1.60, p&lt;0.05), but not significant for FEV<sub>1</sub>/FVC (81.93±12.74 vs. 83.40±12.50, p&gt;0.05). Flour mill workers developed 27.7% of restrictive type and 11.1% of obstructive type of lung disorders. Percentage prevalence of respiratory symptoms was evaluated as dry cough (27.7% vs. 9.3%), productive cough (11.1% vs. 5.6%), wheeze (14.8% vs. 3.8%), and breathlessness (16.6% vs.7.4%) in flour mill workers and controls, respectively.<i> Conclusion.</i> Based on the results of the present study, occupational exposure to flour dust could cause respiratory dysfunction, thereby reducing lung efficiency.

Dessalegn Demeke

Diresibachew W. Haile

Assessment of Respiratory Symptoms and Pulmonary Function Status among Workers of Flour Mills in Addis Ababa, Ethiopia: Comparative Cross-Sectional Study

<i>Rationale</i>. Individuals with a single Z mutation in the<i> SERPINA1</i> gene that codes for alpha-1 antitrypsin (AAT) are at increased risk for COPD if they have ever-smoked. Whether additional variants alter the risk for COPD in this population remains unknown.<i> Objectives</i>. To determine whether additional<i> SERPINA1</i> variants impact COPD development in a previously identified MZ (carrier) cohort.<i> Methods</i>. Individuals with prior MZ results and AAT serum level &#x3c;16uM were recruited from the Alpha-1 Coded Testing study and Alpha-1 Foundation Research Registry. Participants completed smoking history, demographics, and COPD Severity Score (Range 0-33) using REDCap data capture. At-home finger-stick tests were performed for next generation sequencing (NGS) at the Biocerna LLC laboratory. A genetic counselor reviewed records and interviewed participants with additional variants by NGS. A Wilcoxon Rank Sum test was used to assess correlation between variants and the COPD severity score.<i> Results</i>. A second<i> SERPINA1</i> variant of known or possible significance was identified in 6 (5.8&#x25;) participants. One each of ZZ, SZ, FZ, ZSmunich, ZM2obernburg, and Z/c.922G&#x3e;T genotypes were identified. ZZ, SZ, and FZ are known pathogenic genotypes. Smunich is a likely pathogenic variant. M2obernburg and c.922G&#x3e;T are variants of uncertain significance. The ZZ individual was on augmentation therapy when determined MZ by protease inhibitor (Pi) phenotyping; the others had limited targeted genotyping with MZ results. These six participants with biallelic variants had positive COPD severity scores &#x3e;1. Presence of additional variants was not significantly associated with COPD symptoms in this small sample size.<i> Conclusions</i>. Some diagnosed MZ individuals instead have biallelic variants. Larger studies are needed to determine COPD-risk liability of variants. Accurate diagnosis impacts medical management and familial risk assessment. Pi phenotyping can be confounded by augmentation therapy and liver transplantation. Because a normal M allele may be reported in the absence of tested mutation(s) in AATD genotyping, clinicians should consider clinical circumstances and laboratory methods when selecting and interpreting AATD tests. Advanced testing, including NGS, may be beneficial for select individuals with prior MZ results.<i> Clinical Trial Registration</i>. This study was registered with clinicaltrials.gov (NCT <a target="_blank" href="https://clinicaltrials.gov/ct2/show/NCT02810327">NCT02810327</a>).

Kimberly E. Foil

M. Gwen Blanton

Chris Sanders

Joannah Kim

Haitham S. Al Ashry

Suchit Kumbhare

Charlie Strange

Sequencing Alpha-1 MZ Individuals Shows Frequent Biallelic Mutations

<i>Background and Objectives</i>. Clinical pathways are evidence based multidisciplinary team approaches to optimize patient care. Pleural diseases are common and accounted for 3.4 billion US $ in 2014 US inpatient aggregate charges (HCUPnet data). An institutional clinical pathway (“pleural pathway”) was implemented in conjunction with a dedicated pleural service. Design, implementation, and outcomes of the pleural pathway (from August 1, 2014, to July 31, 2015) in comparison to a previous era (from August 1, 2013, to July 31, 2014) are described.<i> Methods</i>. Tuality Healthcare is a 215-bed community healthcare system in Hillsboro, OR, USA. With the objective of standardizing pleural disease care, locally adapted British Thoracic Society guidelines and a centralized pleural service were implemented in the<i> “pathway”</i> era. System-wide consensus regarding institutional guidelines for care of pleural disease was achieved. Preimplementation activities included training, acquisition of ultrasound equipment, and system-wide education. An audit database was set up with the intent of prospective audits. An administrative database was used for harvesting outcomes data and comparing them with the<i> “prior to pathway”</i> era.<i> Results</i>. 54 unique consults were performed. A total of 55 ultrasound examinations and 60 pleural procedures were performed. All-cause inpatient pleural admissions were lower in the “pathway” era <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="22.287pt" style="vertical-align:-2.26807pt" id="M1" height="11.5564pt" version="1.1" viewBox="-0.0498162 -9.28833 22.287 11.5564"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g113-41" d="M300 -147C201 -63 143 98 143 270S200 602 300 686L282 710C136 610 70 450 70 271V270C70 89 136 -72 282 -170L300 -147Z"/></g><g transform="matrix(.013,0,0,-0.013,4.498,0)"><path id="g113-111" d="M495 86L479 114C446 82 419 66 409 66C401 66 401 72 406 97C420 166 436 231 453 297C489 435 454 448 428 448C406 448 384 439 354 422C305 394 222 327 161 247H159L183 345C200 415 194 448 173 448C143 448 82 410 23 351L38 325C64 349 95 371 105 371C111 371 116 365 109 336L25 -4L31 -12C50 -4 77 3 107 9C119 69 132 122 145 168C197 254 321 381 370 381C387 381 393 374 378 305L329 95C309 17 320 -12 345 -12C372 -12 430 19 495 86Z"/></g><g transform="matrix(.013,0,0,-0.013,14.656,0)"><path id="g117-34" d="M535 323V373H52V323H535ZM535 138V188H52V138H535Z"/></g></svg><span class="irelop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="10.948pt" style="vertical-align:-2.26807pt" height="11.5564pt" version="1.1" viewBox="25.869183800000002 -9.28833 10.948 11.5564"><g transform="matrix(.013,0,0,-0.013,25.919,0)"><path id="g113-58" d="M244 635C114 635 38 519 38 422C38 317 111 240 217 240C236 240 255 244 277 256L345 292C311 140 203 39 59 15L64 -15C89 -15 150 -5 204 17C339 72 440 202 440 386C440 521 368 635 244 635ZM228 602C326 602 352 479 352 390C352 370 351 347 348 324C327 308 293 296 258 296C174 296 124 369 124 458C124 517 152 602 228 602Z"/></g><g transform="matrix(.013,0,0,-0.013,32.16,0)"><path id="g113-42" d="M275 270C275 450 212 609 64 710L45 686C145 604 203 442 203 270S147 -63 45 -147L64 -170C213 -68 275 89 275 270Z"/></g></svg></span> compared to the “prior to pathway” era <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="22.287pt" style="vertical-align:-2.26807pt" id="M2" height="11.5564pt" version="1.1" viewBox="-0.0498162 -9.28833 22.287 11.5564"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-41"/></g><g transform="matrix(.013,0,0,-0.013,4.498,0)"><use xlink:href="#g113-111"/></g><g transform="matrix(.013,0,0,-0.013,14.656,0)"><use xlink:href="#g117-34"/></g></svg><span class="irelop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="17.211pt" style="vertical-align:-2.26807pt" height="11.5564pt" version="1.1" viewBox="25.869183800000002 -9.28833 17.211 11.5564"><g transform="matrix(.013,0,0,-0.013,25.919,0)"><path id="g113-50" d="M384 0V27C293 34 287 42 287 114V635C232 613 172 594 109 583V559L157 557C201 555 205 550 205 499V114C205 42 199 34 109 27V0H384Z"/></g><g transform="matrix(.013,0,0,-0.013,32.159,0)"><path id="g113-56" d="M447 623H65C61 580 56 530 47 475H76C100 541 106 550 172 550H388C308 376 196 170 91 -1L98 -12L172 -2C268 204 360 408 455 611L447 623Z"/></g><g transform="matrix(.013,0,0,-0.013,38.401,0)"><use xlink:href="#g113-42"/></g></svg></span>. Gains in average case charges (21,737$ versus 18,818.2$/case) and average length of stay (3.65 versus 2.78 days/case) were seen in the “pathway” era.<i> Conclusion</i>. A “pleural pathway” and a centralized pleural service are associated with reduction in case charges, inpatient admissions, and length of stay for pleural conditions.

Srinivas R. Mummadi

Peter Y. Hahn

Outcomes of a Clinical Pathway for Pleural Disease Management: &#x201c;Pleural Pathway&#x201d;

<i>Objective</i>. Acute pulmonary silicone embolism (APSE) related to subcutaneous silicone injections is a well-known entity. Recently, a few cases of pathologically confirmed chronic pulmonary silicone embolism (CPSE) from breast implants have been reported. The prevalence of CPSE in women with breast augmentation is unknown. This study was done to determine the prevalence of CPSE in female lung transplant recipients with a history of breast augmentation and to determine whether breast augmentation plays a role in chronic lung diseases requiring lung transplantation.<i> Methods</i>. A retrospective chart review was performed to identify female lung transplant recipients with a history of breast augmentation prior to or at the time of lung transplantation. Ten patients meeting these criteria were identified. The pathologic features of the explanted lungs of these patients were reexamined for CPSE by a board-certified pathologist with expertise in lung transplantation and pulmonary embolism.<i> Results</i>. Of 1518 lung transplant recipients at Cleveland Clinic, 578 were females. Of 578 females, 10 (1.73&#x25;) had history of breast augmentation. A total of 84 H&#x26;E-stained slides from the explanted lungs from 10 cases were examined. No pathologic evidence of chronic silicone embolism was seen in any of the 10 cases.<i> Conclusions</i>. CPSE is not associated with pulmonary disease leading to lung transplantation. Breast augmentation is not a significant contributor to pulmonary disease requiring lung transplantation. Further studies are required to ascertain the prevalence of CPSE in the general breast augmentation populace and to define the relationship between breast augmentation and pulmonary disease.

Jarmanjeet Singh

Hanine Inaty

Sanjay Mukhopadhyay

Atul C. Mehta

Chronic Pulmonary Silicone Embolism from Breast Augmentation Is Not a Common Finding in Explanted Lungs

<i>Background</i>. Ultrasonic, jet, and mesh nebulizers have all been used in the treatment for asthma. Mesh nebulizers reportedly offer the best inhalation efficiency.<i> Methods</i>. This study aimed to clarify the utility of the mesh nebulizer, compared to jet nebulizers, in the treatment of pediatric asthma patients. Participants included 88 children &lt;6 years old who were receiving treatment for asthma at Murayama Pediatric Clinic. Heart rate, peripheral oxygen saturation in arterial blood, and Mitsui symptom scores were compared before and after treatment with a mesh nebulizer (<span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="17.789pt" style="vertical-align:-0.2063904pt" id="M1" height="8.55521pt" version="1.1" viewBox="-0.0498162 -8.34882 17.789 8.55521"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g113-111" d="M495 86L479 114C446 82 419 66 409 66C401 66 401 72 406 97C420 166 436 231 453 297C489 435 454 448 428 448C406 448 384 439 354 422C305 394 222 327 161 247H159L183 345C200 415 194 448 173 448C143 448 82 410 23 351L38 325C64 349 95 371 105 371C111 371 116 365 109 336L25 -4L31 -12C50 -4 77 3 107 9C119 69 132 122 145 168C197 254 321 381 370 381C387 381 393 374 378 305L329 95C309 17 320 -12 345 -12C372 -12 430 19 495 86Z"/></g><g transform="matrix(.013,0,0,-0.013,10.158,0)"><path id="g117-34" d="M535 323V373H52V323H535ZM535 138V188H52V138H535Z"/></g></svg><span class="irelop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="12.679pt" style="vertical-align:-0.2063904pt" height="8.55521pt" version="1.1" viewBox="21.3711838 -8.34882 12.679 8.55521"><g transform="matrix(.013,0,0,-0.013,21.421,0)"><path id="g113-53" d="M456 178V225H360V632H320C217 496 115 347 20 206V178H280V106C280 40 276 34 189 27V0H445V27C364 34 360 39 360 106V178H456ZM280 225H82C149 335 214 431 278 520H280V225Z"/></g><g transform="matrix(.013,0,0,-0.013,27.661,0)"><path id="g113-52" d="M285 378C315 398 338 416 353 432C373 451 384 474 384 503C384 579 325 635 236 635H235C182 635 136 610 108 579L65 516L85 496C110 533 150 575 205 575C258 575 300 543 300 481C300 407 232 369 141 339L147 310C163 315 188 321 211 321C268 321 338 284 338 192C338 94 288 40 217 40C160 40 119 68 93 91C85 98 77 97 69 91C60 84 47 71 46 58C44 46 48 35 62 22C75 10 116 -12 162 -12C234 -12 424 62 424 224C424 297 373 359 285 376V378Z"/></g></svg></span>) or jet nebulizer (<span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="17.789pt" style="vertical-align:-0.2063904pt" id="M2" height="8.55521pt" version="1.1" viewBox="-0.0498162 -8.34882 17.789 8.55521"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-111"/></g><g transform="matrix(.013,0,0,-0.013,10.158,0)"><use xlink:href="#g117-34"/></g></svg><span class="irelop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="12.679pt" style="vertical-align:-0.2063904pt" height="8.55521pt" version="1.1" viewBox="21.3711838 -8.34882 12.679 8.55521"><g transform="matrix(.013,0,0,-0.013,21.421,0)"><use xlink:href="#g113-53"/></g><g transform="matrix(.013,0,0,-0.013,27.661,0)"><path id="g113-54" d="M153 550H386L412 615L406 623H120L82 318C104 327 142 338 184 338C294 338 347 275 347 187C347 112 305 39 221 39C160 39 119 71 97 89C88 97 80 96 71 90C59 80 50 67 49 57C48 45 52 36 66 23C80 9 123 -12 169 -12C221 -11 288 15 342 59C403 109 431 165 431 225C431 308 366 395 238 395C212 395 165 379 127 364L153 550Z"/></g></svg></span>) using a salbutamol inhalation solution (0.2 ml for children ≧ 2 years old, <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="17.789pt" style="vertical-align:-0.2063904pt" id="M3" height="8.55521pt" version="1.1" viewBox="-0.0498162 -8.34882 17.789 8.55521"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-111"/></g><g transform="matrix(.013,0,0,-0.013,10.158,0)"><use xlink:href="#g117-34"/></g></svg><span class="irelop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="12.679pt" style="vertical-align:-0.2063904pt" height="8.55521pt" version="1.1" viewBox="21.3711838 -8.34882 12.679 8.55521"><g transform="matrix(.013,0,0,-0.013,21.421,0)"><use xlink:href="#g113-54"/></g><g transform="matrix(.013,0,0,-0.013,27.661,0)"><path id="g113-50" d="M384 0V27C293 34 287 42 287 114V635C232 613 172 594 109 583V559L157 557C201 555 205 550 205 499V114C205 42 199 34 109 27V0H384Z"/></g></svg></span>; 0.1 ml for children &lt; 2 years old, <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="17.789pt" style="vertical-align:-0.2063904pt" id="M4" height="8.55521pt" version="1.1" viewBox="-0.0498162 -8.34882 17.789 8.55521"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-111"/></g><g transform="matrix(.013,0,0,-0.013,10.158,0)"><use xlink:href="#g117-34"/></g></svg><span class="irelop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="12.679pt" style="vertical-align:-0.2063904pt" height="8.55521pt" version="1.1" viewBox="21.3711838 -8.34882 12.679 8.55521"><g transform="matrix(.013,0,0,-0.013,21.421,0)"><use xlink:href="#g113-52"/></g><g transform="matrix(.013,0,0,-0.013,27.661,0)"><path id="g113-56" d="M447 623H65C61 580 56 530 47 475H76C100 541 106 550 172 550H388C308 376 196 170 91 -1L98 -12L172 -2C268 204 360 408 455 611L447 623Z"/></g></svg></span>).<i> Results</i>. Other than required inhalation time, clinical findings did not differ between mesh and jet groups. In both groups, heart rate increased significantly in patients treated with 0.2 ml (1000 microg) of salbutamol.<i> Conclusions and Clinical Relevance</i>. The required inhalation time of the mesh nebulizer was superior to the jet nebulizer. Children ≧ 2 years with mild asthma attacks experienced a significantly increased heart rate in both groups. The dose of salbutamol (0.2 ml for ≧2 years) used for asthma attacks should be reconsidered in mild asthma.

Norihide Murayama

Kikuno Murayama

Comparison of the Clinical Efficacy of Salbutamol with Jet and Mesh Nebulizers in Asthmatic Children

<i>Background</i>. Specific therapy for patients with PAH is associated with good outcomes. Little is known about the effect of this treatment in patients with Cpc-PH (PAPm ≥ 25 mmHg, PAWP &gt; 15 mmHg, DPG ≥ 7 mmHg, and/or PVR &gt; 3 WU). This study evaluates the outcome of treating patients with Cpc-PH using PAH specific therapy.<i> Methods</i>. The primary outcome was survival. Secondary outcomes were WHO functional class and 6-minute walk distance (6-MWD).<i> Results</i>. Twenty-six patients with Cpc-PH (half with VHD and half with HF) received PAHST. Six patients did not tolerate treatment due to pulmonary edema. No predictors for treatment intolerance were identified. In twenty patients who tolerated the treatment, the mean WHO functional class improved from <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="32.223pt" style="vertical-align:-0.3499298pt" id="M1" height="8.69875pt" version="1.1" viewBox="-0.0498162 -8.34882 32.223 8.69875"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g113-51" d="M412 140C382 77 369 73 315 73H129L270 222C362 320 402 379 402 466C402 571 322 635 234 635C177 635 130 609 99 576L42 495L64 475C90 514 133 568 201 568C274 568 318 519 318 435C318 349 255 267 193 193C144 135 87 78 32 23V0H405C417 45 427 89 440 131L412 140Z"/></g><g transform="matrix(.013,0,0,-0.013,6.24,0)"><path id="g113-47" d="M113 -12C146 -12 170 11 170 46C170 78 146 103 114 103S58 78 58 46C58 11 82 -12 113 -12Z"/></g><g transform="matrix(.013,0,0,-0.013,9.204,0)"><path id="g113-56" d="M447 623H65C61 580 56 530 47 475H76C100 541 106 550 172 550H388C308 376 196 170 91 -1L98 -12L172 -2C268 204 360 408 455 611L447 623Z"/></g><g transform="matrix(.013,0,0,-0.013,15.446,0)"><path id="g113-49" d="M241 635C89 635 35 457 35 312C35 153 89 -12 240 -12C390 -12 443 166 443 312C443 466 390 635 241 635ZM238 602C329 602 354 454 354 312C354 172 330 22 240 22C152 22 124 173 124 313S148 602 238 602Z"/></g><g transform="matrix(.013,0,0,-0.013,24.592,0)"><path id="g117-37" d="M535 290V340H323V533H265V340H52V290H265V84H323V290H535ZM535 -22V28H52V-22H535Z"/></g></svg><span class="ibiop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="21.973pt" style="vertical-align:-0.3499298pt" height="8.69875pt" version="1.1" viewBox="35.0781838 -8.34882 21.973 8.69875"><g transform="matrix(.013,0,0,-0.013,35.128,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,41.368,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,44.332,0)"><use xlink:href="#g113-51"/></g><g transform="matrix(.013,0,0,-0.013,50.572,0)"><path id="g113-50" d="M384 0V27C293 34 287 42 287 114V635C232 613 172 594 109 583V559L157 557C201 555 205 550 205 499V114C205 42 199 34 109 27V0H384Z"/></g></svg></span> at initial assessment to <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="32.221pt" style="vertical-align:-0.3499298pt" id="M2" height="8.69875pt" version="1.1" viewBox="-0.0498162 -8.34882 32.221 8.69875"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-51"/></g><g transform="matrix(.013,0,0,-0.013,6.24,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,9.204,0)"><use xlink:href="#g113-51"/></g><g transform="matrix(.013,0,0,-0.013,15.444,0)"><use xlink:href="#g113-51"/></g><g transform="matrix(.013,0,0,-0.013,24.59,0)"><use xlink:href="#g117-37"/></g></svg><span class="ibiop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="21.975pt" style="vertical-align:-0.3499298pt" height="8.69875pt" version="1.1" viewBox="35.076183799999995 -8.34882 21.975 8.69875"><g transform="matrix(.013,0,0,-0.013,35.126,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,41.366,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,44.33,0)"><use xlink:href="#g113-51"/></g><g transform="matrix(.013,0,0,-0.013,50.57,0)"><use xlink:href="#g113-50"/></g></svg></span> (<span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="18.973pt" style="vertical-align:-3.42938pt" id="M3" height="11.7782pt" version="1.1" viewBox="-0.0498162 -8.34882 18.973 11.7782"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g113-113" d="M570 304C570 398 525 448 414 448C385 448 343 445 312 434L329 511L321 518C297 504 262 482 244 460L233 411C195 397 159 381 128 358L135 332C160 347 189 360 224 373L111 -147C97 -210 84 -218 17 -231L13 -257L254 -247L259 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27V0H445V27C364 34 360 39 360 106V178H456ZM280 225H82C149 335 214 431 278 520H280V225Z"/></g></svg></span>) and <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="32.221pt" style="vertical-align:-0.3499298pt" id="M4" height="8.69875pt" version="1.1" viewBox="-0.0498162 -8.34882 32.221 8.69875"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-51"/></g><g transform="matrix(.013,0,0,-0.013,6.24,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,9.204,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,15.444,0)"><path id="g113-55" d="M137 343C167 482 260 545 321 574C357 591 397 603 429 609L423 641C382 634 335 622 295 608C189 570 37 457 37 238C37 84 125 -12 242 -12C362 -12 447 89 447 209C447 311 374 393 267 393C247 393 226 386 204 376L137 343ZM227 337C318 337 361 256 361 173C361 105 336 22 258 22C176 22 126 120 126 240C126 266 127 291 132 310C155 323 189 337 227 337Z"/></g><g transform="matrix(.013,0,0,-0.013,24.59,0)"><use xlink:href="#g117-37"/></g></svg><span class="ibiop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="21.975pt" style="vertical-align:-0.3499298pt" height="8.69875pt" version="1.1" viewBox="35.076183799999995 -8.34882 21.975 8.69875"><g transform="matrix(.013,0,0,-0.013,35.126,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,41.366,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,44.33,0)"><use xlink:href="#g113-51"/></g><g transform="matrix(.013,0,0,-0.013,50.57,0)"><use xlink:href="#g113-50"/></g></svg></span> (<span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="18.973pt" style="vertical-align:-3.42938pt" id="M5" height="11.7782pt" version="1.1" viewBox="-0.0498162 -8.34882 18.973 11.7782"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-113"/></g><g transform="matrix(.013,0,0,-0.013,11.342,0)"><use xlink:href="#g117-91"/></g></svg><span class="irelop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="21.921pt" style="vertical-align:-3.42938pt" height="11.7782pt" version="1.1" viewBox="22.555183800000002 -8.34882 21.921 11.7782"><g transform="matrix(.013,0,0,-0.013,22.605,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,28.845,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,31.809,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,38.049,0)"><path id="g113-52" d="M285 378C315 398 338 416 353 432C373 451 384 474 384 503C384 579 325 635 236 635H235C182 635 136 610 108 579L65 516L85 496C110 533 150 575 205 575C258 575 300 543 300 481C300 407 232 369 141 339L147 310C163 315 188 321 211 321C268 321 338 284 338 192C338 94 288 40 217 40C160 40 119 68 93 91C85 98 77 97 69 91C60 84 47 71 46 58C44 46 48 35 62 22C75 10 116 -12 162 -12C234 -12 424 62 424 224C424 297 373 359 285 376V378Z"/></g></svg></span>) at 6 and 9 months, respectively. Mean 6-MWD improved from <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="38.463pt" style="vertical-align:-0.3499298pt" id="M6" height="8.69875pt" version="1.1" viewBox="-0.0498162 -8.34882 38.463 8.69875"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-51"/></g><g transform="matrix(.013,0,0,-0.013,6.24,0)"><use xlink:href="#g113-56"/></g><g transform="matrix(.013,0,0,-0.013,12.482,0)"><use xlink:href="#g113-55"/></g><g transform="matrix(.013,0,0,-0.013,18.722,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,21.686,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,30.832,0)"><use xlink:href="#g117-37"/></g></svg><span class="ibiop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="28.26pt" style="vertical-align:-0.3499298pt" height="8.69875pt" version="1.1" viewBox="41.3181838 -8.34882 28.26 8.69875"><g transform="matrix(.013,0,0,-0.013,41.368,0)"><use xlink:href="#g113-52"/></g><g transform="matrix(.013,0,0,-0.013,47.609,0)"><path id="g113-57" d="M249 635C141 635 70 555 70 471C70 401 114 353 179 316C143 294 106 267 90 252C68 231 45 202 45 157C45 50 130 -12 237 -12C322 -12 435 52 435 169C435 256 372 304 303 343C349 374 375 398 383 407C401 429 411 458 411 487C411 569 344 635 249 635ZM238 603C285 603 337 567 337 482C337 422 310 385 276 358C205 393 145 426 145 500C145 552 179 603 238 603ZM248 20C183 20 125 70 125 163C125 218 158 268 206 300C284 261 355 217 355 143C355 66 308 20 248 20Z"/></g><g transform="matrix(.013,0,0,-0.013,53.849,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,56.813,0)"><path id="g113-54" d="M153 550H386L412 615L406 623H120L82 318C104 327 142 338 184 338C294 338 347 275 347 187C347 112 305 39 221 39C160 39 119 71 97 89C88 97 80 96 71 90C59 80 50 67 49 57C48 45 52 36 66 23C80 9 123 -12 169 -12C221 -11 288 15 342 59C403 109 431 165 431 225C431 308 366 395 238 395C212 395 165 379 127 364L153 550Z"/></g><g transform="matrix(.013,0,0,-0.013,63.053,0)"><use xlink:href="#g113-49"/></g></svg></span> meters at initial assessment to <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="38.462pt" style="vertical-align:-0.3499298pt" id="M7" height="8.69875pt" version="1.1" viewBox="-0.0498162 -8.34882 38.462 8.69875"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-52"/></g><g transform="matrix(.013,0,0,-0.013,6.24,0)"><use xlink:href="#g113-53"/></g><g transform="matrix(.013,0,0,-0.013,12.48,0)"><use xlink:href="#g113-52"/></g><g transform="matrix(.013,0,0,-0.013,18.721,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,21.685,0)"><path id="g113-58" d="M244 635C114 635 38 519 38 422C38 317 111 240 217 240C236 240 255 244 277 256L345 292C311 140 203 39 59 15L64 -15C89 -15 150 -5 204 17C339 72 440 202 440 386C440 521 368 635 244 635ZM228 602C326 602 352 479 352 390C352 370 351 347 348 324C327 308 293 296 258 296C174 296 124 369 124 458C124 517 152 602 228 602Z"/></g><g transform="matrix(.013,0,0,-0.013,30.831,0)"><use xlink:href="#g117-37"/></g></svg><span class="ibiop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="28.259pt" style="vertical-align:-0.3499298pt" height="8.69875pt" version="1.1" viewBox="41.3181838 -8.34882 28.259 8.69875"><g transform="matrix(.013,0,0,-0.013,41.368,0)"><use xlink:href="#g113-51"/></g><g transform="matrix(.013,0,0,-0.013,47.608,0)"><use xlink:href="#g113-51"/></g><g transform="matrix(.013,0,0,-0.013,53.848,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,56.812,0)"><use xlink:href="#g113-58"/></g><g transform="matrix(.013,0,0,-0.013,63.053,0)"><use xlink:href="#g113-58"/></g></svg></span> meters (<span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="18.973pt" style="vertical-align:-3.42938pt" id="M8" height="11.7782pt" version="1.1" viewBox="-0.0498162 -8.34882 18.973 11.7782"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-113"/></g><g transform="matrix(.013,0,0,-0.013,11.342,0)"><use xlink:href="#g117-91"/></g></svg><span class="irelop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="21.921pt" style="vertical-align:-3.42938pt" height="11.7782pt" version="1.1" viewBox="22.555183800000002 -8.34882 21.921 11.7782"><g transform="matrix(.013,0,0,-0.013,22.605,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,28.845,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,31.809,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,38.049,0)"><use xlink:href="#g113-53"/></g></svg></span>) and <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="38.461pt" style="vertical-align:-0.3499298pt" id="M9" height="8.69875pt" version="1.1" viewBox="-0.0498162 -8.34882 38.461 8.69875"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-52"/></g><g transform="matrix(.013,0,0,-0.013,6.24,0)"><use xlink:href="#g113-55"/></g><g transform="matrix(.013,0,0,-0.013,12.48,0)"><use xlink:href="#g113-53"/></g><g transform="matrix(.013,0,0,-0.013,18.721,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,21.685,0)"><use xlink:href="#g113-55"/></g><g transform="matrix(.013,0,0,-0.013,30.83,0)"><use xlink:href="#g117-37"/></g></svg><span class="ibiop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="28.261pt" style="vertical-align:-0.3499298pt" height="8.69875pt" version="1.1" viewBox="41.317183799999995 -8.34882 28.261 8.69875"><g transform="matrix(.013,0,0,-0.013,41.367,0)"><use xlink:href="#g113-52"/></g><g transform="matrix(.013,0,0,-0.013,47.607,0)"><use xlink:href="#g113-53"/></g><g transform="matrix(.013,0,0,-0.013,53.848,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,56.812,0)"><use xlink:href="#g113-57"/></g><g transform="matrix(.013,0,0,-0.013,63.052,0)"><use xlink:href="#g113-54"/></g></svg></span> meters (<span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="18.973pt" style="vertical-align:-3.42938pt" id="M10" height="11.7782pt" version="1.1" viewBox="-0.0498162 -8.34882 18.973 11.7782"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-113"/></g><g transform="matrix(.013,0,0,-0.013,11.342,0)"><path id="g117-34" d="M535 323V373H52V323H535ZM535 138V188H52V138H535Z"/></g></svg><span class="irelop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="21.921pt" style="vertical-align:-3.42938pt" height="11.7782pt" version="1.1" viewBox="22.555183800000002 -8.34882 21.921 11.7782"><g transform="matrix(.013,0,0,-0.013,22.605,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,28.845,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,31.809,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.013,0,0,-0.013,38.049,0)"><use xlink:href="#g113-56"/></g></svg></span>) at 6 and 9 months, respectively. Twelve patients died during the follow-up period. Mean survival for all patients was <span class="inline_break"><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="44.706pt" style="vertical-align:-0.3499298pt" id="M11" height="8.69875pt" version="1.1" viewBox="-0.0498162 -8.34882 44.706 8.69875"><g transform="matrix(.013,0,0,-0.013,0,0)"><use xlink:href="#g113-50"/></g><g transform="matrix(.013,0,0,-0.013,6.24,0)"><use xlink:href="#g113-51"/></g><g transform="matrix(.013,0,0,-0.013,12.48,0)"><use xlink:href="#g113-56"/></g><g transform="matrix(.013,0,0,-0.013,18.722,0)"><use xlink:href="#g113-58"/></g><g transform="matrix(.013,0,0,-0.013,24.963,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,27.927,0)"><use xlink:href="#g113-56"/></g><g transform="matrix(.013,0,0,-0.013,37.075,0)"><use xlink:href="#g117-37"/></g></svg><span class="ibiop"/><svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" width="34.542pt" style="vertical-align:-0.3499298pt" height="8.69875pt" version="1.1" viewBox="47.5621838 -8.34882 34.542 8.69875"><g transform="matrix(.013,0,0,-0.013,47.612,0)"><use xlink:href="#g113-50"/></g><g transform="matrix(.013,0,0,-0.013,53.852,0)"><use xlink:href="#g113-58"/></g><g transform="matrix(.013,0,0,-0.013,60.093,0)"><use xlink:href="#g113-52"/></g><g transform="matrix(.013,0,0,-0.013,66.333,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.013,0,0,-0.013,69.297,0)"><use xlink:href="#g113-55"/></g><g transform="matrix(.013,0,0,-0.013,75.537,0)"><use xlink:href="#g113-49"/></g></svg></span> days.<i> Conclusion</i>. PAHST may be beneficial in the treatment of Cpc-PH (both short and long term). Prospective randomized controlled trials of PAHST in this population are needed to assess its potential efficacy.

Hassan Alfraidi

Sultan Qanash

Zoheir Bshouty

Pulmonary Arterial Hypertension Specific Therapy in Patients with Combined Post- and Precapillary Pulmonary Hypertension

Noncaseating granulomas are seen surrounding tumors with varying frequency, possibly as part of an immune response to tumor cells. However, data about the association of sarcoid with gynecologic malignancy is sparse. We performed a search of our institutional database for all EBUS-TBNA biopsies conducted within the past five years that revealed granulomatous inflammation. All adult female patients with a history of gynecologic malignancy were included. Patients with a history of sarcoidosis or fungal or mycobacterial infection were excluded. All patients with evidence of malignant cells on TBNA specimen were excluded. Our results revealed 65 patients with histologic diagnosis of a noncaseating granuloma on EBUS-TBNA. Five patients (7.69&#x25;) had a history of gynecologic malignancy. Two patients had evidence of PET-positive nodes on surveillance scans, which led directly to the examination. Our findings suggest that distant malignancies may cause granulomatous lymphadenitis, through yet undefined mechanisms. As such, patients with evidence of mediastinal lymphadenopathy could benefit from routine sampling and histologic examination to define the pathology in the correct clinical context.

Bilal H. Lashari

Megumi Asai

Gissele Randleman

Martha Sack

Rajeshkumar Patel

Sarcoid-Like Mediastinal Lymphadenopathy in Gynecologic Malignancy

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<p><em>Pulmonary Medicine</em> publishes research related to the prevention, diagnosis and management of pulmonary and associated disorders, as well as related molecular genetics, pathophysiology, and epidemiology.</p>


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Pulmonary Medicine - Table of contents 2018

title

Pulmonary Medicine publishes research related to the prevention, diagnosis and management of pulmonary and associated disorders, as well as related molecular genetics, pathophysiology, and epidemiology.

Pulmonary Medicine