Education, Medical ; ethics ; Ethics, Medical ; Humans ; Informed Consent ; Patient Selection ; Risk Assessment ; Teaching Rounds ; ethics

Biopsy, Fine-Needle ; methods ; Bronchi ; diagnostic imaging ; pathology ; Endosonography ; methods ; Humans ; Lung Neoplasms ; diagnosis ; pathology ; Mediastinum ; pathology ; Neoplasm Staging

Adult ; Aged ; Bronchoscopy ; methods ; Endosonography ; Feasibility Studies ; Female ; Humans ; Lung Diseases ; diagnosis ; Male ; Middle Aged ; Respiration, Artificial

Altruism ; COVID-19/epidemiology* ; Delivery of Health Care/ethics* ; Empathy ; Ethics, Medical ; Global Health ; Humans ; International Cooperation ; Physicians ; World Health Organization

INTRODUCTIONThis study assessed the clinical utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the diagnosis of suspected granulomatous mediastinal lymphadenopathy.

MATERIALS AND METHODSRetrospective chart review of all patients who underwent EBUS-TBNA for suspected granulomatous mediastinal lymphadenopathy at Singapore General Hospital between December 2008 and December 2011 inclusive.

RESULTSOver a period of 3 years, a total of 371 patients underwent EBUS-TBNA of whom 33 (9%) had the procedure performed for evaluation of suspected granulomatous mediastinal lymphadenopathy - 18 for suspected tuberculosis (TB) and non-tuberculous mycobacterial (NTM) lymphadenitis, and 15 for suspected sarcoidosis. EBUS-TBNA was diagnostic in 9 of the 13 patients with a final diagnosis of TB/NTM. EBUS-TBNA cultures were positive in 6 of them (46%), 1 showed acid-fast bacilli (AFB) although cultures were negative, and 2 had necrotising granulomatous inflammation from EBUS-TBNA biopsies and sputum cultures grew TB. EBUS-TBNA was diagnostic in 9 of the 14 patients with a final diagnosis of sarcoidosis through histology showing non-caseating granulomatous inflammation. The sensitivities of EBUS-TBNA for diagnosis of TB/NTM, sarcoidosis and overall granulomatous mediastinal lymphadenopathy were 69%, 64%, 64%; the negative predictive values were 56%, 17%, 33%; and accuracies were 78%, 67%, 70%, respectively.

CONCLUSIONEBUS-TBNA can be useful in the diagnosis of suspected granulomatous mediastinal lymphadenopathy with sensitivities and accuracies of >60%.

Bronchoscopy ; Endoscopic Ultrasound-Guided Fine Needle Aspiration ; Female ; Granuloma ; pathology ; Humans ; Lymphatic Diseases ; pathology ; Male ; Mediastinal Diseases ; pathology ; Middle Aged ; Retrospective Studies

INTRODUCTIONHaemodynamic monitoring is an essential element in the management of critically ill patients in the intensive care unit (ICU). However, there have been increasing concerns about the clinical utility and safety profile of the invasive pulmonary artery catheter (PAC). Oesophageal Doppler (ED) monitoring has emerged recently as a safer and less invasive tool which can be used by the intensivist to estimate cardiac output in the critically ill patient. Validation studies have thus far only been performed in surgical patients perioperatively and in mixed surgical/medical ICU patients. Currently, minimal data are available in any sizeable Asian population or in patients with severe sepsis. The assumption that these normograms and data hold true for our local medical ICU patients may not be valid due to differences in body habitus.

MATERIALS AND METHODSOur primary aim is to validate the oesophageal Doppler as a reliable measure of cardiac index, systemic vascular resistance (SVR) and preload in our local Asian population of patients with severe sepsis and septic shock in the medical ICU. This was a prospective pilot study on 12 consecutive mechanically ventilated patients in our medical ICU with the diagnosis of septic shock as defined by SCCM/ESICM/ACCP/ATS/SIS International Sepsis definitions Conference-Critical Care Medicine 2003 and required PAC haemodynamic monitoring as indicated by Medical Intensive Care Unit attending.

RESULTSNinety-seven paired cardiac output measurements were made. Cardiac output ranged from 2.87 to 11.0 L/ min (calculated cardiac index ranging from 1.73 to 6.36 L/min/m2) when measured using the PAC with thermodilution technique and from 2.0 to 12.1 L/min (calculated cardiac index of 1.2 to 7.2 L/min/m2) using the trans-oesophageal Doppler. There was moderately good correlation between CIpac and CIed (correlation coefficient, r = 0.762 with PCA = 58%). The mean bias was 0.26 L/min/m2 (P <0.07), while the limit of agreement was +/- 1.44 L/min/m2.

CONCLUSIONED has good correlation with PAC in measuring cardiac index in Asians with septic shock but is an unreliable measure of both pre-load and SVR.

Cardiac Output ; Critical Care ; Critical Illness ; Echocardiography, Transesophageal ; Esophagus ; diagnostic imaging ; Female ; Hemodynamics ; Humans ; Intensive Care Units ; Male ; Middle Aged ; Pilot Projects ; Prospective Studies ; Pulmonary Artery ; Reproducibility of Results ; Shock, Septic ; diagnostic imaging ; Statistics as Topic ; Ultrasonography, Doppler