Introduction: Thoracentesis is one of the most commonly performed procedures in the inpatient setting. Although coagulation profile is usually evaluated prior to thoracentesis, bleeding is a rare complication, occurring in less than 1% of the cases. Several society guidelines recommend holding antiplatelet medications and anticoagulants prior to thoracentesis. Clinical practice guidelines also recommend correcting international normalised ratios of more than two and platelet counts <50 X10^∧9/L.Methods: This is a retrospective descriptive study that included 292 patients who underwent thoracentesis in the inpatient setting at Ascension St John Hospital in Detroit, Michigan, USA from 2016 to 2018. We identified patients who had uncorrected risk for bleeding and collected data about their demographics, comorbidities, use of antiplatelet or anticoagulants and procedural details including complications. We looked for any postprocedural bleeding events to study their relation to the already established bleeding risk.Results: Two hundred and ninety-two thoracenteses were performed, 95.5% (n=279) were performed by interventional radiology. Majority of patients were at risk of bleeding 83% (n=242). No bleeding events occurred. Medications that were not held prior to thoracentesis included: clopidogrel 11% (n=32), novel anticoagulants 8.2% (n=24) and unfractionated heparin 50% (n=146). Use of ultrasound guidance decreased the amount of haemoglobin decline from 1 to 2 g/L (p=0.029). Seventeen patients suffered pneumothorax, eight of which required intervention.Discussion: Our study suggests that performing thoracentesis without correction of underlying coagulopathy may be safe. This may prevent consequences of holding essential medications and reduce the amount of blood products administered to patients in need of thoracentesis.

Introduction: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the standard diagnostic method for sampling mediastinal and hilar lymph nodes. Non-diagnostic samples have led some pulmonologists to add a miniforceps biopsy (EBUS-TBFB) in order to increase diagnostic yield. Our study aims to analyze the impact of adding EBUS-TBFB to the EBUS-TBNA in cases where Rapid On-site Evaluation (ROSE) was negative for malignancy or was non-diagnostic. Material and methods: This retrospective chart review included 91 patients who were aged 18–90 years old and underwent EBUS with both TBNA and TBFB between January 1, 2013 and July 1, 2018. Results: There was no significant statistical difference in the diagnostic yield of TBNA vs TBFB with a McNemar value of 0.167, and this conclusion was the same when stratified by race, age and lymph node size. Using TBNA as a gold standard, the sensitivity and specificity of TBFB was 87% and 69%, respectively. Out of the non-diagnostic TBNA samples on ROSE and cell-block, subsequent TBFB resulted in additional pathologic diagnoses in 16% of cases, of which 67% were non-caseating granulomas. Furthermore, two additional malignant cases were identified by TBFB consisting of small cell carcinoma and non-Hodgkin’s lymphoma. Conclusion: In conclusion, TBFB is a useful adjunctive tool in the diagnosis of non-malignant conditions (i.e. granulomatous diseases) with the potential to spare the patient from more invasive surgical biopsies. Training of future fellows in performing TBFB in addition to TBNA should be strongly encouraged. Introduction: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the standard diagnostic method for sampling mediastinal and hilar lymph nodes. Non-diagnostic samples have led some pulmonologists to add a miniforceps biopsy (EBUS-TBFB) in order to increase diagnostic yield. Our study aims to analyze the impact of adding EBUS-TBFB to the EBUS-TBNA in cases where Rapid On-site Evaluation (ROSE) was negative for malignancy or was non-diagnostic. Material and methods: This retrospective chart review included 91 patients who were aged 18–90 years old and underwent EBUS with both TBNA and TBFB between January 1, 2013 and July 1, 2018. Results: There was no significant statistical difference in the diagnostic yield of TBNA vs TBFB with a McNemar value of 0.167, and this conclusion was the same when stratified by race, age and lymph node size. Using TBNA as a gold standard, the sensitivity and specificity of TBFB was 87% and 69%, respectively. Out of the non-diagnostic TBNA samples on ROSE and cell-block, subsequent TBFB resulted in additional pathologic diagnoses in 16% of cases, of which 67% were non-caseating granulomas. Furthermore, two additional malignant cases were identified by TBFB consisting of small cell carcinoma and non-Hodgkin’s lymphoma. Conclusion: In conclusion, TBFB is a useful adjunctive tool in the diagnosis of non-malignant conditions (i.e. granulomatous diseases) with the potential to spare the patient from more invasive surgical biopsies. Training of future fellows in performing TBFB in addition to TBNA should be strongly encouraged.

Background: Mechanical ventilation (MV) management is an essential skill for pulmonary and critical care medicine (PCCM) fellows to master during training. The unprecedented emergence of the coronavirus disease (COVID-19) pandemic highlighted the need for advanced operator competency in MV to improve patients’ outcomes. Objective: We aimed to create a standardized case-based curriculum using a blended approach of high-fidelity simulation, rapid-cycle deliberate practice, video didactics, and hands-on small group sessions for rapid accumulation of knowledge and hands-on skills for PCCM fellows before caring for critically ill patients during the COVID-19 pandemic. Methods: The MV curriculum consisted of the following steps: 1) baseline written knowledge test with 15 multiple-choice questions covering MV, the latest evidence-based practices, and pathophysiology of COVID-19; 2) baseline confidence survey using a 5-point Likert scale; 3) a one-on-one session using a high-fidelity simulation manikin, a lung simulator, and a mechanical ventilator to test baseline competencies; 4) a structured debriefing tailored per fellow’s 50-point competency assessment checklist from the simulation using rapid-cycle deliberate practice; 5) video didactics; 6) a hands-on session in small groups for basic knobology, waveforms, and modes of MV; 7) a one-on-one simulation reassessment session; 8) a written knowledge posttest; and 9) a post-training confidence survey using a 5-point Likert scale. Results: Eight PCCM fellows completed the training. The mean multiple-choice question score increased from 7.4 ± 2.9 to 10.4 ± 2.4 (P < 0.05), and the simulation scores increased from 17.1 ± 4.4 to 30.8 ± 3.7 (P < 0.05). Comparing the simulation reassessment to the baseline, fellows showed significant improvement (P < 0.05) in assessing indications for MV; implementing rapid sequence intubation for patients with COVID-19; initiating MV and ventilator bundle per best practices; recognizing and managing mucous plugging, ventilator dyssynchrony, and evidence-based treatments for acute respiratory distress syndrome; and developing a care plan for proning. The post-training survey revealed improved learner confidence in all competencies. Conclusion: This pilot MV curriculum using a blended approach was feasible and allowed PCCM fellows to significantly improve their knowledge and hands-on skills, allowing for the appropriate use of MV during the pandemic. Self-reported improvement scores further reinforced this. The emergent need for novice learners may again be necessary for future pandemic settings where standard training models requiring extensive training time are limited.

Necrotizing pneumonia and empyema caused by Fusobacterium necrophorum are uncommon. The classical presentation of Lemierre′s syndrome, characterized by pharyngotonsillitis and internal jugular vein thrombosis, is not always observed, and incomplete and atypical variants can cause diagnostic uncertainty and delay in treatment. We describe the case of a previously healthy 22‐year‐old male athlete who developed severe necrotizing community‐acquired pneumonia, bilateral empyema, and acute hypoxemic respiratory failure due to F. necrophorum infection, without the typical vascular thrombosis associated with Lemierre′s syndrome. Blood cultures and broad‐range PCR analysis of the empyema fluid confirmed the presence of F. necrophorum . The patient was initially treated with piperacillin–tazobactam, intravenous corticosteroids, and bilateral chest tube placement for empyema management. Treatment with piperacillin–tazobactam was complicated by drug‐induced liver injury requiring antimicrobial change to ampicillin–sulbactam. The patient was discharged on oral amoxicillin–clavulanic acid and completed a total of 5 weeks of antimicrobial therapy with complete recovery. This case highlights the importance of considering F. necrophorum as a potential pathogen in necrotizing community‐acquired pneumonia, even in immunocompetent adults, and in the absence of classic Lemierre′s syndrome features. Furthermore, its novelty and contribution to the medical literature stem from the patient′s presentation with bilateral empyema requiring bilateral drains, the combined blood culture and pleural fluid 16S confirmation of F. necrophorum infection, and the preceding steroid exposure that contributed to clinical deterioration.

Background: Anaplasma phagocytophilum is an emerging tick-borne zoonotic pathogen that typically causes mild infections, which are often successfully managed in outpatient settings. Immunosuppression associated with splenectomy is a well-documented risk factor for severe infections from pathogens such as Babesia microti and encapsulated bacteria. However, splenectomy has not previously been identified as a risk factor for severe anaplasmosis. Case Presentation: This report describes a rare case of severe anaplasmosis complicated by multiorgan failure in a patient who had undergone splenectomy several decades earlier. The clinical course was notable for pneumonia, acute respiratory distress syndrome, acute kidney injury, rhabdomyolysis, atrial fibrillation, and possible myocarditis. Despite the severity of the presentation, prompt initiation of doxycycline led to recovery, albeit with a significantly prolonged hospital stay. Conclusions: Patients with splenectomy might be more likely to develop a serious form of Anaplasmosis infection such as multiorgan failure. Clinicians in tick-borne endemic areas should be aware that non-specific symptoms can indicate anaplasmosis.