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For mediastinal lymph nodes, biopsies must often be performed to accurately stage lung cancer. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) allows real-time guidance in sampling paratracheal, subcarinal, and hilar lymph nodes, and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) can sample mediastinal lymph nodes located adjacent to the esophagus. Nodes can be sampled and staged more completely by combining these procedures, but to date use of two different endoscopes has been required. We examined whether both procedures could be performed with a single endobronchial ultrasound bronchoscope. ⋯ The two procedures can easily be performed with a dedicated linear endobronchial ultrasound bronchoscope in one setting and by one operator. They are complementary and provide better diagnostic accuracy than either one alone. The combination may be able to replace more invasive methods as a primary staging method for patients with lung cancer.
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Tobacco smoking is a well-recognized risk factor for Legionnaires disease. However, it may be potentiated by cannabis use, as there is strong evidence that Δ(9)-tetrahydrocannabinol impairs immune functions in vitro and in vivo. We report herein two out of three cases of severe Legionnaires disease in three men with no overt comorbid illnesses, aged 38, 28, and 48 years, respectively. All of them were heavy cigarette and cannabis smokers.
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Use of nucleic acid amplification techniques has increased the identification of respiratory viruses (RVs) in adult patients with community-acquired pneumonia (CAP). The objectives of the present study were to identify RV in patients with CAP using three different sampling methods and to compare CAP virus proportions and types with two comparison groups. ⋯ The proportion of RV involvement in CAP is higher than previously reported. The proportion of RV identified in healthy subjects is significantly lower than in CAP, but it is not zero and should be weighed when interpreting corresponding proportions among patients.
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The 2008 National Coverage Determination by the US Centers for Medicare and Medicaid Services (CMS) authorizing coverage of positive airway pressure (PAP) treatment of obstructive sleep apnea on the basis of diagnosis by portable monitoring was seen by some as a major advance in reimbursement policy for sleep medicine services. However, along with the national coverage decision came additional rules (local coverage determinations) setting forth the conditions that would apply in order for reimbursement to continue beyond 90 days. These rules specified the means by which adherence must be measured, a rigid threshold for the acceptable degree of adherence, and a requirement for face-to-face evaluation by the clinician to document clinical response, all of which must take place within a specific timeframe. ⋯ What has become abundantly clear to many is the burden that these rules impose on clinicians and DME providers and, more importantly, that indiscriminate enforcement may well result in adverse consequences for some patients. The latter include not only the inconvenience and added expense for patients of complying with the rules, but those resulting from failure by CMS to recognize that a dose-response relationship exists with respect to the degree of PAP adherence and clinical outcome. Moreover, there is reason to believe that patients of low socioeconomic class, or who are unmarried, or who have psychiatric disease will have more difficulty achieving the required adherence and therefore will, in effect, be victims of government-mandated discrimination in the provision of a vital healthcare service.