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Transbronchial cryobiopsy may have diagnostic and safety limitations that are not yet well appreciated, given the state of the published medical literature. Major questions remain regarding the safest procedural protocol to be used when performing transbronchial cryobiopsy. Thorough planning and a high degree of caution are encouraged on first introduction of this technique into a clinical practice.

Cryotherapy is an evolving therapeutic and diagnostic tool used during bronchoscopy. Through rapid freeze-thaw cycles, cryotherapy causes cell death and tissue necrosis or tissue adherence that can be used via the flexible or rigid bronchoscope. This extreme cold can be used through the working channel of the bronchoscope via a specialized cryoprobe or directly with the use of spray cryotherapy. These properties allow for multiple bronchoscopic techniques, each with its own equipment and procedural, safety, and efficacy considerations. Bronchoscopic cryotherapy can be used in a variety of clinical scenarios, including the treatment of malignant and benign central airway obstruction and low-grade airway malignancy, foreign body removal or cryoextraction, endobronchial biopsy, and transbronchial biopsy. The bulk of the experience with bronchoscopic cryotherapy consists of uncontrolled case series of malignant central airway obstruction. There are also controlled data supporting the use of cryoadhesion for endobronchial biopsies, albeit with an increased risk of controllable bleeding. The use of cryoadhesion for transbronchial biopsies is an active area of investigation with limited controlled data. In addition, there are promising future directions using bronchoscopic cryotherapy, including chemosensitizing malignancy with cryotherapy and capitalizing on the synergy between cryotherapy and radiation.

BACKGROUND:Inpatient falls are common adverse events that lead to inpatient injury, increased length of stay, healthcare costs, litigation, and are a focus of patient safety and healthcare quality. Fall prevention methods are currently evolving to address the problem.PURPOSE:To examine the available data evaluating multidisciplinary fall prevention strategies in the acute inpatient setting.DATA SOURCES:A complete literature search of MEDLINE, CINAHL, EMBASE and the Cochrane Library through December 2011 was used. The bibliographies of all systematic reviews and meta‐analyses were hand searched.STUDY SELECTION:Only primary research studies relating to acute care inpatient hospital multidisciplinary fall prevention were included. Selected papers were assessed for quality by 2 authors using a 20‐point scale previously used in the fall literature.DATA EXTRACTION:Each selected study was carefully hand searched by 2 authors for the purposes of data extraction. Study results, in fall rate per 1000‐patient days, and the characteristics of the interventions used were extracted for analysis.DATA SYNTHESIS:Effect sizes (odds ratios) and 95% confidence intervals were derived for individual studies and then combined across research reports using a random‐effects meta‐analysis.CONCLUSIONS:Fall prevention strategies have a significant but small effect on fall rates despite the use of complex, multidisciplinary interventions. Additional randomized trials are needed to examine the possible benefits of multidisciplinary fall prevention strategies in the acute inpatient setting. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine

Elevated bronchoalveolar lavage amylase is associated with risk factors for aspiration and may predict bacterial pneumonia. Bronchoalveolar lavage amylase may be useful as an early screening tool to guide management of patients suspected of aspiration.

Objective To determine whether face-to-face prompting of critical care physicians reduces empirical antibiotic utilization compared to an unprompted electronic checklist embedded within the electronic health record (EHR). Design Random allocation design. Setting Medical intensive care unit (MICU) with high-intensity intensivist coverage at a tertiary care urban medical center. Patients Two hundred ninety-six critically ill patients treated with at least one day of empirical antibiotics. Interventions For one MICU team, face-to-face prompting of critical care physicians if they did not address empirical antibiotic utilization during a patient’s daily rounds. On a separate MICU team, attendings and fellows were trained once to complete an EHR-embedded checklist daily for each patient, including a question asking whether listed empirical antibiotics could be discontinued. Measurements and main results Prompting led to a more than 4-fold increase in discontinuing or narrowing of empirical antibiotics compared to use of the electronic checklist. Prompted group patients had a lower proportion of patient-days on which empirical antibiotics were administered compared to electronic checklist group patients (63.1% vs. 70.0%, P=0.002). Mean proportion of antibiotic-days on which empirical antibiotics were used was also lower in the prompted group, although not statistically significant (0.78 [0.27] vs. 0.83 [0.27], P=0.093). Each additional day of empirical antibiotics predicted higher risk-adjusted mortality (odds ratio 1.14, 95% CI 1.05–1.23). Risk-adjusted ICU length of stay and hospital mortality were not significantly different between the two groups. Conclusions Face-to-face prompting was superior to an unprompted EHR-based checklist at reducing empirical antibiotic utilization. Sustained culture change may have contributed to the electronic checklist having similar empirical antibiotic utilization to a prompted group in the same MICU two years prior. Future studies should investigate the integration of an automated prompting mechanism with a more generalizable EHR-based checklist.

Novel diagnostic techniques for lung cancer are rapidly evolving. Specifically, several novel changes to bronchoscopy are reaching clinical evaluation. It is critical to think about historical standards for evaluating new diagnostic testing, and put those concepts into the framework of lung cancer. Often a thorough evaluation of new technology is not performed as a part of regulatory marketing clearance.Therefore, we must consider how to best study novel testing beyond these regulatory minimums. There are several methodological principles that can achieve this goal such as using a control arm, more thorough reporting of enrolled patients, consecutive patient enrollment, and adequate sample size. We hope clinicians, particularly those performing bronchoscopy for lung nodules, will feel empowered to critically appraise the evaluation of new diagnostic testing for lung cancer moving forward.

ROSE with appropriate triage, including performing a dedicated pass and proper slide preparation, improves MT, and this is enhanced by having >1 cytologist at the start of the procedure. In the era of personalized medicine, "adequate" should denote sufficient tissue for diagnosis and MT.