- Email: [email protected]
Naming and Blaming, SIRS-UO
lower than those reported previously. The diagnostic yield of transbronchial cryobiopsy has varied in studies published to date. This likely reflects the experience of bronchoscopists and pathologists as well as the technique used (ie, size of cryoprobe, freezing time, site and number of biopsy samples, etc.). Aside from the size of cryobiopsy specimens, pathologists likely have differing thresholds in diagnosing histopathologic patterns such as usual interstitial pneumonia (UIP) on bronchoscopic biopsy specimens. Thus, some authors have employed terms such as “possible UIP” and “probable UIP” in the interpretation of cryobiopsy specimens.2 Furthermore, it is notable that the portion of transbronchial cryobiopsy specimens that were interpreted to show a UIP pattern has varied widely in prior studies.2-6 Substantial interobserver variability among pathologists has been demonstrated even in the interpretation of surgical lung biopsies in patients with idiopathic interstitial pneumonias.7,8 Dr Maldonado wonders about the absence of UIP as a histopathologic diagnosis in our study. Our study subjects manifested various radiologic patterns of diffuse parenchymal infiltrates encountered in clinical practice and not enriched for those with fibrotic interstitial pneumonias as in some other studies. Our cryobiopsy technique differed from those of other investigators who placed the cryoprobe more distally (< 10 mm from the thoracic wall) in order to obtain subpleural lung tissue at the cost of an increased rate of pneumothorax.9 In addition, it is our impression, as we mention in our article, that pulmonologists at our medical center tend to proceed directly to surgical lung biopsy for patients suspected of having UIP. For the period of our transbronchial cryobiopsy study (June 2013 to September 2015), 57 patients at our institution underwent surgical lung biopsies for undiagnosed diffuse parenchymal lung disease, and 21 of these biopsy samples (37%) demonstrated UIP. We agree with Dr Maldonado that there is currently considerable variability in transbronchial cryobiopsy technique and patient selection. Clearly, we need more data and consensus on the optimal technique and use of this modality in the diagnostic evaluation of patients with diffuse parenchymal lung disease. Kamonpun Ussavarungsi, MD Eric S. Edell, MD Jay H. Ryu, MD Rochester, MN
journal.publications.chestnet.org
AFFILIATIONS:
Division of Pulmonary and Critical Care Medicine,
Mayo Clinic. FINANCIAL/NONFINACIAL DISCLOSURES: See earlier cited article for author conflicts of interest. CORRESPONDENCE TO: Kamonpun Ussavarungsi, MD, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: [email protected] Copyright Ó 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1016/j.chest.2016.10.046
References 1. Ussavarungsi K, Kern RM, Roden AC, Ryu JH, Edell ES. Transbronchial cryobiopsy in diffuse parenchymal lung disease: retrospective analysis of 74 cases. Chest. 2017;151(2):400-408. 2. Hagmeyer L, Theegarten D, Treml M, Priegnitz C, Randerath W. Validation of transbronchial cryobiopsy in interstitial lung disease: interim analysis of a prospective trial and critical review of the literature. Sarcoidosis Vasc Diffuse Lung Dis. 2016;33(1):2-9. 3. Kropski JA, Pritchett JM, Mason WR, et al. Bronchoscopic cryobiopsy for the diagnosis of diffuse parenchymal lung disease. PLoS One. 2013;8(11): e78674. https://www.ncbi.nlm.nih.gov/pubmed?term¼PLoSþOne% 5BJour%5DþANDþ8%5Bvolume%5DþANDþe78674%5Bpage% 5D&cmd¼detailssearch. Accessed November 8, 2016. 4. Fruchter O, Fridel L, El Raouf BA, Abdel-Rahman N, Rosengarten D, Kramer MR. Histological diagnosis of interstitial lung diseases by cryo-transbronchial biopsy. Respirology. 2014;19(5):683-688. 5. Pajares V, Puzo C, Castillo D, et al. Diagnostic yield of transbronchial cryobiopsy in interstitial lung disease: a randomized trial. Respirology. 2014;19(6):900-906. 6. Tomassetti S, Wells AU, Costabel U, et al. Bronchoscopic lung cryobiopsy increases diagnostic confidence in the multidisciplinary diagnosis of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med. 2016;193(7):745-752. 7. Nicholson AG, Addis BJ, Bharucha H, et al. Inter-observer variation between pathologists in diffuse parenchymal lung disease. Thorax. 2004;59(6):500-505. 8. Flaherty KR, King TE Jr, Raghu G, et al. Idiopathic interstitial pneumonia: what is the effect of a multidisciplinary approach to diagnosis? Am J Respir Crit Care Med. 2004;170(8):904-910. 9. Ravaglia C, Bonifazi M, Wells AU, et al. Safety and diagnostic yield of transbronchial lung cryobiopsy in diffuse parenchymal lung diseases: a comparative study versus video-assisted thoracoscopic lung biopsy and a systematic review of the literature. Respiration. 2016;91(3):215-227.
Naming and Blaming, SIRS-UO To the Editor:
In a recent issue (December 2016) of CHEST, Gupta et al1 clearly describe the epidemiology of culture negative severe sepsis (CNSS). Sepsis is defined as systemic inflammatory response syndrome (SIRS) in the presence of proven or suspected infection.2 However in 40% to 50% of patients, cultures are negative.1,3 Most clinicians will not be surprised by these data. SIRS criteria are met by many critically ill patients. Severe pancreatitis; major trauma; severe hemorrhage; major surgery; infections with viral, fungal, or bacterial pathogens; and autoimmune diseases all can elicit SIRS symptoms. If we cannot detect 1 of these causes, it is convenient to blame an unidentified pathogen and call it
723
CNSS. It is an ancient human habit to give something a name and then feel master of it. (Genesis 2-19: Now the LORD God had formed out of the ground all the wild animals and all the birds in the sky. He brought them to the man to see what he would name them; and whatever the man called each living creature, that was its name.) All the attention for sepsis may have led to framing in the direction of infection4,5; however, although not consistent, there are differences found between the negative and positive cohort involving comorbidity, severity of illness, and outcome.1,3 This suggests that the etiology also might be different and not solely related to undetected infection. In fact, we do not know the etiology of CNSS. The unjustified feeling of confidence because we think we know what we are dealing with might lead to diagnostic and research slackness. We therefor plea to rename CNSS to SIRS-UO: systemic inflammatory response syndrome of unknown origin. Matijs van Meurs, PhD Jack J. M. Ligtenberg, PhD Jan G. Zijlstra, PhD Groningen, The Netherlands From the Departments of Critical Care (Drs van Meurs and Zijlstra) and Emergency Medicine (Dr Ligtenberg), University of Groningen. FINANCIAL/NONFINANCIAL DISCLOSURES: None declared. CORRESPONDENCE TO: Jan G. Zijlstra, PhD, University Medical Center Groningen, University of Groningen, 9700RB, Hanzeplein 1, Groningen, The Netherlands; e-mail: [email protected] Copyright Ó 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1016/j.chest.2016.10.062 AFFILIATIONS:
References 1. Gupta S, Sakhuja A, Kumar G, McGrath E, Nanchal RS, Kashani KB. Culture-negative severe sepsis: nationwide trends and outcomes. Chest. 2016;150(6):1251-1259. 2. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ ATS/SIS International Sepsis Definitions Conference. Intens Care Med. 2003;29(4):530-538. 3. Phua J, Ngerng W, See K, et al. Characteristics and outcomes of culture-negative versus culture-positive severe sepsis. Crit Care. 2013;17(5):R202. 4. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377. 5. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-637.
culture negative severe sepsis. We agree with the authors that systemic inflammatory response syndrome (SIRS) symptoms can be elicited by not only infections (identified or unidentified), but also other inflammatory conditions. It is, however, important to understand that these patients who qualify for the definition of severe sepsis but are in fact culture negative (ie, have culture negative severe sepsis) are a distinct cohort of patients with worse outcomes and therefore need to be looked at more carefully during evaluations. Our study provides an important groundwork for designing future studies to investigate and improve outcomes for this distinct population. It will also be important to see how this cohort changes with the adoption of the new definition of sepsis.2 Rather than defining a new term, the aim of our study was to describe and direct attention toward this vulnerable population. We would, therefore, propose to avoid using the new terminology of SIRSunknown origin as suggested by the authors, especially because SIRS criteria are going out of favor for more updated definitions of sepsis. Ankit Sakhuja, MD Rochester, MN Shipra Gupta, MD Mankato, MN Kianoush Kashani, MD, FCCP Rochester, MN AFFILIATIONS: From the Division of Pulmonary and Critical Care Medicine (Drs Sakhuja and Kashani), Department of Medicine, and the Division of Nephrology and Hypertension (Dr Kashani), Department of Medicine, Mayo Clinic; and Hospital Medicine (Dr Gupta), Mayo Clinic Health System. FINANCIAL/NONFINANCIAL DISCLOSURES: See earlier cited article for author conflicts of interest. CORRESPONDENCE TO: Ankit Sakhuja, MD, Division of Pulmonary and Critical Care Medicine, Department of Medicine, 200 First St SW, Rochester, MN 55905; e-mail: [email protected] Copyright Ó 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1016/j.chest.2016.11.023
References 1. Gupta S, Sakhuja A, Kumar G, McGrath E, Nanchal RS, Kashani KB. Culture-negative severe sepsis: nationwide trends and outcomes. Chest. 2016;150(6):1251-1259. 2. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810.
Response
Eosinophils and COPD Readmission
To the Editor:
To the Editor:
We appreciate the comments by Drs. Meurs et al on our study1 detailing the epidemiology and outcomes of
We read with interest the recent article from Bafadhel et al1 published in CHEST (August 2016) and the more
724 Correspondence
[
151#3 CHEST MARCH 2017
]
journal.publications.chestnet.org
AFFILIATIONS:
Division of Pulmonary and Critical Care Medicine,
Mayo Clinic. FINANCIAL/NONFINACIAL DISCLOSURES: See earlier cited article for author conflicts of interest. CORRESPONDENCE TO: Kamonpun Ussavarungsi, MD, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: [email protected] Copyright Ó 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1016/j.chest.2016.10.046
References 1. Ussavarungsi K, Kern RM, Roden AC, Ryu JH, Edell ES. Transbronchial cryobiopsy in diffuse parenchymal lung disease: retrospective analysis of 74 cases. Chest. 2017;151(2):400-408. 2. Hagmeyer L, Theegarten D, Treml M, Priegnitz C, Randerath W. Validation of transbronchial cryobiopsy in interstitial lung disease: interim analysis of a prospective trial and critical review of the literature. Sarcoidosis Vasc Diffuse Lung Dis. 2016;33(1):2-9. 3. Kropski JA, Pritchett JM, Mason WR, et al. Bronchoscopic cryobiopsy for the diagnosis of diffuse parenchymal lung disease. PLoS One. 2013;8(11): e78674. https://www.ncbi.nlm.nih.gov/pubmed?term¼PLoSþOne% 5BJour%5DþANDþ8%5Bvolume%5DþANDþe78674%5Bpage% 5D&cmd¼detailssearch. Accessed November 8, 2016. 4. Fruchter O, Fridel L, El Raouf BA, Abdel-Rahman N, Rosengarten D, Kramer MR. Histological diagnosis of interstitial lung diseases by cryo-transbronchial biopsy. Respirology. 2014;19(5):683-688. 5. Pajares V, Puzo C, Castillo D, et al. Diagnostic yield of transbronchial cryobiopsy in interstitial lung disease: a randomized trial. Respirology. 2014;19(6):900-906. 6. Tomassetti S, Wells AU, Costabel U, et al. Bronchoscopic lung cryobiopsy increases diagnostic confidence in the multidisciplinary diagnosis of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med. 2016;193(7):745-752. 7. Nicholson AG, Addis BJ, Bharucha H, et al. Inter-observer variation between pathologists in diffuse parenchymal lung disease. Thorax. 2004;59(6):500-505. 8. Flaherty KR, King TE Jr, Raghu G, et al. Idiopathic interstitial pneumonia: what is the effect of a multidisciplinary approach to diagnosis? Am J Respir Crit Care Med. 2004;170(8):904-910. 9. Ravaglia C, Bonifazi M, Wells AU, et al. Safety and diagnostic yield of transbronchial lung cryobiopsy in diffuse parenchymal lung diseases: a comparative study versus video-assisted thoracoscopic lung biopsy and a systematic review of the literature. Respiration. 2016;91(3):215-227.
Naming and Blaming, SIRS-UO To the Editor:
In a recent issue (December 2016) of CHEST, Gupta et al1 clearly describe the epidemiology of culture negative severe sepsis (CNSS). Sepsis is defined as systemic inflammatory response syndrome (SIRS) in the presence of proven or suspected infection.2 However in 40% to 50% of patients, cultures are negative.1,3 Most clinicians will not be surprised by these data. SIRS criteria are met by many critically ill patients. Severe pancreatitis; major trauma; severe hemorrhage; major surgery; infections with viral, fungal, or bacterial pathogens; and autoimmune diseases all can elicit SIRS symptoms. If we cannot detect 1 of these causes, it is convenient to blame an unidentified pathogen and call it
723
CNSS. It is an ancient human habit to give something a name and then feel master of it. (Genesis 2-19: Now the LORD God had formed out of the ground all the wild animals and all the birds in the sky. He brought them to the man to see what he would name them; and whatever the man called each living creature, that was its name.) All the attention for sepsis may have led to framing in the direction of infection4,5; however, although not consistent, there are differences found between the negative and positive cohort involving comorbidity, severity of illness, and outcome.1,3 This suggests that the etiology also might be different and not solely related to undetected infection. In fact, we do not know the etiology of CNSS. The unjustified feeling of confidence because we think we know what we are dealing with might lead to diagnostic and research slackness. We therefor plea to rename CNSS to SIRS-UO: systemic inflammatory response syndrome of unknown origin. Matijs van Meurs, PhD Jack J. M. Ligtenberg, PhD Jan G. Zijlstra, PhD Groningen, The Netherlands From the Departments of Critical Care (Drs van Meurs and Zijlstra) and Emergency Medicine (Dr Ligtenberg), University of Groningen. FINANCIAL/NONFINANCIAL DISCLOSURES: None declared. CORRESPONDENCE TO: Jan G. Zijlstra, PhD, University Medical Center Groningen, University of Groningen, 9700RB, Hanzeplein 1, Groningen, The Netherlands; e-mail: [email protected] Copyright Ó 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1016/j.chest.2016.10.062 AFFILIATIONS:
References 1. Gupta S, Sakhuja A, Kumar G, McGrath E, Nanchal RS, Kashani KB. Culture-negative severe sepsis: nationwide trends and outcomes. Chest. 2016;150(6):1251-1259. 2. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ ATS/SIS International Sepsis Definitions Conference. Intens Care Med. 2003;29(4):530-538. 3. Phua J, Ngerng W, See K, et al. Characteristics and outcomes of culture-negative versus culture-positive severe sepsis. Crit Care. 2013;17(5):R202. 4. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377. 5. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-637.
culture negative severe sepsis. We agree with the authors that systemic inflammatory response syndrome (SIRS) symptoms can be elicited by not only infections (identified or unidentified), but also other inflammatory conditions. It is, however, important to understand that these patients who qualify for the definition of severe sepsis but are in fact culture negative (ie, have culture negative severe sepsis) are a distinct cohort of patients with worse outcomes and therefore need to be looked at more carefully during evaluations. Our study provides an important groundwork for designing future studies to investigate and improve outcomes for this distinct population. It will also be important to see how this cohort changes with the adoption of the new definition of sepsis.2 Rather than defining a new term, the aim of our study was to describe and direct attention toward this vulnerable population. We would, therefore, propose to avoid using the new terminology of SIRSunknown origin as suggested by the authors, especially because SIRS criteria are going out of favor for more updated definitions of sepsis. Ankit Sakhuja, MD Rochester, MN Shipra Gupta, MD Mankato, MN Kianoush Kashani, MD, FCCP Rochester, MN AFFILIATIONS: From the Division of Pulmonary and Critical Care Medicine (Drs Sakhuja and Kashani), Department of Medicine, and the Division of Nephrology and Hypertension (Dr Kashani), Department of Medicine, Mayo Clinic; and Hospital Medicine (Dr Gupta), Mayo Clinic Health System. FINANCIAL/NONFINANCIAL DISCLOSURES: See earlier cited article for author conflicts of interest. CORRESPONDENCE TO: Ankit Sakhuja, MD, Division of Pulmonary and Critical Care Medicine, Department of Medicine, 200 First St SW, Rochester, MN 55905; e-mail: [email protected] Copyright Ó 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1016/j.chest.2016.11.023
References 1. Gupta S, Sakhuja A, Kumar G, McGrath E, Nanchal RS, Kashani KB. Culture-negative severe sepsis: nationwide trends and outcomes. Chest. 2016;150(6):1251-1259. 2. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810.
Response
Eosinophils and COPD Readmission
To the Editor:
To the Editor:
We appreciate the comments by Drs. Meurs et al on our study1 detailing the epidemiology and outcomes of
We read with interest the recent article from Bafadhel et al1 published in CHEST (August 2016) and the more
724 Correspondence
[
151#3 CHEST MARCH 2017
]