we suggest that no additional diagnostic evaluation need be performed (Grade 2C) .Remark : This recommendation applies only to solid nodules. For guidance about follow-up of subsolid nodules, see Recommendations 6.5.1 to 6.5.4 . 2.3.3.In the individual with an indeterminate nodule that is identifi ed by chest radiography, we recommend that CT of the chest should be performed (preferably with thin sections Objectives: The objective of this article is to update previous evidence-based recommendations for evaluation and management of individuals with solid pulmonary nodules and to generate new recommendations for those with nonsolid nodules. Methods: We updated prior literature reviews, synthesized evidence, and formulated recommendations by using the methods described in the "Methodology for Development of Guidelines for Lung Cancer" in the American College of Chest Physicians Lung Cancer Guidelines, 3rd ed. Results: We formulated recommendations for evaluating solid pulmonary nodules that measure . 8 mm in diameter, solid nodules that measure Յ 8 mm in diameter, and subsolid nodules. The recommendations stress the value of assessing the probability of malignancy, the utility of imaging tests, the need to weigh the benefi ts and harms of different management strategies (nonsurgical biopsy, surgical resection, and surveillance with chest CT imaging), and the importance of eliciting patient preferences. Conclusions: Individuals with pulmonary nodules should be evaluated and managed by estimating the probability of malignancy, performing imaging tests to better characterize the lesions, evaluating the risks associated with various management alternatives, and eliciting their preferences for management. CHEST 2013; 143(5)(Suppl):e93S-e120SAbbreviations: AAH 5 atypical adenomatous hyperplasia; ACCP 5 American College of Chest Physicians; AIS 5 adenocarcinoma in situ; EBUS 5 endobronchial ultrasound; ENB 5 electromagnetic navigation bronchoscopy; FDG 5 fl uorodeoxyglucose; HU 5 Hounsfi eld unit; LR 5 likelihood ratio; SPECT 5 single-photon emission CT; TBB 5 transbronchial biopsy; TTNB 5 transthoracic needle biopsy; VATS 5 video-assisted thoracic surgery; VBN 5 virtual bronchoscopy navigation; VDT 5 volume doubling time

No abstract

Objective Trends in severe sepsis mortality derived from administrative data may be biased by changing ICD-9-CM coding practices. We sought to determine temporal trends in severe sepsis mortality using clinical trial data that does not rely on ICD-9-CM coding and compare mortality trends in trial data to those observed from administrative data. Design We searched MEDLINE for multicenter, randomized trials that enrolled patients with severe sepsis from 1991-2009. We calculated standardized mortality ratios (SMR) for each trial from observed 28-day mortality of usual care participants and predicted mortality from severity of illness scores. To compare mortality trends from clinical trials to administrative data, we identified adult severe sepsis hospitalizations in the Nationwide Inpatient Sample, 1993-2009, using two previously validated algorithms. Setting and Patients Hospitalized patients with severe sepsis or septic shock. Measurements and Main Results Of 3244 potentially eligible articles, we included 36 multicenter severe sepsis trials, with a total of 14,418 participants in a usual care arm. Participants with severe sepsis receiving usual care had a 28-day mortality of 33.2%. Observed mortality decreased 3.0% annually (95% CI 0.8%, 5.0%, p=0.009), decreasing from 46.9% [SMR 0.94, 95% CI (0.86, 1.03)] during years 1991-1995 to 29% [SMR 0.53, (95% CI (0.50, 0.57)] during years 2006-2009 (3.0% annual change). Trends in hospital mortality among patients with severe sepsis identified from administrative data [“Angus definition”: 4.7% annual change, (95% CI 4.1%, 5.3%), p=0.69), “Martin definition”: 3.5% annual change, (95% CI 3.0%, 4.1%, p=0.97)] were similar to trends identified from clinical trials. Conclusion Since 1991, patients with severe sepsis enrolled in usual care arms of multicenter randomized trials have experienced decreasing mortality. The mortality trends identified in clinical trial participants appear similar to those identified using administrative data and support the use of administrative data to monitor mortality trends in patients with severe sepsis.

Context New-onset fibrillation (AF) has been reported in 6–20% of patients with severe sepsis. Whereas chronic AF is a known risk factor for stroke and death, the clinical significance of new-onset AF in the setting of severe sepsis is uncertain. Objective To determine the in-hospital stroke and in-hospital mortality risks associated with new-onset AF in patients with severe sepsis. Design Retrospective population-based cohort of California State Inpatient Database administrative claims data from 1/1/2007 through 12/31/2007. Setting Non-Federal acute care hospitals. Patients Data was available from 3,144,787 hospitalized adults. Severe sepsis [N=49,082 (1.56%)] was defined by validated ICD-9-CM code 995.92. New-onset AF was defined as AF that occurred during the hospital stay, after excluding AF cases present at admission. Main Outcome Measures A priori outcome measures were in-hospital ischemic stroke (ICD-9-CM codes of 433, 434, or 436) and mortality. Results Patients with severe sepsis were 69±16 years old and 48% were women. New-onset atrial fibrillation occurred in 5.9% of patients with severe sepsis versus 0.6% of patients without severe sepsis [multivariable-adjusted odds ratio (OR), 6.82; 95% confidence interval (CI), 6.54–7.11; P<0.001]. Severe sepsis was present in 14% of all new-onset AF in hospitalized adults. Compared with severe sepsis patients without new-onset AF, patients with new-onset AF during severe sepsis had greater risks of in-hospital stroke (75/2896 (2.6%) vs. 306/46186 (0.6%) strokes, adjusted OR 2.70; 95% CI, 2.05–3.57; P <0.0001) and in-hospital mortality (1629 (56%) vs. 18027 (39%) deaths, adjusted relative risk, 1.07; 95% CI, 1.04–1.11; P <0.0001). Findings were robust across two definitions of severe sepsis, multiple methods of addressing confounding, and multiple sensitivity analyses. Conclusion Among patients with severe sepsis, patients with new-onset AF were at increased risk for in-hospital stroke and death compared with patients with no AF and patients with pre-existing AF.