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Robotic assisted bronchoscopy (RAB) and electromagnetic navigational bronchoscopy (ENB) are two approaches to biopsy peripheral pulmonary lesions (PPLs). A recently completed cluster randomized controlled trial, RELIANT (NCT05705544), showed no difference in diagnostic yield between these two modalities. The ENB platform used in RELIANT included integrated digital tomosynthesis, allowing for real-time assessment of PPL location for more precise targeting at the time of biopsy. RAB has since been integrated with cone beam computed tomography (CBCT) to accomplish the same intraprocedural correction. It is unclear if the diagnostic yield of RAB with integrated CBCT (RAB-CBCT) is superior to ENB with integrated digital tomosynthesis (ENB-DT). Robotic versus Electromagnetic Bronchoscopy for Pulmonary LesIon AssessmeNT using integrated intraprocedural imaging (RELIANT 2) is an investigator-initiated, multicenter, open label, superiority, cluster randomized trial. At each participating institution, procedural rooms are randomly assigned to either RAB-CBCT or ENB-DT, with each procedure room-day considered a cluster. All adult patients undergoing navigational bronchoscopy for evaluation of PPL(s) are eligible. Allocation is concealed from schedulers, proceduralists, and patients until the morning of procedure when each room is randomized to a platform. The primary endpoint is the diagnostic yield, defined as the proportion of cases yielding a specific benign or malignant diagnosis per current ATS/ACCP definition. Secondary and safety endpoints include procedure duration and procedural complications. Enrollment began on November 11, 2024 and is expected to enroll approximately 440 patients in 220 clusters. RELIANT 2 is an ongoing cluster randomized trial comparing the diagnostic yield of RAB-CBCT to that of ENB-DT in patients undergoing bronchoscopy to biopsy PPLs. This trial will help address some of the limitations of the recently published RELIANT trial. Trial registration The trial was registered in ClinicalTrials.gov (NCT06654271) on October 21, 2024, prior to patient enrollment.

The severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) causes coronavirus disease 2019 (COVID‐19) and has been related to more than 7 million deaths globally since 2019. The association of high levels of IL‐6 with severe cases led to the early evaluation of the anti‐IL6 inhibitor tocilizumab as a potential treatment, which unfortunately failed to improve survival in many trials. Moreover, little is known about the development of COVID‐19 sequelae, and biomarkers are needed to understand and anticipate these processes. Because extracellular vesicles (EVs) play an important role in viral infection and immune response, they could potentially serve as predictive and prognostic biomarkers. We isolated EVs from 39 patients with severe COVID‐19, from which 29 received tocilizumab and 10 were considered controls. Blood samples, which were collected at hospitalisation before treatment, at Day 7, and Day 15 during follow‐up, were assessed by immunoblot for longitudinal expression of spike (S) and nucleocapsid (N) proteins. Dynamic expression was calculated and compared with clinicopathological and experimental variables. Expression of EV S was validated by immunogold and imaging flow‐cytometry, revealing an enrichment in CD9+ EVs. As a result, decreasing expression of EV viral proteins was observed in patients treated with tocilizumab. Moreover, higher increase in EV S was observed in patients with lower antibody response, hyperfibrinogenemia, lower respiratory function, higher blood pressure and shorter outcomes. These findings lay the foundation for future studies characterizing the role of EVs in multiorgan assessment and identifying biomarkers in patients with severe COVID‐19 and possible long COVID.

IntroductionTransbronchial lung biopsy (TBLB) is frequently performed in single-lung and double-lung transplant recipients for evaluation of clinical and radiological findings as well as routine surveillance for acute cellular rejection. While rates of clinically significant TBLB-related haemorrhage are <1% for all comers, the incidence in lung transplant recipients is reported to be higher, presumably due to persistent allograft inflammation and alterations in allograft blood flow. While routinely performed by some bronchoscopists, the efficacy and safety profile of prophylactic administration of topical intrabronchial diluted epinephrine for the prevention of TBLB-related haemorrhage has not been explored in a prospective manner.Methods and analysisIn this randomised, double-blind, placebo-controlled multicentre trial (PROPHET Study), single-lung and double-lung transplant adult recipients from participating institutions who are scheduled for bronchoscopy with TBLB for clinical indications will be identified. Potential participants who meet inclusion and exclusion criteria and sign an informed consent will be randomised to receive either diluted epinephrine or placebo prior to performance of TBLB. The degree of TBLB-related haemorrhage will be graded by the performing bronchoscopist as well as independent observers. The primary analysis will compare the rates of severe and very severe bleeding in participants treated with epinephrine or placebo. The study will also evaluate the safety profile of prophylactic topical epinephrine including the occurrence of serious cardiovascular and haemodynamic adverse events. Additional secondary outcomes to be explored include rates of non-severe TBLB-related haemorrhage, overall yield of the bronchoscopic procedure and non-serious cardiovascular and haemodynamic adverse effects.Ethics and disseminationThe study procedures were reviewed and approved by institutional review boards in participating institutions. This study is being externally monitored, and a data and safety monitoring committee has been assembled to monitor patient safety and to evaluate the efficacy of the intervention. The results of this study will be published in peer-reviewed scientific journals and presented at relevant academic conferences.Trial registration number NCT03126968; Pre-results.

Kaposi sarcoma (KS) is the most common neoplasm associated with Acquired Immune Deficiency Syndrome (AIDS), but antiretroviral therapy has reduced its incidence dramatically. Endobronchial KS is usually associated with concurrent mucocutaneous lesions and is highly vascular; so biopsy generally is not recommended. The use of advanced bronchoscopic techniques for evaluation of endobronchial KS may mitigate the bleeding risks but has not been described previously. We describe an unusual case of KS, which presented as an isolated obstructing endobronchial tumor that was effectively resected using electrocautery snare and argon plasma coagulation (APC) during bronchoscopy.

A 74‐year‐old woman presented with chest pain and dyspnoea following endobronchial ultrasound (EBUS)‐guided transbronchial needle aspiration (TBNA) for presumed malignancy. Computed tomography angiography revealed a left‐sided pleural effusion with hypertrophied and tortuous bronchial arteries (BAs) with contrast blush into the left lung hilum. Tube thoracostomy and pleural fluid analysis confirmed the diagnosis of haemothorax. The mechanism of injury was determined to be BA laceration during EBUS‐TBNA and drainage led to rapid improvement in the patient's symptoms. This is the first reported case of haemothorax due to BA injury during EBUS‐TBNA. Haemothorax following an endobronchial ultrasound‐guided guided transbronchial needle aspiration (EBUS‐TBNA) as a result of bronchial artery laceration resolved with small‐bore chest tube drainage.

Purpose The purpose of this paper is to explore the implications on former accounting firm partners becoming employees of a publicly owned accounting corporation, the responses of the former partners and impacts on the acquiring company. Partners of accounting and other professional service firms selling their firms to publicly owned companies often remain with the acquiring company as employees and receive company shares as consideration for their firms. Agency theory suggests public ownership will result in changes to the roles of senior professionals with potential resistance and motivation consequences. Design/methodology/approach This paper uses a case study approach involving the review of publicly available information and interviews with executives and senior professionals of an Australian publicly owned accounting company, Stockford Limited. Findings The Stockford case indicates that selling their firm to a publicly owned company can have significant negative implications for accounting firm partners. The former partners struggled to adapt to their new roles as senior professional employees and shareholders. Their responses had significant impacts on company performance, which ultimately contributed to the collapse of the company, thus reflecting the power senior professionals retain regardless of the change of ownership form. Research limitations/implications Care is required when generalising findings of a single case to other professions and other geographic jurisdictions. Practical implications This paper has significant implications for entrepreneurs and executives consolidating professional service firms, partners considering selling their firms and investors in publicly owned professional service firms. Originality/value Despite the emergence of publicly owned accounting and other professional service companies and the importance and power of senior professionals in professional service firms, this is the first study to explore the implications on senior professionals of selling their firms to public companies.

Description A woman in her 80s with ventilator-dependent respiratory failure due to severe cardiomyopathy and critical illness myopathy was transferred to our hospital after experiencing recurrent episodes of ventricular fibrillation cardiac arrest requiring cardiopulmonary resuscitation.