Pneumosepsis survival in the setting of obesity leads to persistent steatohepatitis and metabolic dysfunction.

BACKGROUND: As critical care practice evolves, the sepsis survivor population continues to expand, often with lingering inflammation in many organs, including the liver. Given the concurrently increasing population of patients with NAFLD, in this study, we aimed to understand the long-term effect of sepsis on pre-existing NAFLD and hyperglycemia. METHODS: Male mice were randomized to a high-fat diet or a control diet (CD). After 24 weeks on diet, mice were inoculated with Klebsiella pneumoniae (Kpa). Serial glucose tolerance tests, and insulin and pyruvate challenge tests were performed 1 week before infection and at 2 and 6 weeks after infection. Whole tissue RNA sequencing and histological evaluation of the liver were performed. To test whether persistent inflammation could be reproduced in other abnormal liver environments, mice were also challenged with Kpa after exposure to a methionine-choline-deficient high-fat diet. Finally, a retrospective cohort of 65,139 patients was analyzed to evaluate whether obesity was associated with liver injury after sepsis. RESULTS: After Kpa inoculation, high-fat diet mice had normalized fasting blood glucose without a change in insulin sensitivity but with a notable decrease in pyruvate utilization. Liver examination revealed focal macrophage collections and a unique inflammatory gene signature on RNA analysis. In the clinical cohort, preobesity, and class 1 and class 2 obesity were associated with increased odds of elevated aminotransferase levels 1-2 years after sepsis. CONCLUSIONS: The combination of diet-induced obesity and pneumosepsis survival in a murine model resulted in unique changes in gluconeogenesis and liver inflammation, consistent with the progression of benign steatosis to steatohepatitis. In a cohort study, obese patients had an increased risk of elevated aminotransferase levels 1-2 years following sepsis.

Management of pneumothorax in the setting of chronic non-invasive positive pressure ventilation: A case series.

There is a growing population of patients who require chronic noninvasive ventilation. While these patients often have no parenchymal lung disease, the use of positive pressure ventilation itself predisposes to both initial and recurrent pneumothoraces. Furthermore, generally accepted pneumothorax management strategies, such as removing a chest tube after liberation from positive pressure ventilation, are not possible in this population. Despite this, there is a lack of clear guidance on management of pneumothorax in the chronically ventilated patient. In this case series, we discuss the management of pneumothoraces in patients requiring chronic noninvasive mechanical ventilation in our Assisted Ventilation Clinic (AVC). Our experience suggests a potential role of definitive treatment of the initial pneumothorax to prevent reoccurrence.

The Effect of a Dedicated Lung Mass Clinic on Lung Nodule Follow Up.

Introduction: With the increased use of computed tomography (CT) imaging, lung nodules are found yearly requiring tracking and guideline directed follow up imaging. We describe the structure of a clinic dedicated to lung nodule tracking, patient education and the outcomes of lung nodule follow up. Methods: Patient electronic medical record charts were reviewed for lung nodules requiring tracking to determine if a follow up study was ordered, completed by the patient, and completed in an appropriate time frame. Patients were grouped based on referral to pulmonary clinic, lung mass clinic, or no subspecialty clinic. 700 CT reports were extracted from the electronic medical record of which 350 (50%) had lung nodules reported on CT, and 111 (15.9%) were lung nodules that additionally recommended discrete follow up in the radiologist report at the Veterans Health Administration hospital in Baltimore. Of these 111 patients, 95% were male and 5% were female. The mean age of the population was 66.3 ± 7.7 years. Results and Discussion: Patients seen in the lung mass clinic had a statistically significant higher rate of the follow up study being ordered by the provider. The lung mass clinic also had a higher percentage of patients who completed the study and completed the study within the recommended time frame, however, this was not statistically significant. Conclusion: A dedicated lung mass clinic should be considered as a method of improving lung nodule tracking with the added benefit of patient education and multidisciplinary care.

Multi-Organ Failure as the Initial Presentation of Lymphocyte-Depleted Hodgkin Lymphoma in Two Patients with Human Immunodeficiency Virus.

Patients with HIV-associated lymphocyte-depleted Hodgkin lymphoma (HIV-HL) often present with advanced, extranodal disease and aggressive clinical features, limiting definitive therapeutic intervention. Here we report two patients with HIV-HL who presented with multi-organ dysfunction as an initial manifestation of their malignancy. Both were initially treated with brentuximab vedotin (BV), which led only to a temporary partial response, highlighting the challenges of treatment. One patient was eventually started on nivolumab and responded very well to the immune checkpoint inhibitor. To our knowledge, this is the first case to describe successful use of nivolumab in a patient with relapsed lymphocyte-depleted HIV-HL. Prompt recognition of multi-organ dysfunction as an initial presentation of lymphocyte-depleted HIV-HL is essential to ensure rapid provision of therapy. While use of BV remains a reasonable option, earlier introduction of immunotherapy in the treatment of HL may provide an additional option in critically ill patients with lymphocyte-depleted HIV-HL.

Acute Liver Failure Induced by Joss Paper Ingestion.

We present a case of liver failure secondary to ingestion of Joss paper. A 44-year-old female initially presented with fever, nausea and vomiting and was subsequently diagnosed with acute liver failure. Prior to presentation she had consumed 1.3 gram of acetaminophen and 800 mg of ibuprofen. Her acetaminophen level was 18 mcg/mL initially and on repeat check was <10 mcg/ml and all viral hepatology antibodies and antigens were negative. History revealed that the patient ingested a ceremonial paper, Joss paper, daily, which is typically painted with heavy metals. Her mercury level was subsequently found to be elevated to 12 ug/L. Mercury can cause depletion of glutathione (GSH) through production of reactive oxygen species. Acetaminophen metabolism requires sufficient GSH to bind to a reactive metabolite to prevent cell death and hepatic injury. Daily exposure to mercury present in the Joss paper, likely accumulated in our patient's body and allowed hepatic injury from even therapeutic doses of acetaminophen.

Lung Cancer Screening in Patients with COPD-A Case Report.

We present two cases demonstrating the nuances that must be considered when determining if a patient could benefit from low dose computed tomography (LDCT) lung cancer screening. Our case report discusses the available literature, where it exists, on lung cancer screening with special attention to the impact of chronic obstructive pulmonary disease (COPD), and poor functional status. Patients with COPD and concurrent smoking history are at higher risk of lung cancer and may therefore benefit from lung cancer screening. However, this population is at increased risk for complications related to biopsies and lobar resections. Appropriate interventions other than surgical resection exist for COPD patients with poor pulmonary reserve. Risks and benefits of lung cancer screening are unique to each patient and require shared decision-making.

EBUS-TBNA diagnosis of localised amyloidosis presenting as mediastinal lymphadenopathy.

Amyloidosis is a unique disease of localised or systemic deposition of the abnormal extracellular fibril. Localised amyloidosis generally takes a benign course, while systemic requires treatment. Adenopathy, especially mediastinal adenopathy, is an unusual manifestation of localised amyloidosis and often requires mediastinoscopy or surgical resection for diagnosis. With the advent of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), there is potential for a less invasive diagnostic approach. We report a rare case of localised mediastinal amyloidosis diagnosed by EBUS-TBNA.

Radial artery access for peripheral endovascular procedures.

OBJECTIVE: The radial artery is often used for coronary angiography, with a demonstrated decrease in local complications and an increase in postoperative mobility of the patient. Data on radial artery access for peripheral endovascular procedures, however, are limited. We describe our experience with radial artery access for diagnostic and endovascular interventions. METHODS: Between February 2012 and March 2015, there were 95 endovascular procedures performed using radial artery access in 80 unique patients. Demographic and clinical data were recorded. Perioperative, postoperative, and 30-day follow-up data were evaluated retrospectively for major and minor complications. Major adverse events included any immediate hospitalization admission, stroke, hand amputation, bleeding requiring transfusion, hematoma requiring surgery, and death. Minor complications included superficial bleeding and hematoma. RESULTS: The patients (52.6% male, 47.4% female) had a mean age of 72.1 ± 9.4 years. Radial artery access was used for diagnostic purposes in 15.8% of all procedures and for therapeutic intervention, including angioplasty and stenting, in 84.2%. The radial artery was the only access point in 80% of patients and was accessed in conjunction with other sites in 20%. Percutaneous access was achieved in 100% of patients with a 100% technical success rate. Hemostasis after catheterization was achieved by manual compression (22.1%) and TR band (Terumo Medical, Tokyo, Japan; 77.9%). Major adverse events occurred in three cases (3.2%) and were unrelated to radial artery access. Radial artery access site-related complications occurred in three cases (3.2%), all of which were minor hematomas that required no treatment. The risk of radial artery complication was not associated with procedure type, vessels treated, or use of heparin. The incidence of stroke, hand ischemia, and upper extremity limb or finger loss was 0%. CONCLUSIONS: Radial artery access for peripheral endovascular procedures appears to be safe and effective and should be considered more often. Complication rates are lower than those reported for femoral artery access.