Long-term outcomes and predictors of mortality in patients with pulmonary embolism undergoing catheter-directed thrombolysis: a 10-year retrospective study.

BACKGROUND: Data regarding long-term outcomes of catheter-directed thrombolysis (CDT) post intermediate risk pulmonary embolism (PE), the choice of anticoagulation, and factors affecting mortality are not well studied. METHODS: We conducted a ten-year retrospective observational chart review of patients undergoing CDT for intermediate-risk PE. Patients were followed for a period of 1 to a maximum of 5 years from the PE event. Multivariate regression analysis was used to identify independent predictors of mortality post-CDT. RESULTS: We had a total of 373 patients in our study. Significant 5-year mortality was observed (18.7 %) in our patient population, with a 9.2 % cardiopulmonary cause of death. Rate was highest in patients without anticoagulation (78.5 %) and least in patients on apixaban [10.9 %, absolute risk reduction - 63.8 % (40.91 % - 86.60 %)]. Age, female sex and no anticoagulation were independently associated with mortality. CONCLUSION: CDT for intermediate-risk PE has a high 5-year mortality with no anticoagulation as the only modifiable risk factor.

Vasoreactive pulmonary artery hypertension in non-fibrotic hypersensitive pneumonitis.

Group III pulmonary hypertension (PH) is common in patients with hypersensitivity pneumonitis (HSP). Group I PH and vasoreactivity in HSP have not been reported. We describe a case of an elderly veterinarian woman who presented with progressive shortness of breath and desaturation on exertion. The patient was diagnosed with non-fibrotic HSP after consistent findings on chest CT, transbronchial biopsy and a positive HSP serological panel. The patient relocated her birds, and prednisone was started. Due to persistent symptoms, she underwent a right heart catheterisation, which showed PH with vasoreactivity; subsequently, nifedipine was started. Over a 9-month follow-up, there was an improvement in symptoms and a complete resolution of PH and CT scan changes. Our case highlights the rare possibility of group I PH in HSP. It illustrates the importance of confirming the aetiology of PH and initiating treatment early to resolve symptoms.

Spontaneous Resolution of Recurrent Pleural Effusion in Atraumatic Splenic Rupture.

Spontaneous splenic rupture is an uncommon cause of acute-onset left-sided pleural effusion. It is often immediate with a high preponderance for recurrence, sometimes even requiring splenectomy. We report a case of spontaneous resolution of recurrent pleural effusion presenting a month after the initial atraumatic splenic rupture. Our patient was a 25-year-old male without significant medical history who was taking Emtricitabine/Tenofovir for pre-exposure prophylaxis. He presented to the pulmonology clinic for left-sided pleural effusion, diagnosed in the emergency department a day prior. He had a history of spontaneous grade III splenic injury one month before, where he was diagnosed with cytomegalovirus (CMV) and Epstein-Barr virus (EBV) co-infection on polymerase chain reaction (PCR) testing and was managed conservatively. The patient underwent thoracentesis in the clinic, which showed exudative lymphocyte predominant pleural effusion and no malignant cells. The remainder of the infective workup was negative. He was readmitted two days later with worsening chest pain, and imaging revealed re-accumulation of pleural fluid. The patient declined thoracentesis, and a chest X-ray was repeated a week later, showing worsening pleural effusion. The patient insisted on continuing conservative management, and he was seen a week later with a repeat chest X-ray that showed near resolution of pleural effusion. Splenomegaly and splenic rupture can lead to pleural effusion due to posterior lymphatic obstruction, which can be recurrent. There are no current guidelines on management, and treatment options include watchful monitoring, splenectomy, or partial splenic embolization.

A Case of the Unveiling of Pulmonary Pseudoaneurysm Masquerading as a Lung Mass.

Pulmonary artery pseudoaneurysm (PAP) is an abnormal dilatation of the pulmonary vessels. They can mimic the appearance of lung nodules on chest X-rays and noncontrast CT imaging of the chest. We present a case of PAP masquerading as a lung mass for five years before presenting as a pulmonary hematoma. Our patient was an elderly male who presented to the emergency department with dizziness and weakness. He had been on regular follow-ups with annual noncontrast CT scans for a stable lung mass for the past five years. A contrast-enhanced chest CT scan on presentation showed a right lower lobe pseudoaneurysm ruptured into the pleural space with hemothorax, which was confirmed on subsequent chest CTA. The patient underwent an emergent right lower lobe resection and recovered uneventfully. Differentiating a PAP from a lung nodule is challenging and is often missed even by radiologists. A nodule or mass along the pulmonary arterial tree should raise suspicion and trigger further contrast-enhanced imaging, especially angiography, to confirm the diagnosis.

High levels of PEEP may improve survival in acute respiratory distress syndrome: A meta-analysis.

OBJECTIVE: Positive end-expiratory pressure (PEEP) has been viewed as an essential component of mechanical ventilation in acute respiratory distress syndrome (ARDS) and acute lung injury (ALI). However, clinical trials have not yet convincingly demonstrated that high PEEP levels improve survival. The object of this study was to test a priori hypotheses that a small but clinically important mortality benefit of high PEEP did exist, especially in patients with greater overall severity of illness and differences in PEEP protocols might have affected the study results. METHODS: Meta-analysis of randomized controlled trials comparing high versus low PEEP in ARDS/ALI. Studies were identified by search of MEDLINE (1950-2008) and other sources. MEASUREMENTS AND MAIN RESULTS: Five studies including 2447 patients were identified. A pooled analysis showed a significant reduction in hospital mortality in favor of high PEEP (RR=0.89; 95% CI, 0.80-0.99; p=0.03). However, significant statistical and clinical heterogeneities such as differences in disease severity and ventilator protocols were found. The differences in PEEP protocols were not associated with differences in mortality rates. A logistic analysis suggested that the beneficial effect of high PEEP was greater in patients with higher ICU severity scores. CONCLUSIONS: The statistical and clinical heterogeneities make proper interpretation of the results difficult. However, a small, but significant mortality benefit of high PEEP may exist. In addition, our analysis suggests the effects of high PEEP are greater in patients with higher ICU severity scores.

Safety, tolerability and risk benefit analysis of tiotropium in COPD.

COPD is a chronic disease and, like many other chronic diseases, there is no treatment to reverse the severity of the disease except for lung transplant. To date, no inhaled medications have been shown to improve survival. Tiotropium bromide is a long-acting inhaled anticholinergic drug for the treatment of COPD that can improve lung function, reduce symptoms and exacerbations, and improve quality of life with once-daily dosing. It was initially approved and marketed in several countries in Europe in 2002 and then approved in the US in 2004. Tiotropium is generally well tolerated with dry mouth being the main adverse effect. Other adverse effects include constipation, tachycardia, blurred vision, urinary retention and increased intraocular pressure. Despite the recently raised concerns about an excess risk of cardiovascular adverse events with inhaled anticholinergic agents, the risk/benefit ratio of tiotropium appears still favorable given the favorable safety profile demonstrated in the UPLIFT study. However, caution should be advised in patients at high risk for cardiovascular disease given the paucity of data in such patients.