Clinical course and outcome of acute severe asthma (status asthmaticus) in adults.

OBJECTIVE: To evaluate the clinical course and outcomes in patients with acute severe asthma in a tertiary care setting. METHODS: The retrospective cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of patients of age 16 and above who were admitted with a diagnosis of acute severe asthma from January 2000 to December 2013. These patients had undergone clinical evaluation to assess the severity of illness as well as the complications and eventual outcomes. SPSS 16 was used for statistical analysis. RESULTS: Of the 50 patients in the study, 41 (82%) were females. The overall mean age was 53.1±20.3 years. Ventilator support was required by 37(74%) patients. Presence of acidaemia was associated with the need for invasive ventilation (p<0.033) which in turn was associated with increased hospital stay (p<0.043). Complications were observed in 37(74%) patients, the most common being respiratory failure in 35(70%) and arrhythmias in 8(16%). Use of both non-invasive and invasive ventilation was found to be significantly associated with development of complications (p<0.001 and p<0.009). A total of 4(8%) patients died. Presence of acidaemia was found to be significantly associated with mortality (p<0.032). CONCLUSION: Overt acidaemia at initial presentation in patients with acute severe asthma was significantly associated with higher rates of invasive ventilation leading to increased hospital stay, complications and higher mortality rate.

Etiology and outcome of severe community acquired pneumonia in immunocompetent adults.

BACKGROUND: Community Acquired Pneumonia (CAP) is a commonly encountered disease, one third of which is Severe Community Acquired Pneumonia (SCAP) that can be potentially fatal. There is a paucity of data on etiology and outcome of patients with SCAP in South Asian Population. METHODS: A retrospective cross-sectional study was conducted from March 2002 till December 2008 on patients of 16 years and above who were admitted with the diagnosis of SCAP in accordance to the criteria of American Thoracic Society Guidelines (2001). The patients underwent clinical and diagnostic evaluations to detect the severity of illness as well as the etiology and other risk factors influencing the eventual outcome of SCAP. RESULTS: A total of 189 patients were included in the study. The mean age was 60 ± 18.0 years and 110 (58%) patients were males. The most common isolated pathogens were Staphylococcus aureus (15 patients), Streptococcus pneumoniae (14 patients) and Pseudomonas aeruginosa (9 patients). The highest mortality was seen in patients with Pseudomonas aeruginosa (89%) and Staphylococcus aureus (53%). Overall mortality rate was 51%. On univariate analysis, septic shock (p <0.001), prior antibiotic use (p = 0.04), blood urea nitrogen > 30 mg/dl (p = 0.03), hematocrit < 30% (p = 0.03) and Acute Physiology and Chronic Health Evaluation (APACHE) II score > 20 (p < 0.001) were significantly different between the patients who survived as compared to those who did not. On multivariate analysis, septic shock (p <0.001, OR: 4.70; 95% CI= 2.49-8.87) was found to be independently associated with mortality. CONCLUSION: The microbes causing SCAP in our study are different from the usual spectrum. Staphylococcus aureus and Pseudomonas aeruginosa were the common causative pathogens and associated with high mortality. It is important to establish clinical guidelines for managing SCAP according to the etiologic organisms in our setting.

A randomized, double-blind, placebo-controlled trial of oral montelukast in acute asthma exacerbation.

BACKGROUND: Leukotriene receptor antagonists (LTRAs) are well established in the management of outpatient asthma. However, there is very little information as to their role in acute asthma exacerbations. We hypothesized that LTRAs may accelerate lung function recovery when given in an acute exacerbation. METHODS: A randomized, double blind, placebo-controlled trial was conducted at the Aga Khan University Hospital to assess the efficacy of oral montelukast on patients of 16 years of age and above who were hospitalized with acute asthma exacerbation. The patients were given either montelukast or placebo along with standard therapy throughout the hospital stay for acute asthma. Improvements in lung function and duration of hospital stay were monitored. RESULTS: 100 patients were randomized; their mean age was 52 years (SD +/- 18.50). The majority were females (79%) and non-smokers (89%). The mean hospital stay was 3.70 ± 1.93 days with 80% of patients discharged in 3 days. There was no significant difference in clinical symptoms, PEF over the course of hospital stay (p = 0.20 at day 2 and p = 0.47 at day 3) and discharge (p = 0.15), FEV1 at discharge (p = 0.29) or length of hospital stay (p = 0.90) between the two groups. No serious adverse effects were noted during the course of the study. CONCLUSION: Our study suggests that there is no benefit of addition of oral montelukast over conventional treatment in the management of acute asthma attack. TRIAL REGISTRATION NUMBER: 375-Med/ERC-04.

How well can physicians manage tuberculosis? A public-private sector comparison from Karachi, Pakistan.

BACKGROUND: Tuberculosis (TB) is endemic in Pakistan which ranks fifth amongst the twenty two countries designated to be highly burdened by TB according to the World Health Organization. However, there is paucity of data regarding the knowledge of diagnosis of TB and its management amongst public and private practitioners. In this study, we endeavor to identify this gap in knowledge regarding the diagnosis and management of TB between public and private doctors and the factors affecting these knowledge scores in urban Pakistan. METHODS: This cross sectional survey was conducted between June and December 2011. Doctors from public hospitals, private hospitals and private clinics scattered in all eighteen towns of Karachi were included in the study. Qualified MBBS doctors working in any specialty were eligible to participate whereas doctors working in both the public and private sectors were excluded from the study. Vignette based clinical scenarios were given to assess the knowledge score regarding the diagnosis and management of TB. RESULTS: A total of 196 doctors participated in the study. There was a significant difference between private and public physicians in terms of age and years of practice (p-value <0.05). Significant differences in the proportion of knowledge scores were observed between the public and private doctors and National TB Control Program trained and untrained doctors in Karachi. Factors associated with inadequate knowledge scores were being female gender [OR: 2.76 (95% CI: 1.418-5.384)], private employment status [OR: 1.50 (95% CI: 1.258-2.439)], and not trained by NTP [OR: 2.98 (95% CI: 1.286-3.225)] on multivariate logistic regression analysis. CONCLUSION: It is concluded that a knowledge gap exists between the public and private doctors in Karachi. Strengthening of currently implemented public private mix model along with improvement in the trainings of public and private practitioners is highly recommended to control TB in Pakistan.

Pneumocystis jirovecii pneumonia in a patient treated with trastuzumab-deruxtecan.

Trastuzumab-deruxtecan (T-DXd) is a novel antibody drug conjugate that has improved treatment outcomes in patients with ERBB2-positive cancer, including locally advanced or metastatic gastric and gastro-oesophageal junction adenocarcinoma. One of the reported side effects of this medication is drug-induced pneumonitis. We present in this case report, a diagnostic dilemma of a patient presenting with clinical and radiographical features of drug-induced pneumonitis but was found to have pneumocystis jirovecii pneumonia (PJP). Our case is the first of PJP in a patient treated with T-DXd, highlighting the increasing incidence of this opportunistic infection in patients with solid malignancy. It also highlights the clinical and radiographical similarities between the PJP and drug-induced pneumonitis.

Countenance and implication of Β-sitosterol, Β-amyrin and epiafzelechin in nickel exposed Rat: in-silico and in-vivo approach.

The detrimental impact of reactive oxygen species on D.N.A. repair processes is one of the contributing factors to colon cancer. The idea that oxidative stress may be a significant etiological element for carcinogenesis is currently receiving more and more support. The goal of the current study is to evaluate the anti-inflammatory and anticancer activity of three powerful phytocompounds-sitosterol, amyrin, and epiafzelechin-alone and in various therapeutic combinations against colon cancer to identify the critical mechanisms that mitigate nickel's carcinogenic effect. To evaluate the ligand-protein interaction of four selected components against Vascular endothelial growth factor (VEGF), Matrix metalloproteinase-9 (MMP9) inhibitor and Interleukin-10 (IL-10) molecular docking approach was applied using PyRx bioinformatics tool. For in vivo analysis, hundred albino rats were included, divided into ten groups, each containing ten rats of weight 160-200 g. All the groups were injected with 1 ml/kg nickel intraperitoneally per week for three months, excluding the negative control group. Three of the ten groups were treated with ß-sitosterol (100 mg/kg b wt), ß-amyrin (100 mg/kg b wt), and epiafzelechin (200 mg/kg b wt), respectively, for one month. The later four groups were fed with combinatorial treatments of the three phyto compounds for one month. The last group was administered with commercial drug Nalgin (500 mg/kg b wt). The biochemical parameters Creatinine, Protein carbonyl, 8-hydroxydeoxyguanosine (8-OHdG), VEGF, MMP-9 Inhibitor, and IL-10 were estimated using ELISA kits and Glutathione (G.S.H.), Superoxide dismutase (S.O.D.), Catalase (C.A.T.) and Nitric Oxide (NO) were analyzed manually. The correlation was analyzed through Pearson's correlation matrix. All the parameters were significantly raised in the positive control group, indicating significant inflammation. At the same time, the levels of the foresaid biomarkers were decreased in the serum in all the other groups treated with the three phytocompounds in different dose patterns. However, the best recovery was observed in the group where the three active compounds were administered concomitantly. The correlation matrix indicated a significant positive correlation of IL-10 vs VEGF (r = 0.749**, p = 0.009), MMP-9 inhibitor vs SOD (r = 0.748**, p = 0.0 21). The study concluded that the three phytocompounds ß-sitosterol, ß-amyrin, and epiafzelechin are important anticancer agents which can target the cancerous biomarkers and might be used as a better therapeutic approach against colon cancer soon.

The clinical, endoscopic and histological spectrum of the solitary rectal ulcer syndrome: a single-center experience of 116 cases.

BACKGROUND: Solitary rectal ulcer syndrome (SRUS) is an uncommon although benign defecation disorder. The aim of this study was to evaluate the variable endoscopic manifestations of SRUS and its association with other diseases. METHODS: All the patients diagnosed with SRUS histologically from January 1990 to February 2011 at The Aga Khan University, Karachi were included in the study. The medical records were reviewed retrospectively to evaluate the clinical spectrum of the patients along with the endoscopic and histological findings. RESULTS: A total of 116 patients were evaluated. The mean age was 37.4 ± 16.6 (range: 13-80) years, 61 (53%) of the patients were male. Bleeding per rectum was present in 82%, abdominal pain in 49%, constipation in 23% and diarrhea in 22%. Endoscopically, solitary and multiple lesions were present in 79 (68%) and 33 (28%) patients respectively; ulcerative lesions in 90 (78%), polypoidal in 29 (25%), erythematous patches in 3 (2.5%) and petechial spots in one patient. Associated underlying conditions were hemorrhoids in 7 (6%), hyperplastic polyps in 4 (3.5%), adenomatous polyps in 2(2%), history of ulcerative colitis in 3 (2.5%) while adenocarcinoma of colon was observed in two patients. One patient had previous surgery for colonic carcinoma. CONCLUSION: SRUS may manifest on endoscopy as multiple ulcers, polypoidal growth and erythematous patches and has shown to share clinicopathological features with rectal prolapse, proctitis cystica profunda (PCP) and inflammatory cloacogenic polyp; therefore collectively grouped as mucosal prolapse syndrome. This may be associated with underlying conditions such as polyps, ulcerative colitis, hemorrhoids and malignancy. High index of suspicion is required to diagnose potentially serious disease by repeated endoscopies with biopsies to look for potentially serious underlying conditions associated with SRUS.

Acetaminophen induced Steven Johnson syndrome-toxic epidermal necrolysis overlap.

Steven Johnson Syndrome and Toxic Epidermal Necrolysis are rare but severe form of hypersensitivity inflammatory reactions to multiple offending agents including drugs. Acetaminophen is extensively used due to its analgesic and anti-pyretic properties. It is rendered to be relatively safe, with hepatotoxicity considered to be the major adverse effect. However, very few cases of Steven Johnson Syndrome and Toxic Epidermal Necrolysis have been reported with acetaminophen usage in the past. We present the case of a 40 years old lady who developed an overlap of the two condition after taking several doses of acetaminophen for fever. She presented with widespread maculopapular rash, stinging in the eyes, oral mucosal ulcerations and high grade fever. She was successfully treated with corticosteroid therapy along with the supportive treatment. This case addresses the fact, that severe hypersensitivity reactions can occur with acetaminophen which can be potentially life threatening.

Imaging and intervention for coronary artery disease following irradiation of malignant thymoma.

Thymomas are rare malignant epithelial growths, constituting 20% of mediastinal tumours. Resection followed by irradiation may be employed in all thymomas except for stage 1 thymomas. Mediastinal irradiation is associated with coronary artery disease. The mean duration of presentation of post-irradiation coronary artery disease is 16 years (range 3-29 years). In our patient coronary artery disease was found only a year post irradiation. A 55 year old male who presented with complaints of dyspnoea, retrosternal chest pain and heaviness since one year underwent resection for malignant thymoma followed by radiotherapy. He presented with coronary artery disease a year after undergoing mediastinal irradiation. On follow-up, patient was treated successfully by coronary artery bypass graft. This case is an unusual occurrence and suggests that mediastinal irradiation may result in significant coronary artery disease as early as within one year.

Virological and clinical characteristics of hepatitis delta virus in South Asia.

BACKGROUND & AIMS: There is a paucity of data on the impact of hepatitis D virus (HDV) in patients with hepatitis B virus (HBV) infection from South Asia. We studied the impact of HDV co-infection on virological and clinical characteristics. METHODS: We collected data of 480 patients with HBsAg positive and a detectable HBV DNA PCR, who presented to the Aga Khan University, Karachi and Isra University in Hyderabad, Pakistan in the last 5 years. HDV co-infection was diagnosed on the basis of anti-HDV. ALT, HBeAg, HBeAb and HBV DNA PCR quantitative levels were checked in all patients. We divided all patients into two groups based on anti-HDV, and compared their biochemical, serological & virological labs and clinical spectrum. Clinical spectrum of disease included asymptomatic carrier (AC), chronic active hepatitis (CAH), immuno-tolerant phase (IP), and compensated cirrhosis (CC). RESULTS: HDV co-infection was found in 169 (35.2%). There were 164 (34.6%) HBeAg positive and 316 (65.4%) HBeAg negative patients. Mean ALT level was 66 ± 73 IU. 233 (48.5%) had raised ALT. HBV DNA level was ≥ 10e5 in 103(21.5%) patients. Overall, among HBV/HDV co-infection, 146/169 (86.4%) had suppressed HBV DNA PCR as compared to 231/311 (74.3%) patients with HBV mono-infection; p-value = 0.002. Among HBeAg negative patients 71/128(55.5%) had raised ALT levels among HBV/HDV co-infection as compared to 71/188 (37.8%) with HBV mono-infection (p-value = 0.002); levels of HBV DNA were equal in two groups; there were 27/128 (21%) patients with CC among HBV/HDV co-infection as compared to 23 (12%) in HBV mono-infection (p-value = 0.009); there were less AC (p-value = 0.009) and more CAH (p-value = 0.009) among HBV/HDV co-infection patients. Among HBeAg positive patients, serum ALT, HBV DNA levels and the spectrum of HBV were similar in the two groups. CONCLUSIONS: HBV/HDV co-infection results in the suppression of HBV DNA. A fair proportion of HBV/HDV co-infected patients with HBeAg negative have active hepatitis B infection and cirrhosis as compared to those with mono-infection.

Management of hyperparathyroidism: a five year surgical experience.

OBJECTIVE: To summarize the management of hyperparathyroidism at a tertiary care hospital in Lahore, so that the disease characteristics specific to our population could be identified. Also to determine if focused parathyroidectomy was successful without intra operative localization studies. METHODS: Retrospective analysis was conducted on all cases of hyperparathyroidism, managed at the East Surgical Ward, Mayo Hospital, Lahore, during a five year period (2005-2009). RESULTS: Thirty-two cases of primary hyperparathyroidism and 3 cases of secondary hyperparathyroidism were managed at the East Surgical Ward from 2004-2009. For primary hyperparathyroidism the mean age of presentation was 40.78 +/- 15.42 years and the mean duration of symptoms was 33.96 +/- 27.29 months. Advanced musculoskeletal symptoms were the most common presenting feature followed by gastrointestinal complaints and recurrent renal stones. Unilateral neck exploration and excision of adenoma was carried out successfully in all cases where the results of ultrasound neck and technetium-99m sestamibi scan were concordant. Bilateral neck exploration was performed in all other cases. Decreased serum calcium level was achieved post operatively in all cases and no residual disease or recurrence was encountered on follow up. CONCLUSION: Patients of hyperparathyroidism in our country, tend to present late after the development of complications. Pre operative localization studies like ultrasound neck and sestamibi scan have enabled us to carry out directed exploration rather than bilateral neck exploration in every case. Accurate pre operative assessment and safe surgery offers cure to all patients with primary hyperparathyroidism.

Efficacy of fluoroscopically guided, contrast-enhanced lumbosacral interlaminar epidural steroid injections: a pilot study.

OBJECTIVE: To assess the efficacy of fluoroscopically guided, contrast-enhanced lumbar interlaminar epidural steroid injections (IL-ESI) for lower limb pain greater than axial low back pain using self-reported pain scores. STUDY DESIGN: Prospective, single-arm, pilot, observational human study. SETTING: An outpatient private practice interventional spine specialty referral center. DATA/RESULTS: Twenty-one patients were initially included in analysis. Thirteen patients had "complete data" and completed 3 months of data after their most recent IL-ESI. Their self-reported 3-day average Numeric Pain Rating Scale (NPRS) score (0 to 10) at inception, 2 weeks, 6 weeks, and 3 months were 6.38, 3.00, 2.88, and 3.04, respectively. The average NPRS score at 3 months was significantly lower than at inception after the IL-ESI for this group (P = 0.0001, 95% confidence interval [1.69, 5.00]). Eight patients had "incomplete data." Their self-reported 3-day average NPRS scores at inception, 2 weeks, and 6 weeks were 6.69, 4.25, and 4.00, respectively. Of the eight patients who had incomplete data, two patients had surgical intervention, five patients had lumbar transforaminal epidural steroid injections, and one patient was unable to be contacted after 6 weeks. DISCUSSION/CONCLUSION: This prospective, single-arm pilot study demonstrates that subjects who have had fluoroscopically guided, contrast-enhanced lumbar IL-ESIs for radicular > axial pain can have improved (lowered) NPRS for at least 3 months. It would be worthwhile to pursue a more rigorous study.

A 48-Year-Old Woman With Chronic Cough, Dyspnea, and Bronchiectasis.

CASE PRESENTATION: A 48-year-old woman sought a second opinion for dyspnea and chronic productive cough; she was a never smoker. Mild respiratory symptoms persisted since childhood and had progressively worsened over the previous decade. In addition, an unintentional 30-pound weight loss had occurred over several years. Six years previously, a diagnosis of hypersensitivity pneumonitis was made following right upper lobe wedge resection that revealed chronic bronchiolitis with interstitial pneumonia and non-necrotizing granulomatous inflammation. Subsequent use of prednisone elicited mild intermittent improvement. She had used feather pillows in the past without any other significant exposures. There were no reports of sinus or GI symptoms.

Lung Cancer Screening: Characteristics of Nonparticipants and Potential Screening Barriers.

BACKGROUND: Patients eligible and referred for lung cancer screening (LCS) may not complete the visit. We aimed to identify differences in demographic, clinical, and socioeconomic characteristics between LCS participants and LCS-eligible nonparticipants and determine potential reasons for nonparticipation. MATERIALS AND METHODS: LCS-eligible patients referred between April 2015 and August 2016 were divided into participants and nonparticipants. Retrospective data were collected. A telephone survey was conducted in a subset of nonparticipants to identify reasons for not participating and assess their understanding of the benefits and harms of LCS. RESULTS: We identified 542 participants and 276 LCS-eligible nonparticipants. Female sex, lower pack-years, active smoking, the absence of a history of chronic obstructive pulmonary disease, coronary artery disease, or liver disease, and chronic kidney disease or a history of malignancy were associated with not participating. One hundred nonparticipants completed the telephone survey-29% were unaware of the appointment; 19% had concerns about the distance from the screening site and 14% with insurance coverage; 10% had fear of the imaging result; and 10% felt the computed tomography scan was unnecessary. Eighteen percent knew the benefit of LCS, and 69% were not aware of any screening harms. CONCLUSIONS: LCS-eligible nonparticipants are more likely to be female, active smokers, have fewer total pack-years of smoking, chronic kidney disease, a history of prior malignancy, and not have chronic obstructive pulmonary disease, coronary artery disease, or liver disease. Targeted education about the benefits and harms of LCS, verification of insurance coverage, and providing convenient screening locations may improve participation.

80-year-old man with dyspnoea and bilateral groundglass infiltrates: an elusive case of COVID-19.

COVID-19 is a novel viral infection caused by severe acute respiratory syndrome-coronavirus-2 virus, first identified in Wuhan, China in December 2019. COVID-19 has spread rapidly and is now considered a global pandemic. We present a case of a patient with minimal respiratory symptoms but prominent bilateral groundglass opacities in a 'crazy paving' pattern on chest CT imaging and a negative initial infectious workup. However, given persistent dyspnoea and labs suggestive of COVID-19 infection, the patient remained hospitalised for further monitoring. Forty-eight hours after initial testing, the PCR test was repeated and returned positive for COVID-19. This case illustrates the importance of clinical vigilance to retest patients for COVID-19, particularly in the absence of another compelling aetiology. As COVID-19 testing improves to rapidly generate results, selective retesting of patients may uncover additional COVID-19 cases and strengthen measures to minimise the spread of COVID-19.

Do we need to see to believe?-radiomics for lung nodule classification and lung cancer risk stratification.

Despite multiple recent advances, the diagnosis and management of lung cancer remain challenging and it continues to be the deadliest malignancy. In 2011, the National Lung Screening Trial (NLST) reported 20% reduction in lung cancer related mortality using annual low dose chest computed tomography (CT). These results led to the approval and nationwide establishment of lung cancer CT-based lung cancer screening programs. These findings have been further validated by the recently published Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON) and Multicentric Italian Lung Detection (MILD) trials, the latter showing benefit of screening even beyond the 5 years. However, the implementation of lung cancer screening has been impeded by several challenges, including the differentiation between benign and malignant nodules, the large number of false positive studies and the detection of indolent, potentially clinically insignificant lung cancers (overdiagnosis). Hence, the development of non-invasive strategies to accurately classify and risk stratify screen-detected pulmonary nodules in order to individualize clinical management remains a high priority area of research. Radiomics is a recently coined term which refers to the process of imaging feature extraction and quantitative analysis of clinical diagnostic images to characterize the nodule phenotype beyond what is possible with conventional radiologist assessment. Even though it is still in early phase, several studies have already demonstrated that radiomics approaches are potentially useful for lung nodule classification, risk stratification, individualized management and prediction of overall prognosis. The goal of this review is to summarize the current literature regarding the radiomics of screen-detected lung nodules, highlight potential challenges and discuss its clinical application along with future goals and challenges.

A 31-Year-Old Man With Airflow Obstruction, Intrathoracic Adenopathy, and Pulmonary Nodules.

CASE PRESENTATION: A 31-year-old white man presented for evaluation of productive cough and dyspnea on exertion of 2 months' duration. Associated symptoms included wheezing, chest tightness, and postnasal drip. He was recently treated for pneumonia with a 7-day course of levofloxacin because of an abnormal chest radiograph demonstrating bilateral infiltrates, but his symptoms failed to improve. He had a medical history of mild intermittent asthma and was on no active treatment. He was a nonsmoker. He was born in the United States. He denied any recent travel within or outside the United States, sick contacts, or illicit drug use. He did not have any pets and denied exposure to mold, hot tubs, a down comforter, or pillows. He worked in a vocational program and his hobbies included refinishing wood floors.

Diagnosis and treatment of acute pulmonary inflammation in critically ill patients: The role of inflammatory biomarkers.

Pneumonia and acute respiratory distress syndrome are common and important causes of respiratory failure in the intensive care unit with a significant impact on morbidity, mortality and health care utilization despite early antimicrobial therapy and lung protective mechanical ventilation. Both clinical entities are characterized by acute pulmonary inflammation in response to direct or indirect lung injury. Adjunct anti-inflammatory treatment with corticosteroids is increasingly used, although the evidence for benefit is limited. The treatment decisions are based on radiographic, clinical and physiological variables without regards to inflammatory state. Current evidence suggests a role of biomarkers for the assessment of severity, and distinguishing sub-phenotypes (hyper-inflammatory versus hypo-inflammatory) with important prognostic and therapeutic implications. Although many inflammatory biomarkers have been studied the most common and of interest are C-reactive protein, procalcitonin, and pro-inflammatory cytokines including interleukin 6. While extensively studied as prognostic tools (prognostic enrichment), limited data are available for the role of biomarkers in determining appropriate initiation, timing and dosing of adjunct anti-inflammatory treatment (predictive enrichment).

Frequency of Incidental Findings and Subsequent Evaluation in Low-Dose Computed Tomographic Scans for Lung Cancer Screening.

RATIONALE: The U.S. Preventive Services Task Force recommends lung cancer screening with low-dose chest computed tomographic scans (LDCT) for a well-defined high-risk population. Data on the frequency and impact of incidental findings (IFs) based on LDCT scans performed within a centralized lung cancer screening program have not been reported. OBJECTIVES: Researchers in previous studies have reported IFs in the setting of clinical trials. We present our findings in a real clinical setting where the decision to manage these findings may depend on factors that are not captured in a research trial such as disclosing IFs, patient preferences, severity of comorbidities, and physician expertise. METHODS: We conducted a retrospective chart review of participants in the Cleveland Clinic Lung Cancer Screening Program from April 1, 2015, to February 17, 2016. Lung Imaging Reporting and Data System categories and all reported findings were extracted from the structured radiology report. Downstream investigations that occurred as a result of the imaging findings were recorded. Medicare reimbursement rates were documented for all screening-related testing and treatment. RESULTS: A total of 320 LDCT-screened patients' records were reviewed. The most commonly reported IFs were pulmonary (69.6%), cardiovascular (67.5%), and gastrointestinal (25.9%). Fifteen percent of the scans had an IF that resulted in further evaluation. The majority of patients who underwent further testing had cardiovascular findings (10.3%); less frequently, they had thyroid or adrenal nodules (2.1%), hepatic lesions (0.9%), renal masses (0.6%), or pulmonary disease (0.6%). The most frequently ordered investigations were echocardiography (n = 9), cardiac stress test (n = 9), and CT angiography (n = 6). Reimbursement for the screening process, evaluation, and treatment of screening-detected findings averaged $817 per screened patient. CONCLUSIONS: Clinically significant IFs on LDCT scans for lung cancer screening are common, and their potential impact should be included in the shared decision-making process. Screening program staff should develop a standard approach for the evaluation of these findings and consider the financial impact when seeking infrastructure support for screening program implementation.