Utility of Bedside Ultrasound in Percutaneous Tracheostomy.

Background: Percutaneous tracheostomy placement is a common procedure performed in the intensive care unit. The use of an anterior neck ultrasound exam is routinely performed preprocedure, allowing for vessel visualization in determining the safety and feasibility of performing the procedure bedside. This prospective observational cohort study was conducted to determine whether vasculature in the anterior neck, seen on bedside ultrasound exam, contributes to bleeding complications during or after percutaneous tracheostomy (PCT) placement. Research Question: Do the vessels identified on preprocedure neck ultrasound affect the risk of bleeding during and after bedside PCT placement? Study Design and Methods: Preprocedural ultrasound was used to identify standard anatomical landmarks and vascular structures in the anterior neck in all patients undergoing bedside PCT placement under bronchoscopic guidance. A blinded survey of our recorded preprocedural images was provided to an expert panel who regularly perform bedside PCTs to determine the influence the images have on their decision to perform the procedure at the bedside. Results: One out of 15 patients (7%) had intra-operative minimal bleeding which was not clinically significant and resolved by gauze compression for 30 s. None of the patients had post-procedural bleeding after tracheostomy placement. Based on the blinded interpretation of neck ultrasound, there was 0.214 inter-operator variability among the expert panelists for decision-making regarding performing bedside PCT. Interpretation: Vessels visualized with anterior neck ultrasound were found to be small venous structures and did not significantly contribute to bleeding risk in patients who underwent PCT placement. The size and location of veins on neck ultrasound may commonly contribute to abandoning bedside PCT. This study suggests that veins measuring 3.9 mm or smaller identified at the site of access do not increase the risk of bleeding in PCT placement.

A 53-Year-Old With Progressive Dyspnea.

CASE PRESENTATION: A 53-year-old woman with a history of pulmonary embolism treated with rivaroxaban came to the ED after 4 days of acutely worsening dyspnea and chest pressure. On arrival, her temperature was 36.7 °C; heart rate, 71 beats/min; BP, 98/59 mm Hg; respiratory rate, 22 breaths/min; and Spo2 95% on room air. Her WBC count was elevated at 15,770/µL; hemoglobin, 13.3 g/dL; platelets, 280,000/µL; INR (international normalized ratio), elevated at 1.66; and partial thromboplastin time, elevated at 18.8 s. Serum chemistry results were unremarkable, and pro-brain natriuretic peptide was slightly elevated at 530 pg/mL (normal, < 300 pg/mL).

A Rapidly Accumulating Effusion in an Immunocompetent Woman.

CASE PRESENTATION: An 87-year-old woman with a medical history of stroke, paroxysmal atrial fibrillation, type 2 diabetes mellitus, diastolic heart failure, and chronic bilateral lymphedema presents with 1 week of shortness of breath. The patient had a 20-pack-year smoking history and at baseline was able to ambulate freely without assistance. Her symptoms of dyspnea were mostly exertional and progressively worsening for 1 week before admission, despite compliance with her home furosemide. On admission, her temperature was 36.3 °C, BP was 101/59 mm Hg, heart rate was 82 beats/min, respirations were 18 breaths/min, and oxygen saturation was 91% on room air. On physical examination, the patient was tachypneic at rest, and auscultation of the lungs revealed minimal breath sounds on the left side. Admission laboratory test results were notable for leukocyte count of 11.67 × 109/L (82.2% neutrophils, 8.3% monocytes, 6.4% lymphocytes, and 2.1% eosinophils). Results of HIV screening tests were negative.

Torpedo Maculopathy: A Systematic Review of Case Reports.

BACKGROUND AND OBJECTIVE: Torpedo maculopathy (TM) is a rare macular lesion involving the retinal pigment epithelium (RPE). This paper describes a retrospective case report of TM. In addition, the authors present a comprehensive systematic review of 110 cases found in the literature. PATIENTS AND METHODS: A search for the term "torpedo maculopathy" was conducted on PubMed, Embase, and Web of Science databases and yielded 62 relevant studies. RESULTS: The majority of cases in the literature, including this case, reported an asymptomatic hypopigmented temporal lesion with occasional satellite lesions. Fluorescein angiography generally revealed hypofluorescence, whereas optical coherence tomography demonstrated RPE thinning as well as choroid hyperreflectivity. CONCLUSIONS: This is the largest systematic review of torpedo maculopathy to date. The authors' findings confirm that it is a benign, nonprogressive, predominantly unilateral temporal lesion thought to arise during macular development. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:78-83.].

A 54-Year-Old Man With Chronic Cough and Recurrent Upper Respiratory Infection.

CASE PRESENTATION: A 54-year-old man sought treatment at the ED for a productive cough with green phlegm of approximately 6 months' duration that was accompanied by a 10-pound weight loss, night sweats, and occasional subjective fevers. He had made several prior visits to the ED for the cough and was hospitalized 4 months earlier for similar symptoms, at which time he underwent a bronchoscopy with BAL and was discharged with antibiotics for presumed pneumonia. He did not report any itching, rashes, sinus infections, joint swelling, joint pain, or GI symptoms. His long-term medications included omeprazole and amlodipine. The patient had a past medical history of grade III follicular lymphoma for which he completed six cycles of bendamustine 4 years before presentation and had been in remission since. He was a never smoker, had a recent travel history to the Dominican Republic 8 months before admission, and had no recent sick contacts.

Intermittent Cough and Hemoptysis With Tree-in-Bud Opacities on Imaging.

CASE PRESENTATION: A 44-year-old man with hyperthyroidism and no smoking history presented to his internist with 5 months of intermittent cough and hemoptysis. The patient's family history was remarkable only for non-Hodgkin's lymphoma in his father. He had a history of a 25-day exposure to a home renovation at work 2 years prior to presentation. He was treated with oral clarithromycin with no improvement in his symptoms. A chest radiograph showed bilateral nodular opacities with a left lower lobar consolidative opacity (Fig 1A, 1B); the patient underwent CT scanning of the chest, which showed areas of nodular infiltration in the lower lobes with tree-in-bud-like opacities. He was referred to a pulmonologist.