Investigating and managing suspected pulmonary embolism in an outpatient setting: the Leicester experience.

Having established an ambulatory service for patients with suspected and proven PE, we reviewed our outcomes. All patients referred from June 2010 to May 2012 were analysed. Of 971 patients referred, 905 underwent complete assessment (66 admitted as ineligible). 754 (77.7%) patients were discharged and required no follow-up. 96 (10.6%) patients had PE confirmed of whom 70 (72.9%) were managed as outpatients. 14 (1.6%) patients have died since attending the clinic; no death was related to PE. This audit shows that ambulatory investigation and management of selected low risk patients with suspected PE is safe and reduces hospital admissions.

COVID-19 promoting the development of active tuberculosis in a patient with latent tuberculosis infection: A case report.

We report the case of a 40-year-old female diagnosed with COVID-19 after presenting to our institution with fever, cough and myalgia for three days. Her nasopharyngeal swab tested positive for SARS COV-2 by real time PCR and her plain chest radiograph was reported as normal. She did not require hospitalization and at telephone follow up she confirmed her illness lasted 11 days. Seven weeks later she presented with chest pain, dyspnea and fever for two days. Her repeat chest imaging showed right upper zone consolidation and this culminated in a microbiological diagnosis of pulmonary tuberculosis. The patient's daughter had been treated for tuberculosis two years earlier and unfortunately family screening for latent TB was not undertaken. This case appears to confirm the concerns that the CD4+ T-cell depletion associated with COVID-19 may promote the development of active tuberculosis from latent infection much like HIV does. If this effect is widespread it may have a significant impact on the worldwide TB burden. We suggest vigilance to ensure patients are diagnosed early and meticulous contact tracing is undertaken to treat those with latent tuberculosis.

A previously undescribed type of quadricuspid aortic valve: type H.

The discovery is reported of a previously undescribed type of quadricuspid aortic valve, which was comprised of two equal-sized smaller cusps and two unequal-sized larger cusps. This was proposed as the eighth type of quadricuspid valve, type H. This anatomic variation is the only type of quadricuspid valve that could exist in theory, but has not been previously described. It would therefore, complete the morphological classification of this entity.

Safety and efficacy of ambulatory management of secondary spontaneous pneumothorax: a case series.

Introduction: The optimal management of pneumothorax remains undefined. There is a growing consensus that patients with spontaneous pneumothorax can be considered for ambulatory management with the use of a one-way valve. Despite this, there is little data on the outcomes of outpatient management of secondary spontaneous pneumothorax (SSP). Methods: At our institution, selected patients with primary and secondary spontaneous pneumothorax who meet the predefined local criteria are managed on an ambulatory pathway. We prospectively evaluated our practice over a 3-year period and explore outcomes of patients with SSP using primary spontaneous pneumothorax (PSP) as a comparator group. Results: 163 consecutive patients presenting to our hospital between September 2014 and July 2017 were evaluated using a predefined protocol. 111 (49 SSP and 62 PSP) were deemed suitable for outpatient management. Resolution on day 5 was similar between the two groups (65% in the SSP vs 79% in the PSP group; p=0.108). The mean drainage time was 5.84 days in SSP compared with 5.69 days in PSP, representing a difference of 0.15 days (95% CI -2.47 to 2.16; p=0.897). Complications such as infection and drain blockage/falling-out were scarce, with comparable pain and satisfaction scores across both groups. There were no deaths during this period. An estimated £86 796 ($113 920) was saved over the study period, equating to £1118.80 ($1550) per patient. Discussion: This study suggests that outpatient management of selected patients with SSP may be effective, safe and cost-saving.

Partial ambulatory management of severe secondary spontaneous pneumothorax.

Secondary spontaneous pneumothorax can be difficult to manage especially in patients with advanced lung disease and respiratory failure. Such patients are unfit for surgery and may endure prolonged hospital stays with chest drains in situ. We describe two such cases where the air leak was persistent despite conventional management. Ambulatory devices which we ordinarily use to manage pneumothoraces in patients with a good lung reserve, were employed as a palliative measure. The strategy not only allowed the patients to return home, but also resulted in healing of the air leak which had persisted with conventional management.

Cryptogenic organising pneumonia presenting with spontaneous pneumothorax and the value of procalcitonin: A case report.

Cryptogenic Organising Pneumonia (COP) is a relatively rare condition and can be difficult to differentiate from Community acquired pneumonia (CAP). We report two cases which demonstrate the importance of considering this differential diagnosis in patients with spontaneous pneumothorax who have raised inflammatory markers or lung infiltrates. Our report highlights the value of serum procalcitonin as a biomarker in differentiating between community acquired pneumonia and cryptogenic organising pneumonia especially in the context of a high serum C-reactive protein. Furthermore, the cases show early diagnosis and prompt treatment with corticosteroids may impact the clinical outcome.