ABSTRACT
Compared with mortality, the impact of weather and climate on human morbidity is less well understood, especially in the cold season. We examined the relationships between weather and emergency department (ED) visitation at hospitals in Roanoke and Charlottesville, Virginia, two locations with similar climates and population demographic profiles. Using patient-level data obtained from electronic medical records, each patient who visited the ED was linked to that day's weather from one of 8 weather stations in the region based on each patient's ZIP code of residence. The resulting 2010-2017 daily ED visit time series were examined using a distributed lag non-linear model to account for the concurrent and lagged effects of weather. Total ED visits were modeled separately for each location along with subsets based on gender, race, and age. The relationship between the relative risk of ED visitation and temperature or apparent temperature over lags of one week was positive and approximately linear at both locations. The relative risk increased about 5% on warm, humid days in both cities (lag 0 or lag 1). Cold conditions had a protective effect, with up to a 15% decline on cold days, but ED visits increased by 4% from 2 to 5 days after the cold event. The effect of thermal extremes tended to be larger for non-whites and the elderly, and there was some evidence of a greater lagged response for non-whites in Roanoke. Females in Roanoke were more impacted by winter cold conditions than males, who were more likely to show a lagged response at high temperatures. In Charlottesville, males sought ED attention at lower temperatures than did females. The similarities in the ED response patterns between these two hospitals suggest that certain aspects of the response may be generalizable to other locations that have similar climates and demographic profiles.
Subject(s)
Climate , Weather , Aged , Cities , Emergency Service, Hospital , Female , Humans , Male , Seasons , VirginiaABSTRACT
Uncontrolled pilot studies demonstrated promising results of endoscopic lung volume reduction using emphysematous lung sealant (ELS) in patients with advanced, upper lobe predominant emphysema. We aimed to evaluate the safety and efficacy of ELS in a randomised controlled setting.Patients were randomised to ELS plus medical treatment or medical treatment alone. Despite early termination for business reasons and inability to assess the primary 12-month end-point, 95 out of 300 patients were successfully randomised, providing sufficient data for 3- and 6-month analysis.57 patients (34 treatment and 23 control) had efficacy results at 3â months; 34 (21 treatment and 13 control) at 6â months. In the treatment group, 3-month lung function, dyspnoea, and quality of life improved significantly from baseline when compared to control. Improvements persisted at 6â months with >50% of treated patients experiencing clinically important improvements, including some whose lung function improved by >100%. 44% of treated patients experienced adverse events requiring hospitalisation (2.5-fold more than control, p=0.01), with two deaths in the treated cohort. Treatment responders tended to be those experiencing respiratory adverse events.Despite early termination, results show that minimally invasive ELS may be efficacious, yet significant risks (probably inflammatory) limit its current utility.
Subject(s)
Fibrin Tissue Adhesive/therapeutic use , Pneumonectomy/methods , Pulmonary Emphysema/drug therapy , Pulmonary Emphysema/surgery , Quality of Life , Aged , Female , Follow-Up Studies , Humans , Male , Middle Aged , Pulmonary Emphysema/diagnosis , Pulmonary Emphysema/mortality , Respiratory Function Tests , Risk Assessment , Severity of Illness Index , Survival Rate , Time Factors , Tomography, X-Ray Computed/methods , Treatment OutcomeABSTRACT
Background: Bilothorax is defined as the presence of bile in the pleural space. It is a rare condition, and diagnosis is confirmed with a pleural fluid-to-serum bilirubin ratio of >1. Methods: The PubMed, Embase, Google Scholar, and CINAHL databases were searched using predetermined Boolean parameters. The systematic literature review was done per PRISMA guidelines. Retrospective studies, case series, case reports, and conference abstracts were included. The patients with reported pleural fluid analyses were pooled for fluid parameter data analysis. Results: Of 838 articles identified through the inclusion criteria and removing 105 duplicates, 732 articles were screened with abstracts, and 285 were screened for full article review. After this, 123 studies qualified for further detailed review, and of these, 115 were pooled for data analysis. The mean pleural fluid and serum bilirubin levels were 72 mg/dL and 61 mg/dL, respectively, with a mean pleural fluid-to-serum bilirubin ratio of 3.47. In most cases, the bilothorax was reported as a subacute or remote complication of hepatobiliary surgery or procedure, and traumatic injury to the chest or abdomen was the second most common cause. Tube thoracostomy was the main treatment modality (73.83%), followed by serial thoracentesis. Fifty-two patients (51.30%) had associated bronchopleural fistulas. The mortality was considerable, with 18/115 (15.65%) reported death. Most of the patients with mortality had advanced hepatobiliary cancer and were noted to die of complications not related to bilothorax. Conclusion: Bilothorax should be suspected in patients presenting with pleural effusion following surgical manipulation of hepatobiliary structures or a traumatic injury to the chest. This review is registered with CRD42023438426.
Subject(s)
Bilirubin , Pleural Effusion , Female , Humans , Bile , Bilirubin/blood , Pleural Effusion/etiology , Thoracentesis , Thoracostomy , AgedABSTRACT
PURPOSE: Utilization of intensive care services by patients with malignancy has risen during the past several decades. Newer cancer therapies have improved overall survival and outcomes. Patients with respiratory failure from central airway obstruction related to tumor growth were previously viewed as inappropriate candidates for ventilator support. However, an increasing number of reports suggest that interventional pulmonary (IP) procedures may benefit such patients. METHODS: We reviewed the literature for case reports or case series from the past 20 years regarding the use of IP procedures for the treatment of respiratory failure from malignancy-associated central airway obstruction. RESULTS: As a whole, IP procedures were greater than 60 % successful in liberating patients from mechanical ventilation. Moreover, IP procedures served to palliate respiratory symptoms, prolong overall survival, allow for additional cancer treatments, and reduce hospitalization costs. Nevertheless, it remains unclear who may benefit the most from these procedures. CONCLUSIONS: Although data are limited, IP procedures are generally safe and should be considered for appropriate patients with respiratory failure from malignancy-associated central airway obstruction as a potential means of liberation from mechanical ventilation.
Subject(s)
Airway Obstruction/etiology , Airway Obstruction/therapy , Neoplasms/complications , Respiration, Artificial/statistics & numerical data , Airway Obstruction/economics , Airway Obstruction/surgery , Hospitalization/economics , Humans , Neoplasm Metastasis , Respiratory Insufficiency/economics , Respiratory Insufficiency/therapy , Stents/economics , Ventilator Weaning/economics , Ventilator Weaning/statistics & numerical dataABSTRACT
A twenty-two-year-old woman with a history of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) on rituximab presented with fever, abdominal pain, and worsening shortness of breath requiring supplemental oxygen via nasal cannula one month after a severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection from which she was minimally symptomatic and had recovered. Radiographic studies revealed bilateral patchy consolidations interspersed with ground-glass opacities (GGO). She was started on antibiotics for presumed community-acquired pneumonia with no improvement. Echocardiography revealed preserved biventricular function and a suspected intracardiac mass. A cardiac magnetic resonance imaging (CMRI) revealed myocarditis and no intracardiac mass. Fever persisted and oxygen requirements increased from FiO2 0.4 to 1.0. Repeat CXR showed subtotal left hemithorax opacification. Bronchoscopic samples showed a negative Gram stain and an unremarkable cell count differential. In view of this and given her lack of response to antibiotics with worsening respiratory status, high-dose steroids were started. She improved rapidly, and six days later she was off oxygen. Transbronchial biopsies showed benign parenchyma with some intra-alveolar fibrin deposition with no definitive evidence of viral cytopathic effect, vasculitis, or diffuse alveolar damage (DAD). Follow-up imaging in the pulmonary clinic revealed improvement of prior airspace disease with some new migratory opacities that completely resolved after 12 weeks. Pulmonary function tests and repeat CMRI were normal three months after discharge. Multisystem inflammatory syndrome in adults (MISA), post-covid organizing pneumonia (OP), and immune reconstitution inflammatory syndrome (IRIS) are rare and potentially steroid-responsive causes of pneumonia, which were in our differential diagnosis. It is imperative to consider the rare possibility of steroid-responsive pneumonia-like MISA, post-COVID-OP, and IRIS in patients with worsening respiratory symptoms following a recent SARS-CoV 2 infection.
ABSTRACT
Intercostal lung hernias are uncommon and usually a consequence of trauma or surgery. True spontaneous lung hernias are extremely rare, with only 51 cases identified over the past four-and-half decades. We report a case of nontraumatic chest wall ecchymosis secondary to spontaneous posterior-lateral lung herniation followed by a review of the literature. Interesting radiographic images are presented. The pathophysiology and therapeutic options of this condition are discussed. The case highlights that advanced chronic obstructive pulmonary disease (COPD) may be an etiological factor for the development of this rare entity, with cough being the precipitating event. Given the increasing prevalence of COPD, the authors believe further awareness of this pathology is needed.
ABSTRACT
Background This study aimed to evaluate the role of disturbed circadian rhythm in potentiating intensive care unit (ICU)-acquired delirium.Previous studies have demonstrated bright light therapy (BLT) as an effective modality to improve sleeping patterns and cognitive function in non-critically ill patients. However, its benefit in the ICU has not been clearly established. In this study, we aimed to evaluate the application of daily high-intensity phototherapy at the bedside to deter ICU delirium incidence and duration. Methodology This was a single center, prospective study conducted in ICUs at the Carilion Roanoke Memorial Hospital in Roanoke, VA. Adults patients admitted to the ICU from July 9, 2018 to March 20, 2020 were included in the study. The patients were subjected to 30-minute BLT session (10,000 lux) at the bedside starting at 0700 while in the ICU. Patients were randomized into either the control group (standard hospital lighting) or phototherapy group. Data were analyzed using Wilcoxon rank sum test for continuous variables, Pearson chi-square test for categorical variables, and logistic regression for multivariable analysis that examined significant risk factors for ICU delirium. Results Delirium incidence between BLT (18%) and control (17.5%) groups was non-significant. Total number of delirium-free, coma-free days, as determined by Confusion Assessment Method for the ICU, demonstrated no differences between groups with a median of 28 days (p = 0.516). In multivariable analysis, patients with a Sequential Organ Failure Assessment Score >3 also showed no significant change in ICU delirium incidence when provided bedside BLT compared to those with standard hospital lighting (odds ratio: 0.08; 95% confidence interval: 0.002-1.40; p = 0.867). Conclusions In this randomized control pilot study, daily morning 10,000 lux BLT of 30-minute duration alone was not associated with a significant decrease in ICU-acquired delirium incidence or duration compared to standard hospital lighting. Future studies should consider a nuanced approach to better elucidate the role of disturbed circadian rhythm in influencing ICU-acquired delirium by not only undertaking BLT during the day but also minimizing nighttime light exposure.
ABSTRACT
Cryosurgery has proven effective in managing malignant tracheobronchial tumors, yet its role in benign lesions is not well established. A case of isolated tracheal papillomas recurring 15 years following laser surgery is reported. Cryosurgery allowed improvement in symptoms and adequate control of the papillomas.
Subject(s)
Cryosurgery , Papilloma/surgery , Tracheal Neoplasms/surgery , Humans , Male , Middle Aged , Papilloma/diagnosis , Recurrence , Tracheal Neoplasms/diagnosisABSTRACT
Hyalinizing clear cell carcinomas (HCCC), now referred to as clear cell carcinomas (CCC) by the World Health Organization (WHO), are rare tumors usually arising from the salivary glands of the head and neck. We present the first case of a CCC originating from the trachea. A 66 year-old woman with history of hypertension, former smoker, presented to the emergency department reporting worsening shortness of breath. Computed chest tomography revealed a polypoid mass arising from the left posterior-lateral wall of the trachea. The patient developed worsening respiratory failure requiring mechanical ventilation. Bronchoscopy was completed which relieved a malignant airway obstruction and pathology revealed nests of cells with monomorphic nuclei and clear cytoplasm set in a hyalinized stroma. Using break apart probe fluorescence in situ hybridization testing the tissue revealed the presence of a recurring translocation of the Ewing sarcoma (EWSR1) gene, confirming the diagnosis. CCC is a rare primary airway tumor. CCC was first reported to originate in the lung in 2015. We present the first case of CCC arising from the trachea.
Subject(s)
Adenocarcinoma, Clear Cell/pathology , Lung Neoplasms/pathology , Trachea/pathology , Aged , Female , Humans , Neoplasm Recurrence, Local/pathologyABSTRACT
INTRODUCTION: The management of airway secretions in the mechanically ventilated patient is a routine task throughout all intensive care units. The current treatment strategies are primarily based on anecdotal experiences rather than statistical evidence. Areas covered: This review article evaluates the data from published trials surrounding mucoactive agents and their use in the critically ill patient population. We completed an extensive search through PUBMED and CINAHL via EBSCO, along with the Cochran library to find all trials using mucoactive agents in the critically ill patient population. Expert commentary: Overall, the role of mucoactive agents in the intensive care unit is a field within pulmonary critical care that is in need of evidence-based recommendations. We feel that there is great opportunity for investigators to evaluate different mucoactive therapies in this patient population and to determine their effect on clinical outcomes.
Subject(s)
Expectorants/therapeutic use , Mucociliary Clearance , Respiration, Artificial , Acetylcysteine/therapeutic use , Ambroxol/therapeutic use , Critical Care , Critical Illness , Deoxyribonuclease I/therapeutic use , Guaifenesin/therapeutic use , Humans , Intensive Care Units , Mannitol/therapeutic use , Potassium Dichromate/therapeutic use , Recombinant Proteins/therapeutic use , Saline Solution, Hypertonic/therapeutic use , Sodium Bicarbonate/therapeutic useABSTRACT
Transtracheal oxygen therapy is a well-established modality for improving oxygenation in patients with chronic obstructive pulmonary disease, sleep apnea, pulmonary fibrosis, and other conditions causing hypoxic respiratory failure. In spite of its proven track record, the device remains underutilized. This article reviews benefits and complications related to the use of this modality with an illustrative case presentation.
ABSTRACT
Viral influenza is a seasonal infection associated with significant morbidity and mortality. Rapidly fatal hemorrhagic pneumonia has been described in previously healthy individuals with ß-hemolytic Streptococcus pneumoniae in a small series of patients, but it is not common in patients coinfected with influenza B and ß-hemolytic Streptococcus, particularly since influenza B is considered less pathogenic than influenza A. However, despite being uncommon, this coinfection seems to be associated with high morbidity and mortality, particularly in healthy individuals. We present a case of a 46-year-old previously healthy white woman presenting with 4 days of shortness of breath, sore throat, subjective fevers, and nonproductive cough with rapidly fatal hemorrhagic pneumonia confirmed to have Group A ß-hemolytic Streptococcus and influenza B coinfection. On admission, she had a temperature of 103° F, room air oxygen saturation of 95%, a positive nasal swab for influenza B, and negative rapid strep test. Initial chest radiograph showed increased bibasilar interstitial markings. She was admitted to a regular floor and started on oseltamivir. Preliminary throat culture was positive for Group A ß-hemolytic Streptococcus and penicillin V was started. Respiratory status deteriorated requiring intubation and transfer to Intensive Care Unit. Subsequently, copious bleeding was noted in her endotracheal tube. A bedside bronchoscopy with bronchoalveolar lavage revealed a hemorrhagic pneumonitis. Despite aggressive efforts, she developed shock, arrested, and died Western District Office of the Chief Medical Examiner, Roanoke, VA, USA postadmission. Blood cultures, bronchoalveolar lavage, and postmortem pulmonary tissue grew Group A ß-hemolytic Streptococcus, only resistant to erythromycin.
ABSTRACT
Eosinophilic lung diseases are a diverse group of pulmonary disorders with an extensive list of differential diagnoses. Multiple drugs particularly antibiotics can cause pulmonary eosinophilia with variable pulmonary manifestations. Cutaneous drug reactions are common. Diagnosis is usually made on clinical history and blood eosinophilia with an accumulation of eosinophils in alveolar spaces on histologic analysis. Imaging findings are nonspecific. Stopping the offending agent is often enough while a short course of corticosteroids can hasten recovery. We present a unique case of eosinophilic pneumonia due to meropenem that highlights the importance of keeping a low threshold of suspicion regarding the etiology of drug-induced lung diseases as the current list is not exhaustive, and new agents are being identified continuously. A 51-year-old African American woman presented with fever, dyspnea, and diffuse pustular rash. She had been treated with meropenem intravenously through a peripherally inserted central catheter for 6 weeks before presentation for Pseudomonas aeruginosa septic arthritis of the left knee. She had a temperature of 102.2 F and SpO2of 86% on room air. Chest roentgenogram had scattered infiltrates and chest tomography showed bilateral ground-glass opacities. Laboratory workup showed peripheral eosinophilia. Bronchoalveolar lavage revealed a white blood cell of 2230 with 89% eosinophils. Skin lesions' biopsies showed pustular dermatosis, compatible with acute drug-induced eosinophilic lung disease with skin involvement. As meropenem was the only medication she had been exposed to, it was stopped and systemic steroids were initiated with improvement in respiratory and clinical status and complete recovery on follow-up.
Subject(s)
Lymphatic Diseases/diagnosis , Mediastinal Diseases/diagnosis , Sarcoidosis/diagnosis , Vocal Cord Paralysis/etiology , Humans , Lymphatic Diseases/complications , Male , Mediastinal Diseases/complications , Middle Aged , Nerve Compression Syndromes/etiology , Sarcoidosis/complications , Tomography, X-Ray ComputedABSTRACT
Broncholithiasis is the presence of calcific material within the tracheobronchial tree. Asymptomatic patients can be managed with observation only, whereas symptomatic disease requires surgery, rigid or flexible bronchoscopic removal. Recent reports have shown that flexible bronchoscopy can be a safe and effective option for removal of loose in addition to partially imbedded broncholiths. We present a case of a 65-yearold man with chronic cough that underwent successful cryotherapy assisted bronchoscopic removal of an imbedded broncholith. We will also review current literature regarding the management broncholithiasis.
ABSTRACT
Since the development of portable ultrasonography equipment, this technology has provided clinicians the ability to evaluate a variety of lung pathology at the bedside, but we are still learning how to accurately interpret the acquired images. Adequate interpretation and recognition of certain signs is crucial to diagnosing pathological processes. In addition, such signs must be adequately correlated with the patient's medical condition. For instance, the "lung point sign" has been traditionally considered to be pathognomonic for the presence of a pneumothorax, yet such finding may be present in patients with bullous lung disease without a pneumothorax.We present a case of an 83-year-old man with underlying chronic obstructive pulmonary disease. Bedside ultrasonography identified a "lung point sign" initially suggesting a possible pneumothorax. Further evaluation demonstrated absence of pneumothorax, with the patient having a large bulla.To our knowledge, this is the first case reported demonstrating that the "lung point sign" is not always indicative of a pneumothorax. We discuss the importance of both clinical correlation and understanding of the underlying pathophysiology when reviewing ultrasound images to accurately interpret ultrasound findings.
Subject(s)
Lung Diseases/diagnostic imaging , Pneumothorax , Point-of-Care Systems , Ultrasonography/methods , Aged, 80 and over , Diagnosis, Differential , Humans , Image Processing, Computer-Assisted/methods , Lung/diagnostic imaging , MaleABSTRACT
Scimitar syndrome is characterized by an anomalous venous return with the characteristic chest roentgenogram (CxR) appearance of the anomalous vein draining into the inferior vena cava (IVC). This appears as a curvilinear opacity paralleling the right border of the heart resembling a curved sword or Scimitar. A 27-year-old white woman with a reported history of dextrocardia was admitted after a drug overdose. Examination demonstrated an obtunded woman with tachycardia and right sided heart sounds. Her CxR revealed a right sided heart image with two curvilinear opacities in the retrocardiac area. Chest computed tomography (CT) demonstrated that these opacities join to represent an anomalous vein draining into IVC. Furthermore, an anomalous systemic artery arising from the abdominal aorta was seen to supply the right lower lobe. The patient was eventually diagnosed with Scimitar syndrome. This syndrome affects 1-3 in 100,000 live births while nearly half of the patients remain asymptomatic with some initially being misdiagnosed as dextrocardia, such as in our case. Correctly diagnosing these patients is of paramount importance as some can develop severe pulmonary hypertension and right ventricular failure. In turn, close ongoing echocardiographic monitoring can help identify those that may benefit from surgical interventions to prevent them from developing these complications.
ABSTRACT
The benefit of prophylaxis for Pneumocystis jirovecii pneumonia (PJP) is well documented in immunocompromised patients, particularly those with HIV and/or AIDS; therefore, guidelines dictate this as standard of care. However, there is a paucity of literature regarding those without HIV and/or AIDS who are potentially predisposed to PJP, including patients with sarcoidosis, cryptogenic organizing pneumonia, interstitial lung disease, asthma and chronic obstructive pulmonary disease, who may require high dose of prolonged corticosteroids for disease maintenance or to prevent relapses. In this review, the authors examine the available literature regarding prophylaxis in these groups, elaborate on the pathogenesis of PJP, when to suspect PJP in these patients, as well as explore current recommendations that guide clinical practice regarding implementation of PJP prophylaxis, namely with trimethoprim/sulfamethoxazole being the preferred agent. In summary, the role of PJP prophylaxis in non-HIV patients on chronic steroids remains controversial. The authors present a review of the literature to provide better guidance to the clinician regarding the need to initiate PJP prophylaxis in this patient population.
Subject(s)
Adrenal Cortex Hormones/adverse effects , Anti-Bacterial Agents/administration & dosage , Antibiotic Prophylaxis/methods , Opportunistic Infections/prevention & control , Pneumocystis carinii/pathogenicity , Pneumonia, Pneumocystis/prevention & control , Trimethoprim, Sulfamethoxazole Drug Combination/administration & dosage , Adrenal Cortex Hormones/administration & dosage , Antibiotic Prophylaxis/standards , Drug Administration Schedule , Humans , Immunocompromised Host , Opportunistic Infections/chemically induced , Opportunistic Infections/immunology , Opportunistic Infections/microbiology , Pneumocystis carinii/immunology , Pneumonia, Pneumocystis/chemically induced , Pneumonia, Pneumocystis/immunology , Pneumonia, Pneumocystis/microbiology , Practice Guidelines as Topic , Risk Factors , Time Factors , Treatment OutcomeABSTRACT
Small cell lung cancer (SCLC) is a devastating disease with limited treatment options. Due to its early metastatic nature and rapid growth, surgical resection is rare. Standard of care treatment regimens remain largely unchanged since the 1980's, and five-year survival lingers near 5%. Patient-derived xenograft (PDX) models have been established for other tumor types, amplifying material for research and serving as models for preclinical experimentation; however, limited availability of primary tissue has curtailed development of these models for SCLC. The objective of this study was to establish PDX models from commonly collected fine needle aspirate biopsies of primary SCLC tumors, and to assess their utility as research models of primary SCLC tumors. These transbronchial needle aspirates efficiently engrafted as xenografts, and tumor histomorphology was similar to primary tumors. Resulting tumors were further characterized by H&E and immunohistochemistry, cryopreserved, and used to propagate tumor-bearing mice for the evaluation of standard of care chemotherapy regimens, to assess their utility as models for tumors in SCLC patients. When treated with Cisplatin and Etoposide, tumor-bearing mice responded similarly to patients from whom the tumors originated. Here, we demonstrate that PDX tumor models can be efficiently established from primary SCLC transbronchial needle aspirates, even after overnight shipping, and that resulting xenograft tumors are similar to matched primary tumors in cancer patients by both histology and chemo-sensitivity. This method enables physicians at non-research institutions to collaboratively contribute to the rapid establishment of extensive PDX collections of SCLC, enabling experimentation with clinically relevant tissues and development of improved therapies for SCLC patients.