Thirty-Day Readmissions After Pneumonia: How Many Are Preventable?

INTRODUCTION: Pneumonia remains a continuing target for performance measurement and quality improvement. The aim of this analysis was to examine 30-day all-cause readmissions after pneumonia to identify reasons for readmission and potential opportunities for improvement. METHODS: A retrospective chart review was performed on patients readmitted within 30 days after an index pneumonia hospitalization at the University of Connecticut Health Center in 2011. RESULTS: There were 54 readmissions involving 40 patients and only five (12.5%) patients had readmissions that were deemed potentially preventable. Reasons for readmissions were CHF exacerbation (3), malnutrition (1), and pericardial tamponade (1). Of the 49 non-preventable readmissions, 16 were related to pneumonia/bronchitis. Four out of 16 had known aspiration risks, while the rest had comorbidities including cystic fibrosis, COPD, CHF, HIV, and sickle cell disease. Other readmissions were secondary to underlying co-morbid conditions. CONCLUSION: These results suggest that most 30-day readmissions after hospitalization for pneumonia may not be preventable.

An Unusual Cause of a Solitary Lung Cavity.

Sarcoidosis is a systemic granulomatous disease of unknown etiology. Pulmonary involvement is common, but lung nodules in sarcoidosis are uncommon, and solitary nodules that cavitate are extremely rare. Nodular sarcoidosis is usually found in young, healthy, predominantly female individuals. These lesions need to be differentiated from multiple other conditions, including neoplasms and granulomatous infections. A thorough workup for other etiologies of cavitary lung lesions is required for diagnosis. Despite an ominous presentation, nodular cavitary sarcoidosis portends a favorable outcome. We report a patient who presented with a solitary cavitary nodular lung lesion that was diagnosed as sarcoidosis after extensive workup.

New therapeutic options for noncystic fibrosis bronchiectasis.

PURPOSE OF REVIEW: Patients with noncystic fibrosis bronchiectasis (NCFB) share many of the respiratory symptoms of cystic fibrosis and often are provided therapies effective in cystic fibrosis, often without clear evidence of benefit. There are currently no approved therapies for NCFB, but in recent years, there has been increased interest in developing new therapies due to the increasing prevalence and perceived unmet needs. This review is meant to provide the most recent information to clinicians about currently available and pipeline therapies for NCFB. RECENT FINDINGS: Inhaled antibiotics may provide effective bacterial suppressive therapy with an acceptable safety profile in adults with NCFB, although evidence of improved outcomes is limited. Inhaled hyperosmolar agents such as hypertonic saline and mannitol are promising but study results have been mixed. Macrolide antibiotics have anti-inflammatory properties and, in several randomized controlled trials, demonstrated the benefit of chronic low-dose treatment. Other anti-inflammatory agents that have shown promising preliminary results include statins and neutrophil elastase inhibitors. SUMMARY: There is high-quality evidence supporting chronic low-dose macrolide therapy in patients with NCFB. There is limited evidence of benefit of other therapies, including inhaled antibiotics and pharmacologic agents to enhance mucus clearance.

An Unusual Cause of Acute-Onset Chest Pain: Spontaneous Pneumomediastinum.

Spontaneous pneumomediastinum (SPM) is the presence of air in the mediastinum without any precipitating factor or predisposing disease. It is an uncommon, usually benign condition predominantly seen in young males. It typically presents with chest pain or dyspnea. It occurs after intrathoracic pressure changes leads to alveolar rupture and dissection of air along the tracheobronchial tree. It is reported to occur in 1/30,000 to 1/40,000 hospital admissions. Despite its low incidence, SPM should be considered in the differential diagnosis of acute chest pain or dyspnea in young patients. Diagnosis requires a high index of suspicion, as evidence of its occurrence may not be present on examination or chest X-ray. Patients with SPM respond well to medical treatment, with no recurrence in the majority of cases. We report a case of a young healthy male who developed a spontaneous pneumomediastinum and pneumopericardium while playing volleyball and did well with conservative management.

An Older Woman With Transient Cough, Mild Airway Obstruction, and Lung Nodules.

CASE PRESENTATION: A 66-year-old woman with no significant medical history presented initially to her primary care physician's office with a 2-weeks history of productive cough and associated wheezing after cough paroxysms. Empiric antibiotic was started, with no improvement. Chest radiograph was performed, which showed bilateral nodular opacities (Fig 1). The patient's cough resolved in 6 weeks after empiric treatment with oral steroids, inhaled steroids, and bronchodilators. A follow-up chest radiograph done at 6 weeks showed persistent abnormalities, and she was referred for a pulmonary evaluation. She denied any fevers, cough, hemoptysis, shortness of breath, wheezing, loss of appetite, or weight loss at that time. She had no significant medical problems and was not on any medications at that time. She was a nonsmoker. She worked in an office setting and denied any occupational or recreational exposures or recent travels. There was no family history of lung diseases or cancer.

Bordetella bronchiseptica in non-cystic fibrosis bronchiectasis.

Bordetella bronchiseptica is a rare pulmonary infection, often associated with zoonotic transmission. It has been described in immunocompromised patients and those with underlying pulmonary disease. However, there are no case series describing the spectrum of disease caused by Bordetella bronchiseptica in patients with non-cystic fibrosis bronchiectasis. Here, we report three cases of Bordetella bronchiseptica infection in patients with non-cystic fibrosis bronchiectasis and highlight the pathophysiology of the microbe. While the clinical presentation can be quite variable, it is important to note that Bordetella bronchiseptica can be a cause of pulmonary exacerbations and can be difficult to eradicate.

A Woman in Her 50s With a Mass in One Lung and a Cavitary Lesion in the Other.

CASE PRESENTATION: A woman in her 50s with no significant medical history presented with low-grade fever and cough of 3 days' duration, which was productive of blood-streaked sputum. She was an active smoker, with a 30 pack-year history of smoking. She denied chest pain, chronic cough, exertional dyspnea, or constitutional symptoms.

A 44-Year-Old Man With Sore Throat and Fatigue After Using an Old Camper Van.

A 44-year-old man from Connecticut with no significant past medical history presented to the ED with a 2-week history of sore throat and fatigue, subsequently developing cough, dyspnea, fevers, and chills. The patient reported buying an old camper van and noticed a large infestation of rodent droppings, which he had cleaned thoroughly from the cabin. He used the camper van on several camping trips in Vermont, and symptoms started on his return.

Is the present definition of health care-associated pneumonia the best way to define risk of infection with antibiotic-resistant pathogens?

Health care-associated pneumonia (HCAP) is associated with an increased risk of infection with multidrug-resistant pathogens compared with community-acquired pneumonia. Recent studies suggest that the designation of HCAP is a poor predictor of resistant pathogens and that antibiotic coverage for multidrug-resistant pathogens is not necessary in all patients with HCAP. This article reviews existing literature on HCAP, discusses the utility of the current definition of HCAP in identifying patients at risk for potentially drug-resistant pathogens, and compares how well the current HCAP designation predicts the risk of drug-resistant pathogens with other proposed algorithms for doing so.

Reversible bronchiectasis in an adult: a case report.

Bronchiectasis is classically defined as irreversible bronchial dilatation that represents the sequelae of chronic airway inflammation and is permanent, reflecting the presence of bronchiectasis. It is increasingly being recognized with the wider availability of high-resolution computed tomography. In contrast to adults, children with noncystic fibrosis bronchiectasis may have resolution or significant improvement in bronchial dilatation. We report a case of reversible bronchial dilatation in an adult as evidenced by high-resolution computed tomography, which demonstrates that, although quite rare in adults, spontaneous resolution may occur.