Incidental Lung Cavity in the Heartland.

Necrotizing sarcoid granulomatosis (NSG) is a rare inflammatory disease. Although considered by some to be a subtype of sarcoidosis, this opinion is not universal. NSG is histologically characterized by the presence of necrotizing sarcoid like granuloma and granulomatous vasculitis. The exclusion of potential etiologies for necrotizing granulomatous inflammation is necessary to establish a diagnosis of NSG. A 70-year old female presented to our office after she was incidentally found to have a right lung cavitary lesion on a shoulder X-ray. She had an extensive serologic workup for anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, mycobacterial and fungal etiologies, but they were all negative. She subsequently underwent bronchoscopic evaluation and biopsies. The histopathologic analysis revealed sarcoid-like granulomatous inflammation with large necrosis and mild granulomatous vasculitis. The pulmonary function test revealed a restrictive ventilatory defect. The patient was treated with steroid therapy with rapid radiologic and spirometric improvement.

The association of ABO blood type with the risk and severity of COVID-19 infection.

BACKGROUND: There is conflicting data in the literature about the association of ABO blood type and susceptibility to COVID-19 infection. Moreover, very few studies have examined the effect of blood type on severity of COVID-19 infection. METHODS: This was a retrospective, single-center analysis of adult patients with COVID-19 infection who were hospitalized between March 8th to July 31st, 2020 at a regional tertiary care hospital. All patients who were hospitalized with a diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) infection and had a documented ABO blood type were enrolled in this analysis. Aims of this study were to examine the prevalence of ABO blood types in patients with COVID-19 infection and to determine the frequency of severe COVID-19 infection among ABO blood types. RESULTS: A total of 227 cases were identified. Our cohort had a mean age of 63.3 years and 60% were males. The most common blood type was O (49%) followed by A (36%), which was similar to the prevalence of ABO blood types in our regional population. Moreover, there was no significant difference in the frequency of severe COVID-19 infection between ABO blood types (O: 50%, A: 53%, B: 56%, AB: 57%; P=0.93), or any additional outcomes including in-hospital mortality rate (P=0.72), need for ICU admission (P=0.66), ICU free days at day 28 (P=0.51), hospital free days at day 28 (P=0.43), or need for acute renal replacement therapy (P=0.09). CONCLUSION: We did not find an increased susceptibility of any blood type to COVID-19 infection, nor was there an increased risk of severe COVID-19 infection in any ABO blood types.

Overutilisation of imaging studies for diagnosis of pulmonary embolism: are we following the guidelines?

OBJECTIVE: To evaluate if imaging studies such as CT pulmonary angiography (CTPA) or ventilation-perfusion (V/Q) scan are ordered according to the current guidelines for the diagnosis of pulmonary embolism (PE). METHODS: We performed a retrospective observational cohort study in all adult patients who presented to the Sparrow Hospital Emergency Department from January 2014 to December 2016 and underwent CTPA or V/Q scan. We calculated the Wells' score retrospectively, and d-dimer values were used to determine if the imaging study was justified. RESULTS: A total of 8449 patients underwent CTPA (93%) or V/Q scan (7%), among which 142 (1.7%) patients were diagnosed with PE. The Wells' criteria showed low probabilities for PE in 96 % and intermediate or high probabilities in 4 % of total patients. Modified Wells' criteria demonstrated PE unlikely in 99.6 % and PE likely in 0.4 % of total patients. D-dimer was obtained in only 37 % of patients who were unlikely to have a PE or had a low score on Wells' criteria. Despite a low or unlikely Wells' criteria score and normal d-dimer levels, 260 patients underwent imaging studies, and none were diagnosed with PE. CONCLUSION: More than 99 % of CTPA or V/Q scans were negative in our study. This suggests extraordinary overutilisation of the imaging methods. D-dimer, recommended in patients with low to moderate risk, was ordered in only one-third of patients. Much greater emphasis of current guidelines is needed to avoid inappropriate utilisation of resources without missing diagnosis of PE.

End-of-Life Care for an Undocumented Mexican Immigrant: Resident Perspective.

The immigrant population in the United States has grown over the past years. Undocumented immigrants account for 14.6% of the uninsured population in the United States. Decisions about end-of-life treatment are often difficult to reach in the best of situations. We present a 43-year-old undocumented Mexican female immigrant with metastatic sarcomatoid squamous cell cervical cancer and discuss the barriers that she faced during her treatment. Limited English proficiency, living below the poverty line, low level of education, and lack access to Medicare, Medicaid, or other insurance coverage under the Affordable Care Act are major causes of decreased health-care access and service utilization by the immigrant population. Latinos are less likely to be referred to hospice by oncologists, and nearly a third of hospice agencies offer limited or no services to undocumented immigrants. Undocumented immigrants with terminal diagnoses generally do not have access to comprehensive or multidisciplinary follow-up treatment. Instead, one of their few options is to return to their home countries without any long-term treatment. This article discusses the many barriers and proposes areas for reform.

Diagnosing isolated hepatosplenic tuberculosis in an immunocompetent patient: a case report.

For many years, tuberculosis (TB) has been endemic in Pakistan; many rare and unusual presentations have been reported. There is a myriad of non-specific symptoms which always requires a high index of clinical suspicion for TB. World Health Organization data suggest that Pakistan ranks as the fifth highest country burdened with TB and has the fourth highest prevalence of multi-drug resistant TB globally. With an annual incidence of 277 cases per 100,000, the importance of early diagnosis and treatment is self-evident. We present a case where a strong suspicion of isolated hepatosplenic TB in an immunocompetent patient justified a directed approach.

Metastatic Sarcomatoid Squamous Cell Carcinoma of the Cervix Presenting with Chest Mass.

BACKGROUND: Sarcomatoid squamous cell carcinoma is a rare and aggressive form of cervical cancer. We report a case of metastatic sarcomatoid squamous cell carcinoma (SSCC) of cervix that presented with an anterior chest wall mass. CASE: A 43-year-old Hispanic female presented with a two-month history of a central chest wall mass. The patient's only past medical history was SSCC of the cervix, stage IIB, diagnosed two years priorly. She underwent neoadjuvant chemoradiation therapy (CRT) with cisplatin followed by radical hysterectomy. Surgical margins were positive which led to adjuvant CRT with carboplatin and paclitaxel. PET scan 4 months after the postoperative treatment was negative for recurrence and metastatic disease. On current presentation, the CT chest revealed anterior mediastinal destructive soft tissue mass involving sternum, and the biopsy showed SSCC. The patient received palliative radiation therapy to her chest with improvement in pain and ability to swallow. After discussing the prognosis she refused further chemotherapy and decided on hospice care. CONCLUSION: Despite good response to first-line therapy, SSCC tends to recur early and does not respond to second-line therapy. Radiation therapy seems to be the most effective modality for treatment, but randomized controlled trials of therapy are impractical.

Assessing Acceptability of Short Message Service Based Interventions towards Becoming Future Voluntary Blood Donors.

All blood bank services, especially those of developing countries, face a major shortfall of blood donations due to lack of voluntary blood donors. Our study aims to evaluate the acceptability of Short Message Service based interventions towards becoming voluntary blood donors among medical university students of Karachi, Pakistan. Methods. A total of 350 medical students were approached in medical universities of Karachi, Pakistan, using a nonprobability convenient sampling technique. Data collectors administered a self-made questionnaire to each participant using an interview based format. All data was recorded and analyzed on SPSS 16. Results. 350 participants, having a mean age of 21.47 ± 1.36, were included in our study with 30.6% (107/350) being males and 69.4% (243/350) being females. 93.4% (327/350) of participants agreed that donating blood was healthy, but only 26% had donated blood in the past with 79.1% donating voluntarily. 65.7% (230/350) of the participants agreed to take part in Short Message Service based behavioral interventions to become voluntary blood donors with 69.7% (244/350) also agreeing that Short Message Service reminders will promote them to donate blood more often. Conclusion. With university students willing to become voluntary blood donors, Pakistani blood banks can carry out Short Message Service based interventions to encourage them to donate blood.

Post-traumatic stress disorder in patients with acute burn injury.

OBJECTIVE: To determine the risk of PTSD in patients with acute burn incidents. METHOD: This was an observational prospective cross-sectional study conducted in admitted patients in Burns Ward of Civil Hospital, Karachi during a period of 6 months from January 1 to June 30, 2011. Data was collected through questionnaire having socio demographic variables and the Impact of Event-Scale (IES-R) was used to determine the risk of PTSD. RESULTS: Out of 145 patients, 12 (77.3%) were at risk of PTSD with 75 (66.9%) males and 37 (33%) females. Out of these 112 cases, 50% belonged to age group 16-29 years. All burn patients with more than 60% total body surface area (TBSA) involved in injury were at risk. CONCLUSION: The study reports an astronomic number of burns patients with PTSD risk. PTSD drastically affects the quality of life. The earlier this disorder is diagnosed and assessed; better chances are there for enhanced treatment and better recovery.