Portopulmonary hypertension: A focused review for the internist.

Portopulmonary hypertension, ie, pulmonary arterial hypertension in a patient with portal hypertension, affects transplant eligibility and has a poor prognosis. The pathogenesis remains an area of active research, with various mechanisms proposed. Diagnosing it requires a detailed history, physical examination, laboratory tests, and echocardiographic evaluation, followed by a careful hemodynamic assessment.

Infection control in the bronchoscopy suite: effective reprocessing and disinfection of reusable bronchoscopes.

PURPOSE OF REVIEW: With advancements in technology, flexible bronchoscopes have become thinner in diameter and in need of more thorough reprocessing to prevent infection transmission than ever before. Many experienced bronchoscopists are not aware of the critical steps involved in effective bronchoscope reprocessing and we hope to bridge this gap by describing this process in detail. RECENT FINDINGS: Bronchoscope reprocessing includes several distinct steps (precleaning, leak testing, manual cleaning, visual inspection, terminal reprocessing, rinsing and drying). Each step is comprehensive and needs to be carried out systematically by trained personnel. Failure of any step can lead to serious downstream events such as outbreaks and pseudo-outbreaks. Some experts now recommend sterilization when feasible, although high-level disinfection remains the minimum standard. We also will review some literature on the utility of borescopes, automated endoscope reprocessors and disposable bronchoscopes. SUMMARY: Our article will focus on the most recent recommendations for effective reprocessing and disinfection of reusable bronchoscopes.

Hemodynamic indices in pulmonary hypertension: a narrative review.

Background and Objective: Pulmonary hypertension (PH) is defined as a mean pulmonary artery pressure (mPAP) >20 mmHg and its presence is associated with worse outcomes. A comprehensive hemodynamic evaluation of the pulmonary circulation is essential for diagnosis, hemodynamic classification, and prognostication. A multitude of indices assess different aspects of the pulmonary circulation but there are no reviews that describe their specific value in PH. Methods: We performed a thorough literature search of relevant articles in English from 1970-2021 using PubMed. Key Content and Findings: In this article, we present both static and dynamic indices used for the hemodynamic assessment of PH. While some of these indices are routinely used in clinical practice, including cardiac index (CI), stroke volume (SV), and pulmonary vascular resistance (PVR); others such as pulmonary artery compliance (PAC), pulmonary effective arterial elastance (Ea), and pulmonary artery pulsatility index (PAPi) are gaining popularity by enhancing the understanding of different aspects of the pulmonary circulation. We described the advantages and pitfalls of various indices, including when to use them in the hemodynamic evaluation of patients with PH. Conclusions: A variety of indices measuring different aspects of the right ventricle (RV)-pulmonary arteries (PA) system provide valuable information in patients with PH. However, it remains important to develop and validate indices that provide a comprehensive hemodynamic evaluation to improve outcomes in patients with PH.

Impact of Pulmonary Rehabilitation Stewardship Program on COPD Patients, Quality Improvement Project.

Background: Pulmonary rehabilitation (PR) has multiple benefits in COPD patients. There are multiple barriers to utilize PR including lack of knowledge about the benefits of PR by providers. Objective: We are conducting a Quality Improvement project to improve the referral rate of patients hospitalized for acute exacerbation of COPD to PR. Methods: All patients admitted with a primary diagnosis of acute exacerbation of COPD requiring systemic steroids to Rochester General Hospital in the period between 7/1/2019 and 7/31/2019 were reviewed retrospectively. Between 7/15/2020 and 11/15/2020, we started a PR stewardship program, where we daily review patients hospitalized with acute COPD exacerbation, and then a note will be placed in the chart for the primary team to consider referring patients to PR upon discharge, patients' charts were reviewed after discharge. The rate of referral before and after the intervention was compared. Results: During the pre-intervention period, 16 patients (mean age 67.7) with confirmed COPD by spirometry were hospitalized for COPD exacerbation, among them only 2 were referred to PR upon discharge (12.5%). During the post intervention period, 16 patients (mean age 65.0) were admitted with acute COPD exacerbation, among them 10 were referred to PR upon discharge (62.5%) [50% difference (16.5%-71%, 95% CI), P value = 0.004]. Conclusion: In our QI improvement project, we conclude that having a PR stewardship program to review patients hospitalized with COPD exacerbation significantly improves the referral rate to PR, and might help to improve utilization of those programs by patients who need them.

Clinical characteristics and outcomes of critically ill patients with COVID-19 in a tertiary community hospital in upstate New York.

Background: There are limited reports describing critically ill COVID-19 patients in the state of New York. Methods: We conducted a retrospective analysis of 32 adult critically ill patients admitted to a community hospital in upstate New York, between 14 March and 12 April 2020. We collected demographic, laboratory, ventilator and treatment data, which were analyzed and clinical outcomes tabulated. Results: 32 patients admitted to the intensive care unit (ICU) were included, with mean (±SD) follow-up duration 21 ± 7 days. Mean (±SD) age was 62.2 ± 11.2 years, and 62.5% were men. 27 (84.4%) of patients had one or more medical co-morbidities. The mean (±SD) duration of symptoms was 6.6 (±4.4) days before presentation, with cough (81.3%), dyspnea (68.7%), and fever (65.6%) being the most common. 23 (71.9%) patients received invasive mechanical ventilation. 5 (15.6%) died, 11 (34.4%) were discharged home, and 16 (50%) remained hospitalized, 8 (25%) of which were still in ICU. Mean (±SD) length of ICU stay was 10.2 (±7.7) days, and mean (±SD) length of hospital stay was 14.8 (±7.7) days. Conclusion: Majority of patients were of older age and with medical comorbidities. With adequate resource utilization, mortality of critically ill COVID-19 patients may not be as high as previously suggested. Abbreviations: ACE-i: Angiotensin converting enzyme inhibitor; ARB: Angiotensin receptor blocker; ARDS: Acute Respiratory Distress Syndrome; BiPAP: Bilevel positive airway pressure; CABG: Coronary artery bypass graft; CFR: Case fatality rate; COVID-19: Coronavirus disease 19; CPAP: Continuous positive airway pressure; CRP: C - Reactive Protein; CT: Computed tomography; DVT: Deep vein thrombosis; ECMO: Extra Corporeal Membrane Oxygenation; ESICM: European Society of Intensive Care Medicine; FiO2: Fraction of inspired O2; HFNC: High Flow Nasal Cannula; HITF: Hypoxia-Inducible Transcription Factor; IBM: International Business Machines; ICU: Intensive Care Unit; IL: Interleukin; IMV: Invasive Mechanical Ventilation; IQR: Interquartile Range; ISTH: International Society of Thrombosis Hemostasis; NIV: Non Invasive Ventilation; NY: New York; PAI: Plasminogen activator inhibitor; PaO2: partial pressure of arterial oxygen; PCV: Pressure Control Ventilation; PEEP: Positive End Expiratory Pressure; RGH: Rochester General Hospital; RRH: Rochester Regional Health; RT-PCR: Reverse transcriptase polymerase chain reaction; RSV: Respiratory Syncytial virus; SARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus 2; SD: Standard Deviation; STEMI: ST segment elevation myocardial infarction; TNF: Tumor necrosis factor; USA: USA; VTE: Venous thromboembolism.

Appendiceal sarcoidosis presenting as acute appendicitis.

Sarcoidosis is a chronic inflammatory multisystem disease. The stomach is the most commonly involved gastrointestinal organ. Symptomatic appendicular sarcoidosis is extremely rare. We present a case of a 49-year-old woman with abdominal pain. An ultrasound of the abdomen was suggestive of acute appendicitis. Laparoscopic appendectomy was performed and the pathology revealed nonnecrotizing granulomas. Biopsy of the mediastinal lymph nodes suggested noncaseating granulomas. She was treated with steroid therapy followed by mycophenolate mofetil. Our case demonstrates the importance of considering appendiceal sarcoid among the differentials in a patient with systemic sarcoidosis presenting with an acute abdomen.

Recurrence of Pheochromocytoma With Metastases After Resection of Primary Tumor.

Pheochromocytomas and paragangliomas are rare tumors that arise from the chromaffin cells of the adrenal medulla or sympathetic paravertebral ganglia, respectively. Long-term surveillance is recommended regardless of the thoroughness of surgical resection. Here, we present a patient who was diagnosed with pheochromocytoma who underwent right adrenalectomy and was lost to follow up. She presented 15 years later with recurrence and was found to have multiple metastases. Subsequent genetic testing was also negative.

Invasive Aspergillosis Masquerading as Multiple Pulmonary Nodules: A Challenging Diagnosis.

Invasive pulmonary aspergillosis (IPA) is an aggressive fungal infection of the lungs characterized by tissue invasion by fungal hyphal elements. The definitive diagnosis is challenging because it relies on histopathological demonstration of fungal elements, and these days clinicians are relying more on bronchoalveolar lavage (BAL) cultures and serum biomarkers (galactomannan and beta-D-glucan). We would like to emphasize through our case the necessity to keep a high index of suspicion for IPA despite negative cultures and serum biomarkers in immunosuppressed patients and consider surgical biopsy early.

ST segment elevation in an adult chest pain patient: A case of coronary artery vasospasm.

Chest pain is one of the most common symptoms of patients presenting to the emergency department (ED) in the United States, accounting for up to eight million cases annually. We present a 55-year-old male who was brought in to the ED with sudden onset chest pain and was found to have ST-segment elevations in the infero-lateral leads on electrocardiogram (ECG). These changes resolved with nitroglycerin. Coronary artery vasospasm was diagnosed as coronary angiogram was normal. Calcium channel blocker was prescribed with good symptom relief. The most important teaching point is, coronary vasospasm as a cause of ST-segment elevation is missed frequently and should be considered among the differentials in patients presenting with chest pain. Nitrates and/or calcium channel blockers along with avoidance of triggers can help in symptom management.

Case Report: A Polymicrobial Vision-Threatening Eye Infection Associated with Polysubstance Abuse.

We report a patient with risk factors for both microbial keratitis and endophthalmitis, which were initially challenging to distinguish. Cultures of corneal scrapings yielded several organisms, including an uncultivable Gram-negative rod, eventually identified as Kingella negevensis. Kingella negevensis is so named because most strains have been isolated in the Negev, a desert region of southern Israel. The epidemiology of K. negevensis remains incompletely understood. We found no other reports in the literature of this organism causing microbial keratitis.

Excessive sleepiness, sleep hygiene, and coping strategies among night bus drivers: A cross-sectional study.

BACKGROUND: Sleep disruption and excessive sleepiness are the known consequences of shift work. The recent spate of night-time road and air accidents, with some being directly attributed to driver sleepiness prompted us to undertake this study. AIMS: To screen for excessive sleepiness, coping practices, and post-shift sleep hygiene in night bus drivers. SETTINGS AND DESIGN: This prospective study was carried out on night bus drivers of a public transport organization in Bengaluru, Karnataka, India. MATERIALS AND METHODS: Bus drivers driving for ≥8 h at night were screened with the Epworth Sleepiness Scale (ESS) and a prevalidated shift work questionnaire. STATISTICAL ANALYSIS: Descriptive statistics were used to analyze the compiled data using Statistical Package for the Social Sciences (SPSS) version 20. RESULTS: One hundred and eighty bus drivers aged 22-63 years were screened. EXCESSIVE SLEEPINESS: Although only 2 (1.1%) drivers scored above the cutoff on ESS, 10 (5.6%) and 103 (57.2%) drivers admitted to feeling sleepy during daytime and night driving respectively. None of the drivers admitted to causing accidents related to sleepiness. The coping strategies for nocturnal sleepiness included consuming coffee/tea (16.7%), chewing tobacco (12.8%), smoking (6.1%), and walking (3.9%). POST-SHIFT SLEEP PRACTICES: Post-shift sleep duration ranged between 1 h and 10 h. Twenty-six (14.4%) and 16 (8.9%) drivers had difficulty initiating and maintaining sleep, respectively, while 9 (5%) reported frequent awakening during daytime sleep. CONCLUSION AND IMPLICATIONS: This study has demonstrated a high incidence of nocturnal sleepiness and daytime sleep disruption among night bus drivers, thus necessitating the need for education about shift work and alertness testing among shift workers in critical professions.