A Case Series of E-cigarette or Vaping-Associated Lung Injury With a Review of Pathological and Radiological Findings.

There has been a recent outbreak of e-cigarette or vaping-associated lung injury (EVALI) but the exact pathophysiology remains unknown. Tetrahydrocannabinol (THC) and vitamin E derivates are the major components in vaping-generated aerosols that are associated with EVALI. So far, there is no standard treatment for EVALI. Most cases are treated with antibiotics and steroids. Counseling for smoking cessation is an integral part of care for EVALI patients. Referral to addiction medicine may be beneficial. Considering the nonspecific presenting symptoms and the growing popularity of vaping devices, providers need to consider EVALI in the differential diagnosis of bilateral patchy ground-glass opacities with respiratory, constitutional, or gastrointestinal symptoms in patients using e-cigarettes. Here, we present four EVALI cases and review the pertinent imaging and pathological findings.

Utilization of a New Customizable Scoring Tool to Recruit and Select Pulmonary/Critical Care Fellows.

BACKGROUND: Finding the ideal candidate for a residency/fellowship program has always been difficult. Finding the "perfect" match has always been the ultimate goal. However, many factors affect obtaining that "perfect" match. In the past, we would have each attending physician review around 20 to 50 Electronic Residency Application Service (ERAS) applications and rank them into three categories: high, middle, or low. Depending on their ranking, the applicant would be invited for an interview. After the interview, the applicants' files (ERAS and interview) would be reviewed and ranked by the faculty as a group. This was time-consuming and fraught with too much subjectivity and minimal objectivity. We, therefore, sought to find a way to assess and rank applicants in a more objective and less time-consuming manner. By creating a customizable scoring tool, we were able to screen applicants to our pulmonary/critical care fellowship program in an efficient and a more objective manner. OBJECTIVES: A customizable scoring tool was developed weighting components in the ERAS and interview process, allowing residency/fellowship programs to create a final rank list consistent with the programs' desired applicants. METHODS: Two hundred and sixty pulmonary/critical care fellowship applications were reviewed from 2013 to 2018. In 2018, we used our new scoring rubric to create a rank list and rescore previous applicants. The traditional and new lists were compared to the final rank list submitted to the National Residency Matching Program (NRMP) for 2018. We wanted to ascertain which scoring method correlated best with the final rank list submitted to the NRMP. We obtained feedback from eight faculty members who had reviewed applicants with both scoring tools. RESULTS: The novel customizable scoring tool positively correlated with the final rank list submitted to the NRMP (r= 0.86). The novel tool showed a better correlation to the final rank list than the traditional method. Faculties (6/6, 100%) responded positively to the new tool. CONCLUSIONS:  Our new customizable tool has allowed us to create a final rank list that is efficient and more focused on our faculty's desired applicants. We hope to assess and compare the quality of applicants matched through this scoring system and the traditional method by using faculty evaluations, milestones, and test scores.

Prospective Randomized Controlled Pilot Study of High-Intensity Lightbox Phototherapy to Prevent ICU-Acquired Delirium Incidence.

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.

Normal saline versus Normosol™-R in sepsis resuscitation: A retrospective cohort study.

OBJECTIVE: To determine the effect of Normosol™-R as compared to normal saline on the outcomes of acute kidney injury and the need for renal replacement therapy in the resuscitation phase of sepsis. DESIGN: Our study is a retrospective before-and-after cohort study. SETTING: The study occurred at a 700-bed tertiary academic level 1-trauma center. PATIENTS: A total of 1218 patients were enrolled through emergency department admissions. The normal saline (before) cohort was defined as the dates between 1 March and 30 September 2014 and the Normosol™-R (after) cohort was assessed from 1 March to 30 September 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Intravenous fluid volumes received during the first 24 h, 72 h, and total hospital stays were compared. Sodium, chloride, potassium, and bicarbonate levels at 72 h were also compared. The medical coded diagnosis of acute kidney failure, need for renal replacement therapy, hospital LOS, ICU admission, ICU LOS, in-hospital mortality, and need for mechanical ventilation were all compared. There was no significant difference in intravenous fluid volumes between groups. Regression modelling controlling for baseline characteristics and 24-h fluid intake volume found no differences between groups for the primary outcomes of acute kidney injury (P = 0.99) and renal replacement therapy (P = 0.88). Patients in the Normosol™-R cohort were found to have a lower rate of hyperchloremia at 72 h post-admission (28% vs. 13%, P < 0.0001). There was a trend toward a decrease in the hospital and ICU LOS in the Normosol™-R cohort; however, the data were not statistically significant. CONCLUSIONS: This study was unable to detect any difference in outcomes between sepsis patients who received intravenous fluid resuscitation with either a balanced crystalloid (Normosol™-R) or normal saline, except for a decreased rate of hyperchloremia.

The Lung Point Sign, not Pathognomonic of a Pneumothorax.

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.

Pulmonary toxicity of polymeric hexamethylene diisocyanate aerosols in mice.

The acute pulmonary response of male C57BL/6 mice exposed to respirable polymeric hexamethylene diisocyanate biuret trimer aerosol (HDI-BT), a component of polyurethane spray paints, was examined. Mice were exposed to concentrations of 1 and 10 mg/m(3) HDI-BT for 5 h and were evaluated 6, 18, 42, 90, 186, and 378 h after the end of exposure. Mice exposed to 1 or 10 mg/m(3) HDI-BT exhibited dose-dependent lung function impairment, edema, neutrophilic inflammation, cellular proliferation, and histologic lesions in terminal bronchioles and alveolar ducts. Impairment of pulmonary function, indicated by decreased frequency and increased enhanced pause (Penh), was maximal immediately after exposure and progressively recovered at later time points. Lung weight and lavage fluid protein content peaked at 6 and 18 h after exposure, respectively. Total cells and macrophages recovered in lavage fluid peaked 90 h after exposure. Neutrophils recovered in lavage fluid peaked between 18 and 42 h after exposure. Proliferative lesions, as identified histologically and by bromodeoxyuridine incorporation, were maximal 90 h after exposure. In contrast, no inflammatory cell influx, protein leakage, or lung pathology were observed in mice exposed to 360 ppb HDI monomer vapor. This model will be useful for investigating molecular mechanisms by which HDI-BT causes lung injury, which is known to occur in humans exposed occupationally to this pulmonary toxicant.

Lymphangioleiomyomatosis: an unusual cause of dyspnea in young women.

Lymphangioleiomyomatosis is a rare and complicated disorder that affects the young, almost exclusively women. It may be associated with the tuberous sclerosis complex, which includes renal angiolipoma, chylothorax and lymph node myomatosis. Its clinical pulmonary manifestations vary from simple cough to the development of recurrent pneumothoraces, hemoptysis, and even complicated pleural effusions. Progressive dyspnea develops as the disease evolves. Eventually most patients require lung transplantation. This wide array of symptoms and signs makes the differential diagnosis extensive, and the clinician must be familiar with this disorder to arrive promptly to the correct diagnosis. We report a case of a 36-year-old woman with a long history of recurrent pleuritic chest pain with associated dyspnea before being diagnosed with lymphangioleiomyomatosis. A review of the literature pertinent to this case is provided.

Airway obstruction due to bilateral giant pulmonary artery aneurysms.

Large pulmonary artery aneurysms are rare, but they are associated with significant morbidity and mortality. Significant airway obstruction due to extrinsic compression solely by a pulmonary artery aneurym is an extremely rare occurrence. We present a case of large bilateral pulmonary artery aneurysms causing extrinsic airway compression with collapse of the left primary bronchus in a 51-year-old woman. This is the first report in an adult in which airway compression due solely to the pulmonary artery aneurysm resulted in airway collapse. Furthermore, we describe the use of interventional bronchoscopy with stent placement as a minimally invasive alternative to surgery for treatment of these patients.