Immune Checkpoint Inhibitor-induced Pneumonitis: Incidence, Clinical Characteristics, and Outcomes.

BACKGROUND: Immune checkpoint inhibitors (ICIs) are the newest class of anticancer drugs. Pneumonitis is increasingly being recognized as a potential complication of these agents. METHODS: We conducted a retrospective study of patients who received ICIs at a comprehensive cancer center. We collected data on demographics, type of malignancy, type of ICI agent, incidence of pneumonitis up to 6 weeks after receiving ICI agent, clinical characteristics, and risk factors for overall survival in patients who develop pneumonitis. RESULTS: A total of 654 patients received ICIs during the study period. The most common type of cancer for which ICI was given was adenocarcinoma of the lung (29%), followed by renal cell cancer (12%) and squamous cell lung cancer (12%). Among the study patients, 41% received nivolumab and 32% received pembrolizumab. Other patients in the study received combination of ICIs or ICI plus chemotherapeutic agent, or were part of clinical trial involving ICI. Overall 42 (6.4%) patients developed pneumonitis within 6 weeks after the last dose of treatment of any ICI agent. Of these, 81% of patients had Grade ≥ 2 pneumonitis and 45% of these required hospital admission for pneumonitis, with 10% of them requiring admission to intensive care unit. Overall, patients who received pembrolizumab-containing regimen, had prior chemotherapy, or who never had cancer-related surgery had increased risk of death. CONCLUSION: Our large retrospective study shows real-life data of incidence of pneumonitis in patients who are treated with ICIs for cancer treatment. Our data indicate that the incidence of pneumonitis is overall lower than that reported previously with relatively good outcomes.

Management of ARDS - What Works and What Does Not.

Acute respiratory distress syndrome (ARDS) is a clinically and biologically heterogeneous disorder associated with a variety of disease processes that lead to acute lung injury with increased non-hydrostatic extravascular lung water, reduced compliance, and severe hypoxemia. Despite significant advances, mortality associated with this syndrome remains high. Mechanical ventilation remains the most important aspect of managing patients with ARDS. An in-depth knowledge of lung protective ventilation, optimal PEEP strategies, modes of ventilation and recruitment maneuvers are essential for ventilatory management of ARDS. Although, the management of ARDS is constantly evolving as new studies are published and guidelines being updated; we present a detailed review of the literature including the most up-to-date studies and guidelines in the management of ARDS. We believe this review is particularly helpful in the current times where more than half of the acute care hospitals lack in-house intensivists and the burden of ARDS is at large.

Amyloid cystic lung disease presenting in a patient with human immunodeficiency virus.

A 30-year-old gentleman with a medical history of HIV, on HAART therapy and pulmonary amyloidosis proven by lung biopsy presented with progressive, worsening shortness of breath and chronic productive cough over the last year. Pulmonary function tests showed a severely obstructive process and CT scan of the thorax manifested diffusely thin-walled, air-filled cysts. After reviewing the patient's prior histories, PFTs and CTof the thorax, the most likely cause of his symptoms was amyloid-related cystic lung disease. After being placed on a LABA/ICS, and LAMA inhaler, the man's condition remained stable. Active oncologic and pulmonary surveillance were continued every three to six months as the patient's respiratory status, PFTs and imaging remained stable. Thoughts of chemotherapy and lung transplant have been suggested, but not initiated at this time. Amyloid-related cystic lung disease is a rare presentation of amyloidosis in the thorax. It has been associated with collagen vascular diseases and mucosa-associated lymphoid tissue lymphoma. After an extensive literature search, it does not appear that this condition has been referenced in an HIV-positive patient; thus making this report unique. More case reports will need to be published and reviewed to see whether an association with HIV and amyloid-associated cystic lung disease exists.

Infectious Complications of Cryoablation and Microwave Ablation in Metastatic Solid Tumors.

Cryoablation and microwave ablation are commonly used techniques to reduce tumor burden in unresectable neoplasms. This retrospective study demonstrated low risk for infectious complications (1.4%) following these invasive procedures. Abscess formation was the most common infection around the ablation sites. All infections were successfully treated with imaging-guided drainage and antibiotics.Infect Control Hosp Epidemiol 2018;39:723-726.

Surgical Site Infections Following Birmingham Hip Resurfacing.

The Birmingham Hip Resurfacing procedure (BHR) is metal-on-metal resurfacing procedure for hip arthritis. BHR was associated with low risk of surgical site infection (SSI; 0.6%). In addition to antimicrobials, superficial SSIs were treated with incision and drainage, whereas deep incisional or organ-space SSIs required removal of prosthesis. Infect Control Hosp Epidemiol 2016;1-4.

Yield of computed tomography pulmonary angiogram in the emergency department in cancer patients suspected to have pulmonary embolism.

OBJECTIVE/BACKGROUND: The use of computed tomography pulmonary angiography (CTPA) in the emergency department (ED) for patients suspected to have pulmonary embolism (PE) has been steadily rising in the last 2decades. However, there are limited studies that specifically address the use of CTPA in the ED for cancer patients suspected to have PE. The objective of this study is to assess the rate of positive PE by CTPA in the ED in cancer patients and the variables that are associated with positive results. METHODS: A retrospective review of electronic medical records for 208 consecutive patients with cancer who presented to the ED and received a CTPA for suspected PE over a 12-month period. The review included demographics, type and status of cancer, presenting symptoms, CTPA results, calculation of Wells Score, management based on CT findings, and outcome of patients. RESULTS: Among the 208 patients who met the inclusion criteria during our study period (mean age 57±13.37years, 73% women, 59% African American, and 32% Caucasians), 5.7% were diagnosed with PE. One hundred and eighty-two (83.7%) had a Wells Score ⩽4, of which 2.2% were found to have to have PE, 22 (16.3%) patients had a Wells Score >4, of which 36.4% were found to have PE (p<.0001). Sensitivity and specificity of Wells >4 was 66.7% and 92.9%, respectively, with an odds ratio of 27 (95% CI 6.6-113.6). Receiver operator characteristics area under the curve for Wells Score was 0.868. Age, race, sex, malignancy type, stage, status, clinical presentation, D-dimer, and a previous history of venous thromboembolism were not found to have statistically significant predictive values. CONCLUSION: The yield of CTPA to rule out PE in patients with cancer presenting in the ED is low. Following a validated decision-making protocol such as Wells Criteria may significantly decrease the number of CTPA used in the ED.

Clostridium Difficile Colonization in Hematopoietic Stem Cell Transplant Recipients: A Prospective Study of the Epidemiology and Outcomes Involving Toxigenic and Nontoxigenic Strains.

Clostridium difficile is a leading cause of infectious diarrhea in hematopoietic stem cell transplant (HSCT) recipients. Asymptomatic colonization of the gastrointestinal tract occurs before development of C. difficile infection (CDI). This prospective study examines the rates, risk factors, and outcomes of colonization with toxigenic and nontoxigenic strains of C. difficile in HSCT patients. This 18-month study was conducted in the HSCT unit at the Karmanos Cancer Center and Wayne State University in Detroit. Stool samples from the patients who consented for the study were taken at admission and weekly until discharge. Anaerobic culture for C. difficile and identification of toxigenic strains by PCR were performed on the stool samples. Demographic information and clinical and laboratory data were collected. Of the 150 patients included in the study, 29% were colonized with C. difficile at admission; 12% with a toxigenic strain and 17% with a nontoxigenic strain. Over a 90-day follow-up, 12 of 44 (26%) patients colonized with any C. difficile strain at admission developed CDI compared with 13 of 106 (12%) of patients not colonized (odds ratio [OR], 2.70; 95% confidence interval [95% CI], 1.11 to 6.48; P = .025). Eleven of 18 (61%) patients colonized with the toxigenic strain and 1 of 26 (4%) of those colonized with nontoxigenic strain developed CDI (OR, 39.30; 95% CI, 4.30 to 359.0; P < .001) at a median of 12 days. On univariate and multivariate analyses, none of the traditional factors associated with high risk for C. difficile colonization or CDI were found to be significant. Recurrent CDI occurred in 28% of cases. Asymptomatic colonization with C. difficile at admission was high in our HSCT population. Colonization with toxigenic C. difficile was predictive of CDI, whereas colonization with a nontoxigenic C. difficile appeared protective. These findings may have implications for infection control strategies and for novel approaches for the prevention and preemptive treatment of CDI in the HSCT patient population.