Retraction: An Aspirated Tooth Masquerading As Lung Cancer: A Unique Case Report.

[This retracts the article DOI: 10.7759/cureus.55890.].

An Aspirated Tooth Masquerading As Lung Cancer: A Unique Case Report.

Tooth aspiration, while commonly linked to predisposing conditions such as loose teeth, facial surgeries, or injuries, can also affect patients without apparent risk factors. Such small foreign body aspirations may go undiagnosed for many months as patients often tolerate the symptoms, such as chronic cough. However, the protracted course of unaddressed foreign body aspiration has the potential to resemble symptoms of malignancy, including persistent hemoptysis, weight loss, and fatigue. In this report, we detail the case of a 51-year-old man with underlying chronic obstructive pulmonary disease (COPD) whose history and symptoms initially suggested lung carcinoma. Further investigation uncovered an aspirated tooth as the culprit. The sequelae of pulmonary complications arising from endobronchial obstruction, such as post-obstructive pneumonia and atelectasis, as demonstrated in our case, further emphasize the importance of prompt detection and management of tooth aspiration.

Durvalumab-Induced Myocarditis and Dilated Cardiomyopathy in a Patient With Non-small Cell Lung Cancer: A Diagnostic Conundrum.

Immune checkpoint inhibitors have been a therapeutic oncological breakthrough in managing diverse malignancies. We present a 78-year-old male with stage IIIb non-small cell lung cancer (NSCLC) managed by concurrent chemotherapy with carboplatin/pemetrexed and radiotherapy followed by monthly durvalumab injections. He presented to the hospital with shortness of breath and fluid overload after eight months of starting durvalumab. Workup, including laboratory investigations, coronary angiography, and stress myocardial magnetic resonance imaging, increased our suspicion for the diagnosis of durvalumab-induced myocarditis and nonischemic dilated cardiomyopathy. He was managed with aggressive diuresis and pulse dose steroids with an improvement in his symptoms and his cardiac function. This case illustrates an under-reported clinical side effect in the era of advancement in oncological immunotherapy.

Expert provider survey of longitudinal assessment in patients with pulmonary arterial hypertension.

BACKGROUND: Patients suffering from pulmonary arterial hypertension (PAH) demand frequent assessment to keep pace with a dynamic and sometimes rapidly progressive disease course. To improve our understanding of patient monitoring, we conducted a survey of pulmonary hypertension (PH) providers to establish real-world practice patterns. OBJECTIVE: To evaluate the type and frequency of patient assessment methods employed by expert PH providers following PAH diagnosis METHODS: A descriptive cross-sectional survey of PH providers across the United States was utilized to assess provider practices. Between September 14, 2017 to October 17, 2017, a survey was distributed electronically to PH experts assessing follow-up frequency and testing evaluation of patients with PAH. RESULTS: 40 (11.4%) providers completed the survey, representing cardiologists, pulmonologists, and advanced practice providers at centers who cared for an average of 95 patients per year with PAH. Follow-up testing and clinic evaluation was influenced by severity of patient illness. Frequency of re-assessment of clinic follow-up, six-minute walk test, echocardiogram, brain natriuretic peptide, and right heart catheterization in various clinical scenarios all reflected disparate practice. CONCLUSIONS: Current clinical practice patterns in the monitoring of patients with PAH are variable and do not necessarily reflect guideline-based practices, suggesting the need for further research and improved guidelines on the frequency of follow up and repeat testing.

Interhospital Transfer of Patients With Acute Pulmonary Embolism: Challenges and Opportunities.

Acute pulmonary embolism (PE) is associated with significant morbidity and mortality. The management paradigm for acute PE has evolved in recent years with wider availability of advanced treatment modalities ranging from catheter-directed reperfusion therapies to mechanical circulatory support. This evolution has coincided with the development and implementation of institutional pulmonary embolism response teams (PERT) nationwide and internationally. Because most institutions are not equipped or staffed for advanced PE care, patients often require transfer to centers with more comprehensive resources, including PERT expertise. One of the unmet needs in current PE care is an organized approach to the process of interhospital transfer (IHT) of critically ill PE patients. In this review, we discuss medical optimization and support of patients before and during transfer, transfer checklists, defined roles of emergency medical services, and the roles and responsibilities of referring and receiving centers involved in the IHT of acute PE patients.

Machine learning methods to predict mechanical ventilation and mortality in patients with COVID-19.

BACKGROUND: The Coronavirus disease 2019 (COVID-19) pandemic has affected millions of people across the globe. It is associated with a high mortality rate and has created a global crisis by straining medical resources worldwide. OBJECTIVES: To develop and validate machine-learning models for prediction of mechanical ventilation (MV) for patients presenting to emergency room and for prediction of in-hospital mortality once a patient is admitted. METHODS: Two cohorts were used for the two different aims. 1980 COVID-19 patients were enrolled for the aim of prediction ofMV. 1036 patients' data, including demographics, past smoking and drinking history, past medical history and vital signs at emergency room (ER), laboratory values, and treatments were collected for training and 674 patients were enrolled for validation using XGBoost algorithm. For the second aim to predict in-hospital mortality, 3491 hospitalized patients via ER were enrolled. CatBoost, a new gradient-boosting algorithm was applied for training and validation of the cohort. RESULTS: Older age, higher temperature, increased respiratory rate (RR) and a lower oxygen saturation (SpO2) from the first set of vital signs were associated with an increased risk of MV amongst the 1980 patients in the ER. The model had a high accuracy of 86.2% and a negative predictive value (NPV) of 87.8%. While, patients who required MV, had a higher RR, Body mass index (BMI) and longer length of stay in the hospital were the major features associated with in-hospital mortality. The second model had a high accuracy of 80% with NPV of 81.6%. CONCLUSION: Machine learning models using XGBoost and catBoost algorithms can predict need for mechanical ventilation and mortality with a very high accuracy in COVID-19 patients.

Life-Threatening Massive Hemoptysis After Cryoablation for Atrial Fibrillation.

A 59-year-old man developed massive hemoptysis, 1 month after undergoing cryoablation procedure for atrial fibrillation. He underwent emergent bronchoscopy that revealed massive, active bleeding with clots requiring repeated suctioning, epinephrine, and cold saline injection. The source of bleeding was identified in a follow-up bronchoscopy performed few days later-a 2×3 cm area of ulceration of the left main stem bronchus which was missed in the initial bronchoscopy owing to blood obscuring the field of vision. Considering the timeline, the ulcer most likely resulted from cryoablation-induced bronchial injury. Patient remained asymptomatic after stabilization and 2 months following discharge, another bronchoscopy was performed which showed the ulcer to be healing. Hemoptysis following cryoablation is quite rare with a reported incidence <2%. The cases of hemoptysis reported thus far have all been mild and self-limiting and manifesting within hours to days following the procedure. To our knowledge, this is the first reported case of massive hemoptysis associated with cryoballoon ablation, presenting 1 month after procedure.

Constrictive pericarditis-induced shunting through a PFO: Persistence despite pericardiectomy.

A patent foramen ovale (PFO) is found in around 25-30% of patients. The discovery is often made only on autopsy, as most PFOs are clinically silent and any inter-atrial blood exchange typically shunts from the left to right heart [1]. Thus, when a patient presents with hypoxic respiratory failure, concern for presence of a PFO is rarely at the top of the differential. However, in the setting of elevated right heart pressures, PFOs can become of great hemodynamic importance and can lead to deadly complications, including right to left shunting and refractory hypoxic respiratory failure. We present an unusual care of constrictive pericarditis leading to significant shunting through a PFO, and resultant hypoxic respiratory failure which only resolved with PFO closure.

Right heart thrombus in transit: a series of two cases.

Right heart thrombus in transit is an increasingly recognized medical emergency with very high mortality rate. Echocardiography helps to establish the diagnosis and can differentiate between right heart thrombi that result from atrial fibrillation and those originating from deep venous thrombosis. We present two cases of right heart thrombus in transit diagnosed with echocardiography that were managed with different approaches.

Drug-induced pulmonary arterial hypertension: a review.

Pulmonary arterial hypertension (PAH) is a subgroup of PH patients characterized hemodynamically by the presence of pre-capillary PH, defined by a pulmonary artery wedge pressure (PAWP) ≤15 mmHg and a PVR >3 Wood units (WU) in the absence of other causes of pre-capillary PH. According to the current classification, PAH can be associated with exposure to certain drugs or toxins such as anorectic agents, amphetamines, or selective serotonin reuptake inhibitors. With the improvement in awareness and recognition of the drug-induced PAH, it allowed the identification of additional drugs associated with an increased risk for the development of PAH. The supposed mechanism is an increase in the serotonin levels or activation of serotonin receptors that has been demonstrated to act as a growth factor for the pulmonary artery smooth muscle cells and cause progressive obliteration of the pulmonary vasculature. PAH remains a rare complication of several drugs, suggesting possible individual susceptibility, and further studies are needed to identify patients at risk of drug-induced PAH.

Impact of Anticoagulation in Elderly Patients With Pulmonary Embolism That Undergo IVC Filter Placement: A Retrospective Cohort Study.

BACKGROUND: Anticoagulation is the primary treatment for pulmonary embolism (PE). Inferior vena cava (IVC) filters are an adjunctive intervention to prevent recurrent pulmonary embolism. Long-term outcomes in elderly patients with contraindications to anticoagulation after IVC filter placement for prevention of recurrent pulmonary embolism have yet to be assessed. MATERIALS AND METHODS: Patients ≥60years of age, that had an IVC filter placed between 1 January, 2008 and 2 February, 2013, with a primary diagnosis of pulmonary embolism, were included. Patients that died during index hospitalisation, were discharged to hospice, or had active malignancy were excluded. The primary endpoint was overall survival. Patients were divided depending on whether they were treated with an approved anticoagulant for VTE or had no anticoagulant. RESULTS: Of the 152 patients identified, 55 were not anti-coagulated after IVC filter placement. The incidence of death was 0.4 per 1000 filter days and 0.7 per 1000 filter days in the anti-coagulated and untreated groups respectively (p-value=0.06). After statistical correction for co-morbid conditions, the effect of anticoagulation was not significant (HR 0.82 CI 0.49-1.37, p-value 0.46). Age was a significant confounder that was associated with death. Increased BMI was protective. Indications for IVC filter placement were numerous, but similar between the two groups. CONCLUSION: Treatment with an approved anticoagulant is recommended after IVC filter placement for prevention of recurrent PE, however its effect may be attenuated by advanced age. In elderly patients that have undergone IVC filter placement for prevention of recurrent PE, survival may be more dependent on age and co-morbid conditions than exposure to anticoagulation.

A Rare Case of Hydromorphone-Induced Angioedema Effectively Managed by a Difficult Airway Response Team.

Hydromorphone, unlike other opioids associated with histamine release, has never been reported to cause angioedema. We report a rare case of hydromorphone-induced angioedema in a 34-year-old woman with history of deep venous thrombosis and pulmonary embolism who presented with leg swelling and pain after trauma. Hydromorphone was administered with subsequent rapid development of stridor and edematous changes of the tongue, uvula, and surrounding mucosa. The difficult airway response team was activated, and the airway was secured by emergent awake fiberoptic intubation in the operating room. After being treated with antihistamines and steroids for 24 hours, the airway edema had resolved, leading to a successful extubation.

Heparin dosing in critically ill patients undergoing therapeutic hypothermia following cardiac arrest.

PURPOSE: To determine the effects of anticoagulation with intravenous unfractionated heparin (IVUH) during therapeutic hypothermia (TH) post-cardiac arrest. METHODS: Single-center, retrospective, observational trial in the intensive care units of two hospitals within the Detroit Medical Center. Unresponsive survivors of cardiac arrest, receiving treatment doses of IVUH during TH were included. Patients were required to have at least 1 measured activated partial thromboplastin time (aPTT) during TH. Coagulation parameters were collected at 3 distinct temperature phases: baseline, TH, and post-re-warming (±37 °C) target aPTT defined as 1.5-2 times baseline. RESULTS: Forty-six patients received IVUH during TH, with 211 aPTTs. Heparin starting rate was 13±4 units/kg/h. Average baseline, TH and post-TH aPTT were 34±12, 142±48, and 56±17 s, respectively. Using standard dosing strategies, initial aPTT was above the target range in 89% of patients. After re-warming, aPTT significantly decreased (142±48s vs. 56±17 s, p=0.005), and heparin dose significantly increased (7.9±3 vs. 9±4 units/kg/h, p<0.001). There was a significant difference between aPTT among all three groups, and heparin dose between TH and post-TH even after correcting for age, sex, body mass index, heparin rate, and APACHE II score (p<0.001). Three patients experienced a major bleeding event. CONCLUSIONS: Current dosing protocols for IVUH should not be utilized during TH. Heparin requirements are drastically reduced during TH and prolonged interruptions may be required to allow for adequate clearance of UH.

Distance saturation product predicts health-related quality of life among sarcoidosis patients.

BACKGROUND: Sarcoidosis is a chronic disease with different phenotypic manifestations. Health-related quality of life is an important aspect in sarcoidosis, yet difficult to measure. The objective of this study was to identify clinical markers predictive of poor quality of life in sarcoidosis patients that can be followed over time and targeted for intervention. METHODS: We assessed the quality of life of 162 patients with confirmed sarcoidosis in a prospective, cross-sectional study using the Sarcoidosis Health Questionnaire (SHQ) and Short Form-36 Health Survey (SF-36). We evaluated the validity of these questionnaires and sought to identify variables that would best explain the performance scores of the patients. RESULTS: On multivariate regression analyses, the very best composite model to predict total scores from both surveys was a model containing the distance-saturation product and Borg Dyspnea Scale score at the end of a 6-min walk test. This model could better predict SF-36 scores (R² = 0.33) than SHQ scores (R² = 0.24). Substitution of distanced walked in 6 min for the distance-saturation product in this model resulted in a lesser ability to predict both scores (R² = 0.26 for SF-36; R² = 0.22 for SHQ). CONCLUSIONS: Both the SHQ and SF-36 surveys are valuable tools in the assessment of health-related quality of life in sarcoidosis patients. The best model to predict quality of life among these patients, as determined by regression analyses, included the distance-saturation product and Borg score after the 6-min walk test. Both variables represent easily obtainable clinical parameters that can be followed over time and targeted for intervention.

Outcome of patients with injection drug use-associated endocarditis admitted to an intensive care unit.

PURPOSE: The purpose of this study was to study the outcome of patients with injection drug use-associated infective endocarditis (IDU-IE) admitted to an intensive care unit (ICU). MATERIAL AND METHODS: A retrospective review of medical records of 33 consecutive patients with IDU-IE admitted to ICU was conducted. RESULTS: Main indications for admission to ICU were as follows: severe sepsis or septic shock (36%), respiratory failure (33%), and neurologic deterioration (18%). Staphylococcus aureus was found in 94% of patients, and 15% had polymicrobial infection. Fifteen (45%) patients had septic emboli to 1 or more organs, including 12 (36%) to lungs and 7 (21%) to central nervous system. In-hospital mortality was 27%, and in univariate analysis, previous history of endocarditis (odds ratio [OR], 11.2; P = .03), respiratory failure (OR, 7; P = .03), neurologic failure (OR, 6.25; P = .03), and high Acute Physiology and Chronic Health Evaluation II (OR, 1.21; P = .016) and Sequential Organ Failure Assessment scores (OR, 1.25; P = .01) increased risk of death. By multivariate logistic regression analysis, previous history of endocarditis and high Acute Physiology and Chronic Health Evaluation II score were independently associated with poor survival. CONCLUSIONS: Complicated IDU-IE necessitating admission to ICU is associated with high mortality. In addition to consequences of sepsis, septic embolization to central nervous system and lungs contributes to development of organ failure. Increased severity of illness and prior history of endocarditis are associated with poor outcome.

The clinical and radiologic features of nodular pulmonary sarcoidosis.

STUDY OBJECTIVES: Nodular sarcoidosis is an uncommon presentation of sarcoidosis. Our objective was to describe the clinical characteristics of a large cohort of patients with nodular sarcoidosis. METHODS: We performed a retrospective study of patients with nodular sarcoidosis diagnosed at an urban teaching hospital over a 10-year period. RESULTS: Thirty-three patients with nodular sarcoidosis were identified. All patients were African-American. The mean age was 35 and the female-to-male ratio was 5:1. Twenty-six patients were current or former smokers. All patients had chest CT scan and/or chest radiograph evidence of pulmonary masses. Twenty-seven patients had multiple pulmonary masses/nodules and six had solitary pulmonary nodules/masses. The upper lobes were involved in 27 patients. Mediastinal lymphadenopathy and pleural-based masses were present in 30 and 20 patients, respectively. Extrapulmonary manifestations were present in 14 patients. All patients had tissue diagnosis of noncaseating granulomas with negative culture. Twenty-two patients underwent bronchoscopy with transbronchial biopsies, which were diagnostic in 19. Follow-up data were available on 27 patients: complete or nearly complete resolution of the pulmonary masses--either spontaneously or with systemic treatment--was documented for 19 patients, no change in the radiologic findings for 7 patients, and progression to pulmonary fibrosis for 1 patient. CONCLUSIONS: Nodular sarcoidosis is a rare presentation of pulmonary sarcoidosis. It usually presents with multiple pulmonary masses that tend to be peripheral and are associated with mediastinal lymphadenopathy. Bronchoscopy with transbronchial biopsies has high diagnostic yield. Despite its ominous presentation, nodular sarcoidosis has favorable prognosis.