CT-guided microwave ablation of the nonsurgical aspergilloma.

Background: Aspergillosis is a fungal infection that can lead to development of an aspergilloma, especially in patients with a history of cavitary lung disease. It is generally managed with antifungal therapy followed by surgical intervention. There are, however, limited options for the nonsurgical patient. Microwave ablation is already an effective, minimally invasive treatment being used in some lung malignancies and may be an alternative and definitive treatment in the inoperable patient. Methods: Two patients were considered for microwave ablation following their diagnoses of aspergillosis with hemoptysis. We sought to evaluate the efficacy of CT-guided microwave ablation of an aspergilloma in these patients who were not good candidates for surgical intervention. Results: Two male patients presented with hemoptysis and were found to have an aspergilloma. Case 1 was initially treated with antifungals and did not improve. He proceeded with VATS, and the procedure was aborted intraoperatively secondary to a frozen chest cavity. The patient subsequently elected to undergo CT-guided microwave ablation. He did not experience any immediate complications but was hospitalized for hemoptysis several weeks later. He developed alveolar hemorrhage and ultimately succumbed to PEA arrest.Case 2 was without hemoptysis at follow up and chose to pursue microwave ablation for definitive treatment. Case 2 developed post ablation pneumothorax requiring chest tube placement. Follow-up CT chest imaging was consistent with resolution of the aspergilloma. Conclusion: Microwave ablation is a safe and effective therapeutic approach in the treatment of lung malignancy with no severe or death related complications. There are almost no absolute contraindications. Microwave ablation may be utilized as a therapeutic option in the treatment of an aspergilloma in the non-surgical patient. This novel application may challenge the current gold standard of surgical intervention.

Expectant management of pneumothorax in intubated COVID-19 positive patients: a case series.

BACKGROUND: There is an increasing amount of literature describing the pathogenesis of coronavirus disease 2019 (COVID-19) pneumonia and its associated complications. Historically, a small pneumothorax has been shown to be successfully treated without chest tube insertion, but this management has yet to be proven in COVID-19 pneumonia patients. In addition, pneumothorax in an intubated patient with high positive end-expiratory pressure (PEEP) provides additional uncertainty with pursuing non-operative management. CASE PRESENTATION: In this series we report four cases of patients with respiratory distress who tested positive for COVID-19 via nasopharyngeal swab and developed ventilator-induced pneumothoraces which were successfully managed with observation alone. CONCLUSIONS: Management of patients with COVID-19 pneumonia on positive pressure ventilation who develop small stable pneumothoraces can be safely observed without chest tube insertion.

Dysphagia of aberrant right subclavian artery treated by endoscopic dilation: An alternative to surgical treatment in select cases-A case report.

INTRODUCTION: The aberrant right subclavian artery (ARSA) is a rare cause of dysphagia. Surgical intervention has remained the mainstem of therapy, accompanied with certain morbidities and mortalities. Although rarely reported in literature, endoscopic dilation may be considered a suitable treatment alternative in patients who are not a surgical candidate or do not consent for surgery. We report a case suffering from dysphagia and diagnosed with ARSA treated by endoscopic dilation. PRESENTATION OF CASE: A 52-year-old male presented to our clinic in 2015 with dysphagia. Chest Computed Tomography scan confirmed the diagnosis of ARSA. He first underwent esophagogastroduodenoscopy (EGD) with staged dilation of the stricture, making him free of his symptoms for an approximate 2.5 years. Upon recurrence of symptoms in 2018, he underwent repeat endoscopic dilation, which again completely resolved the symptom with an excellent peri-operative and post-operative course. CONCLUSION: Endoscopic dilation of the esophageal stricture in patients with ARSA is a safe alternative to surgery in patients who are unable or unwilling to undergo surgery. It provides relief for a relatively long time and can be safely repeated multiple times upon recurrence.

A Community-based Pulmonary Nodule Clinic: Improving Lung Cancer Stage at Diagnosis.

Objective Pulmonary nodules (PNs) are a common incidental finding and are often how lung cancer is discovered. Our goal was to determine if establishing a pulmonary nodule clinic (PNC) in a community healthcare setting would lead to an earlier stage at diagnosis. Methods A single healthcare system retrospective review was conducted of all PNC patients from 2010-2015 diagnosed with lung cancer. The stage at diagnosis was analyzed and compared to lung cancer patients in our healthcare system outside the PNC and to national data. Five-year survival rates for PNC patients from 2010-2012 were also analyzed. Results  A total of 119 patients and 127 lung cancers were diagnosed through the PNC from 2010-2015. There were 990 lung cancers, with a known stage, diagnosed outside the PNC in our healthcare system from 2010 to 2015. Two hundred and eighty one (28.4%) cancers were Stage I, compared to 69 (54.3%) (p <0.0001) through the PNC; 110 (11.1%) cancers were diagnosed at Stage II compared to 17 (13.4%) through the PNC (0.4471); 277 (25.7%) cancers were diagnosed at Stage III, compared to 21 (16.5%) through the PNC (p 0.0060); 598 (60.4%) cancers were diagnosed at Stage IV, compared to 20 (15.7%) through the PNC (p <0.0001). Five-year survival rates for patients diagnosed in 2010 were 80% (four of five patients), 79.2% (19/24) in 2011, and 62.2% (23/37) in 2012. Conclusions  Lung cancer survival is directly related to the stage at diagnosis. Establishment of our PNC has led to an earlier stage at diagnosis compared to the general lung cancer population in our community.

The Untapped Potential of Tunneled Pleural Catheters.

BACKGROUND: Tunneled pleural catheters (TPCs) are routinely used for outpatient drainage of malignant pleural effusions, although use in recurrent pleural effusions resulting from nonmalignant conditions requires further evaluation. We hypothesized that TPCs could decrease inpatient admission rates for exacerbations of nonmalignant pleural effusions. METHODS: A retrospective chart review was done of patients with TPCs inserted for recurrent nonmalignant pleural effusions. Patients were set up with home care nursing support and catheter draining two to three times per week and were then followed on an outpatient basis until spontaneous pleurodesis and catheter removal. Data collection included demographics, comorbidities, and hospital admission rates relative to TPC placement as well as removal. RESULTS: Thirty-seven patients with recurrent, nonmalignant pleural effusions were enrolled (17 female and 20 male patients). Patients had comorbid conditions including hypertension (86%), chronic kidney disease (59%), congestive heart failure (67%), liver disease (11%), and malnutrition (22%), and most patients (89%) had multiples of these conditions. Total admissions for pleural effusion exacerbations decreased from 59 to 15 in the 1 year before and after TPC placement and from 42 to 6 in the respective 3-month periods (p < 0.0001). Six of the 37 patients still had TPCs in place; for the remaining 31 patients, admissions decreased from 60 to 9 in the 1-year periods before and after TPC removal and from 33 to 2 in the respective 3-month periods (p < 0.0001); no patients required subsequent pleural interventions. CONCLUSIONS: The study results support TPC placement in recurrent nonmalignant pleural effusions refractory to medical management as an effective and plausible management option.

Paradoxical hemodynamic instability complicating pericardial window surgery for cardiac tamponade in a cancer patient.

Paradoxical hemodynamic instability is defined as unexpected hemodynamic compromise that develops in a patient after pericardial fluid drainage. The overall incidence of the condition is about 5%, and it has a high in-hospital mortality rate. The condition has been reported to occur regardless of the approach that is used to drain the fluid or the underlying cause of the disease. The pathophysiology of paradoxical hemodynamic instability and the appropriate intervention are not very clear, and further studies are needed to identify appropriate preventive measures.We report a rare manifestation of paradoxical hemodynamic instability in a 65-year-old woman who had a history of stage IV lung cancer. She presented with a one-week history of pleuritic chest pain and shortness of breath on exertion. Echocardiography revealed a large circumferential pericardial effusion with right atrial and ventricular collapse during diastole, suggesting a compressive effect of the pericardial fluid; however, left ventricular systolic function was well preserved. The patient underwent the scheduled creation of a subxiphoid pericardial window. Immediately after the pericardial fluid was evacuated, her heart began to beat more vigorously, but this was abruptly followed by an episode of asystole. Pacing and medical therapy were unsuccessful in preventing repeated episodes of asystole, and the patient died.To our knowledge, this is the 2nd report of unexpected asystole after the creation of a subxiphoid pericardial window, and it is the first report of a takotsubo-like contractile pattern associated with paradoxical hemodynamic instability.