A comparison of the effect of weather and climate on emergency department visitation in Roanoke and Charlottesville, Virginia.

Compared with mortality, the impact of weather and climate on human morbidity is less well understood, especially in the cold season. We examined the relationships between weather and emergency department (ED) visitation at hospitals in Roanoke and Charlottesville, Virginia, two locations with similar climates and population demographic profiles. Using patient-level data obtained from electronic medical records, each patient who visited the ED was linked to that day's weather from one of 8 weather stations in the region based on each patient's ZIP code of residence. The resulting 2010-2017 daily ED visit time series were examined using a distributed lag non-linear model to account for the concurrent and lagged effects of weather. Total ED visits were modeled separately for each location along with subsets based on gender, race, and age. The relationship between the relative risk of ED visitation and temperature or apparent temperature over lags of one week was positive and approximately linear at both locations. The relative risk increased about 5% on warm, humid days in both cities (lag 0 or lag 1). Cold conditions had a protective effect, with up to a 15% decline on cold days, but ED visits increased by 4% from 2 to 5 days after the cold event. The effect of thermal extremes tended to be larger for non-whites and the elderly, and there was some evidence of a greater lagged response for non-whites in Roanoke. Females in Roanoke were more impacted by winter cold conditions than males, who were more likely to show a lagged response at high temperatures. In Charlottesville, males sought ED attention at lower temperatures than did females. The similarities in the ED response patterns between these two hospitals suggest that certain aspects of the response may be generalizable to other locations that have similar climates and demographic profiles.

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.

Initiation and characterization of small cell lung cancer patient-derived xenografts from ultrasound-guided transbronchial needle aspirates.

Small cell lung cancer (SCLC) is a devastating disease with limited treatment options. Due to its early metastatic nature and rapid growth, surgical resection is rare. Standard of care treatment regimens remain largely unchanged since the 1980's, and five-year survival lingers near 5%. Patient-derived xenograft (PDX) models have been established for other tumor types, amplifying material for research and serving as models for preclinical experimentation; however, limited availability of primary tissue has curtailed development of these models for SCLC. The objective of this study was to establish PDX models from commonly collected fine needle aspirate biopsies of primary SCLC tumors, and to assess their utility as research models of primary SCLC tumors. These transbronchial needle aspirates efficiently engrafted as xenografts, and tumor histomorphology was similar to primary tumors. Resulting tumors were further characterized by H&E and immunohistochemistry, cryopreserved, and used to propagate tumor-bearing mice for the evaluation of standard of care chemotherapy regimens, to assess their utility as models for tumors in SCLC patients. When treated with Cisplatin and Etoposide, tumor-bearing mice responded similarly to patients from whom the tumors originated. Here, we demonstrate that PDX tumor models can be efficiently established from primary SCLC transbronchial needle aspirates, even after overnight shipping, and that resulting xenograft tumors are similar to matched primary tumors in cancer patients by both histology and chemo-sensitivity. This method enables physicians at non-research institutions to collaboratively contribute to the rapid establishment of extensive PDX collections of SCLC, enabling experimentation with clinically relevant tissues and development of improved therapies for SCLC patients.

A randomised trial of lung sealant versus medical therapy for advanced emphysema.

Uncontrolled pilot studies demonstrated promising results of endoscopic lung volume reduction using emphysematous lung sealant (ELS) in patients with advanced, upper lobe predominant emphysema. We aimed to evaluate the safety and efficacy of ELS in a randomised controlled setting.Patients were randomised to ELS plus medical treatment or medical treatment alone. Despite early termination for business reasons and inability to assess the primary 12-month end-point, 95 out of 300 patients were successfully randomised, providing sufficient data for 3- and 6-month analysis.57 patients (34 treatment and 23 control) had efficacy results at 3 months; 34 (21 treatment and 13 control) at 6 months. In the treatment group, 3-month lung function, dyspnoea, and quality of life improved significantly from baseline when compared to control. Improvements persisted at 6 months with >50% of treated patients experiencing clinically important improvements, including some whose lung function improved by >100%. 44% of treated patients experienced adverse events requiring hospitalisation (2.5-fold more than control, p=0.01), with two deaths in the treated cohort. Treatment responders tended to be those experiencing respiratory adverse events.Despite early termination, results show that minimally invasive ELS may be efficacious, yet significant risks (probably inflammatory) limit its current utility.

Cryobiopsy: should this be used in place of endobronchial forceps biopsies?

UNLABELLED: Forceps biopsies of airway lesions have variable yields. The yield increases when combining techniques in order to collect more material. With the use of cryotherapy probes (cryobiopsy) larger specimens can be obtained, resulting in an increase in the diagnostic yield. However, the utility and safety of cryobiopsy with all types of lesions, including flat mucosal lesions, is not established. AIMS: Demonstrate the utility/safety of cryobiopsy versus forceps biopsy to sample exophytic and flat airway lesions. SETTINGS AND DESIGN: Teaching hospital-based retrospective analysis. METHODS: Retrospective analysis of patients undergoing cryobiopsies (singly or combined with forceps biopsies) from August 2008 through August 2010. Statistical Analysis. Wilcoxon signed-rank test. RESULTS: The comparative analysis of 22 patients with cryobiopsy and forceps biopsy of the same lesion showed the mean volumes of material obtained with cryobiopsy were significantly larger (0.696 cm(3) versus 0.0373 cm(3), P = 0.0014). Of 31 cryobiopsies performed, one had minor bleeding. Cryopbiopsy allowed sampling of exophytic and flat lesions that were located centrally or distally. Cryobiopsies were shown to be safe, free of artifact, and provided a diagnostic yield of 96.77%. CONCLUSIONS: Cryobiopsy allows safe sampling of exophytic and flat airway lesions, with larger specimens, excellent tissue preservation and high diagnostic accuracy.

Recurring tracheal papillomatosis treated with cryosurgery.

Cryosurgery has proven effective in managing malignant tracheobronchial tumors, yet its role in benign lesions is not well established. A case of isolated tracheal papillomas recurring 15 years following laser surgery is reported. Cryosurgery allowed improvement in symptoms and adequate control of the papillomas.

Treatment of toxic epidermal necrolysis with intravenous immunoglobulin.

Toxic epidermal necrolysis is a severe adverse drug reaction that produces extensive mucocutaneous damage, with full-thickness epidermal detachment, and has many clinical similarities to severe burn injuries. The treatment is mainly supportive and aimed at preventing complications while the disease takes its natural course, and the skin reepithelializes. Much interest exists in the development of a specific therapy targeted at the disease process itself. Because the diagnosis has an incidence of only 0.5-1 case/million/year, large controlled studies are lacking, but a recent, better understanding of this disease has provided the rationale for the use of intravenous immunoglobulin. We present a case of toxic epidermal necrolysis that showed a good response to intravenous immunoglobulin G and review the recent literature condition and its management.

Thoracoscopic management of pleural effusions in Kaposi's sarcoma: a rapid and effective alternative for diagnosis and treatment.

Kaposi's sarcoma (KS) is one of the most common causes of pleural effusion in patients with acquired immunodeficiency syndrome (AIDS). Pleural effusions due to KS carry a high morbidity and mortality. Their treatment is difficult, and they respond poorly to chemical pleurodesis. Even systemic chemotherapy against KS has little effect on the pleural effusions. Commonly, repeated therapeutic thoracentesis or chest tube drainage is required. We present a case of advanced KS with bilateral pleural effusions. We believe this is the first reported case in which medical thoracoscopy with talc pleurodesis has been shown to achieve adequate control of the effusions.

Endoscopic management of obstruction due to an acquired bronchial web.

Bronchial webs are thin, membrane-like diaphragms that may obstruct the airway. Several congenital cases have been reported. Though rare, the true incidence of these lesions is probably underestimated because many of them are unrecognized. The case of a 71-year-old woman with an acquired bronchial web causing right main stem bronchus obstruction that went unrecognized for 47 years post-trauma is reported. The lesion was successfully treated using rigid bronchoscopy with laser therapy, balloon dilation and stent placement. This is the first reported case of an acquired bronchial web formation. It is also the first reported case that was successfully treated with this technique.

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.