Timing and Outcomes of Tracheostomy Performed by Pulmonary and/or Critical Care Physicians.

BACKGROUND: Although pulmonary and/or critical care (P/CC) physicians perform percutaneous tracheostomy in mechanically ventilated patients, the trends, timing, and outcomes of this procedure have not been well described. This study aims to describe the trends, timing, and outcomes of this procedure. METHODS: Using 5% medicare data, we retrospectively examined a cohort who had tracheostomy performed after initiation of mechanical ventilation during acute hospitalization to describe the timing of tracheostomy placement by pulmonary and/or critical care (P/CC) physicians and associated outcomes. RESULTS: There were 4864 participants in the study cohort from 2007 to 2014. We examined the timing of tracheostomy (in days from initiation of mechanical ventilation), length of hospital stay, in-hospital death, and death within 30 days after hospital discharge. The percentage of tracheostomies performed by P/CC physicians increased significantly, from 7.2% in 2007 to 14.1% in 2014 (Cochran-Armitage test for trend, P = .001). Tracheostomies performed by P/CC physicians were more common in larger hospitals and major academic medical centers. After adjustment for baseline characteristics, the following parameters did not differ by provider: time to tracheostomy, length of hospital stay (days), in-hospital death, and death within 30 days after discharge. A tracheostomy was more likely to be performed by a P/CC physician at a larger (≥500 beds) hospital (adjusted odds ratio: 1.85, 95% confidence interval: 1.47-2.34). CONCLUSIONS: Tracheostomies are increasingly performed by P/CC physicians with similar outcomes, likely related to patient selection.

Durability of Sirolimus for Lymphangioleiomyomatosis.

Lymphangioleiomyomatosis (LAM), a rare, multisystem disorder primarily affecting women of reproductive age, is characterized by cystic-appearing lung lesions, progressive loss of lung function, chylous effusions and renal angiomyolipomas. Sirolimus, an mammalian target of rapamycin inhibitor, has been shown to stabilize lung function, reduce symptoms and resolve chylous effusions in the short term for patients with LAM. Herein, we report a premenopausal female with LAM who experienced complete and durable resolution of her chylothoraces with significant and sustained improvement in lung function on sirolimus.

Mixing It Up: Coadministration of tPA/DNase in Complicated Parapneumonic Pleural Effusions and Empyema.

BACKGROUND: A recent randomized controlled trial showed 12 serial doses of tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) is safe and effective in managing complicated parapneumonic pleural effusions and empyema (CPEE). However, this regimen is laborious, requiring trained personnel to open/close the chest tube 8 times daily for 3 days. We present our observational data using a simplified regimen of coadministered tPA/DNase. MATERIALS AND METHODS: This is a retrospective observational study of patients who received coadministered tPA/DNase for CPEE from January 2012 to April 2015 at the University of Texas Medical Branch. Patient demographics, pleural fluid, radiologic and treatment characteristics, and outcomes were collected. Data are presented as proportions and percentages. Our primary outcome was successful treatment without need of surgery and discharge home alive. Secondary outcomes were dose and length of treatment and hospital stay, treatment complications, and 90-day mortality. RESULTS: The study included 39 patients. All pleural effusions were loculated, 59% macroscopically purulent, 50% had a positive organism in Gram stain, and 40% were culture positive. A median of 6 (interquartile range, 3.5 to 6) doses were coadministered mainly via small bore chest tube (≤14 Fr in 79%) with a median of 14.5 (interquartile range, 9.5 to 21.5) hospital days. Overall, 85% were successfully treated without need for surgery. Treatment failures occurred in 15%: 3/39 (7%) received surgery; 3/39 (7%) died. Only 1 (2.5%) complication of hemorrhagic pleural effusion resolved after discontinuation of intrapleural treatment. CONCLUSIONS: Our study shows intrapleural coadministration of tPA/DNase was effective and safe in management of CPEE.

Removal of Self-Expanding Metallic Stents.

BACKGROUND: Despite their safety profile, self-expanding metallic stents (SEMS) have been difficult to remove. We aim to describe our experience in removal of SEMS at Henry Ford Hospital with a specific emphasis on safety. METHODS: We reviewed the charts of all patients who underwent removal of a SEMS at Henry Ford Hospital between 2003 and 2013. We recorded demographic information, indication for initial stent placement, indication for stent removal, time to stent removal, procedure of removal, and any complications. RESULTS: In all, 19 stents were removed in 16 separate procedures in 14 patients. The median age was 62 years, and 50% of the patients were female. Stents were removed at a median of 35 days (range, 2 to 595 d). No complications occurred in 10/16 (62.5%) procedures. In the remaining 5 patients, complications were not directly related to the stent removal, and serious complications were mostly related to severity of underlying lung disease. Of the 10 procedures done as outpatients, 70% were discharged immediately after the procedure. CONCLUSIONS: Removal of SEMS can be done safely. Routine postoperative ventilation and intensive care unit monitoring is not required. In the absence of severe underlying lung disease, patients can safely be discharged if there are no immediate postprocedure complications.

Muddying the water for a clear diagnosis.

Pulmonary sporotrichosis, such as other chronic fungal and mycobacterial infections, can be difficult to diagnose. We present a novel twist on the old technique of bronchoalveolar lavage that leads to improved diagnostic yield.

Current clinical diagnostic tests for asthma.

Asthma involves variable airflow obstruction in both large and small airways. The physiological consequences of obstruction include increased airway resistance and decreased expiratory flow rates, which lead to air trapping and dynamic hyperinflation. This chapter reviews current methods for pulmonary function testing to detect these physiological changes for both diagnosis and monitoring.

Outcomes of patients on multiple vasoactive drugs for shock.

INTRODUCTION: Vasoactive drugs are routinely used in critically ill patients with shock to optimize the hemodynamic state while evaluating and treating potentially reversible causes. Limited data exist on the use of multiple vasoactive drugs in the intensive care unit. We hypothesize that the use of 3 or more vasoactive drugs is associated with worse outcomes. METHODS: We retrospectively examined the outcome in patients, at least 18 years of age, in whom 3 or more vasoactive drugs were administered simultaneously. We included patients admitted between November 2007 and August 2009. Vasoactive drugs included dopamine, dobutamine, epinephrine, norepinephrine, phenylephrine, and vasopressin. The primary end point was survival to hospital discharge. RESULTS: Sixty-six patients received 3 or more vasoactive drugs simultaneously. Nine patients (14%) survived to ICU discharge and 6 patients (9%) survived to hospital discharge. There was a significant difference in mean Simplified Acute Physiology Score II between survivors (32.3 ± 28.6) and nonsurvivors (72.1 ± 30.4), P = .003. Five of the 6 survivors had an acute cardiac procedure, either percutaneous cardiac intervention or heart transplantation. The 1 patient with septic shock who survived had surgery for a bowel perforation. All patients who survived received inotropic therapy (dobutamine). None of the patients who received 4 or more vasoactive drugs survived. CONCLUSION: Patients requiring 3 or more vasoactive drugs rarely survive in the absence of an intervention aimed at correcting the underlying cause such as revascularization or source control surgery.

Management of calcium channel antagonist overdose with hyperinsulinemia-euglycemia therapy: case series and review of the literature.

Calcium channel antagonists (CCAs) are commonly involved in drug overdoses. Standard approaches to the management of CCA overdoses, including fluid resuscitation, gut decontamination, administration of calcium, glucagon, and atropine, as well as supportive care, are often ineffective. We report on two patients who improved after addition of hyperinsulinemia-euglycemia (HIE) therapy. We conclude with a literature review on hyperinsulinemia-euglycemia therapy with an exploration of the physiology behind its potential use.

Rapid response team in an academic institution: does it make a difference?

BACKGROUND: Although data remain contradictory, rapid response systems are implemented across US hospitals. We aimed to determine whether implementation of a rapid response team (RRT) in a tertiary academic hospital improved outcomes. METHODS: Our hospital is a tertiary academic medical center with 24-h in-house resident coverage. We conducted a retrospective cohort study comparing 27 months after implementation of the RRT (April 1, 2006, to June 31, 2008) and 9 months before (January 1, 2005, to September 31, 2005). Outcomes included incidence of codes (cardiac and/or respiratory arrests), outcome of the codes, and overall hospital mortality. RESULTS: We analyzed 16,244 nonobstetrics hospital admissions and 70,208 patient days in the control period and 45,145 nonobstetrics hospital admissions and 161,097 patient days after the RRT was implemented. The RRT was activated 1,206 times (7.7 calls per 1,000 patient days). There was no difference in the code rate (0.83 vs 0.98 per 1,000 patient days, P = .3). There was a modest but nonsustained improvement in nonobstetrics hospital mortality during the study period (2.40% vs 2.15%; P = .05), which could not be explained by the RRT effect on code rates. The mortality was 2.40% in the control group and 2.06%, 1.94%, and 2.46%, respectively, during the next three consecutive 9-month intervals. CONCLUSIONS: In our single-institution study involving an academic hospital with 24-h in-house coverage, we found that RRT implementation did not reduce code rates in the 27 months after intervention. Although there was a decrease in overall hospital mortality, this decrease was small, nonsustained, and not explained by the RRT effect on code rates.

Pulmonary alveolar proteinosis in a 67-year-old woman with Wegener's granulomatosis.

Mycophenolate mofetil (MM) is commonly used in patients with autoimmune diseases or who have undergone transplantation. Common side effects of MM include anemia, leukopenia, mucositis and opportunistic infections. We report an unusual case of pulmonary alveolar proteinosis (PAP) in a 67-year-old woman on MM for Wegener's granulomatosis (WG). PAP is a disease characterized by defects in macrophage-mediated processing of surfactants, leading to accumulation of periodic acid-Schiff (PAS)-positive lipoproteinaceous material within the alveolar spaces.

Symptomatic persistent sciatic artery in a newborn.

Persistent sciatic artery is an unusual anatomical anomaly first noted in 1832. Approximately 60 to 70 cases have been documented in the literature, but none described symptomatic persistent sciatic artery presenting in the neonate. We report a case of a newborn infant who presented after birth with an atrophic right lower extremity and ischemia. Ultrasound with Doppler and magnetic resonance angiography revealed a right persistent sciatic artery with hypoplastic external iliac artery. The common femoral artery was reconstituted above the bifurcation into the superficial femoral and profunda femoral artery via collaterals from the internal iliac and the persistent sciatic artery. The infant's blood flow to the right extremity gradually improved for the next 4 days without treatment and continues to have adequate blood flow.

Current regulations and modest proposals regarding disposal of unused opioids and other controlled substances.

There are no uniform protocols in the United States for safe, environmentally acceptable disposal of controlled substances by patients. In addition, there are conflicting protocols used by various institutions for the disposal of narcotic medications. Although the US Drug Enforcement Administration oversees the prescribing, acquisition, and distribution of controlled substances and works to prevent the illegal diversion of these products, it stops short of recommending specific mechanisms for consumers to dispose of unused medications. The lack of specific regulations in this area increases the risk of illegal diversion of prescription medications and other controlled substances. The authors review and examine the dilemma posed by an ill-defined set of guidelines for disposal of controlled substances by patients and institutions not registered with the US Drug Enforcement Administration. The authors encourage public officials to update and reform ambiguous policies regarding opioid disposal by consumers and allied healthcare workers.

Periodontal disease and control of diabetes mellitus.

Data from the Centers for Disease Control and Prevention indicate that more than 20 million people (approximately 7% of the population) in the United States have diabetes mellitus. Physicians often fail to examine the mouths and teeth of their patients, even though the condition of the mouth and teeth have clinical relevance for the treatment of patients with diabetes mellitus. The authors examine the current state of knowledge regarding periodontal disease and the effect of periodontal disease on worsening of glycemic control. They review several studies investigating how the management of periodontal disease affects the ability of patients to control symptoms of diabetes mellitus. The authors conclude with several recommendations for the treatment of patients with periodontal disease to improve glycemic control.

Current role of magnetic resonance imaging in breast imaging: a primer for the primary care physician.

Magnetic resonance imaging (MRI) is a widely used imaging tool. Interest in the applicability of this modality in the realm of breast imaging has been steadily increasing over the past 25 years. The purpose of this article is to explore the use of contrast-enhanced MRI in breast imaging as it relates to the primary care physician. The mechanism, factors affecting image quality, basics of interpretation guidelines, and the uses and contraindications for this technique are explored. In addition, studies exploring the use of MRI in various areas of breast imaging are presented. It is hoped that the reader will become knowledgeable in the current utility of the tool as it relates to breast imaging.

Headache in medical education: medical schools, neurology and family practice residencies.

OBJECTIVE: To explore the extent of headache education received by medical students and residents. BACKGROUND: Headache is a common, often severe, and sometimes disabling problem. However, 49% of sufferers do not seek professional treatment-of those who do, only 28% are very satisfied. One possible reason is limited education of physicians about headache. METHODS: Surveys were sent to all allopathic and osteopathic medical schools, 200 family medicine residencies, and all 126 neurology residencies. Information requested included the amount and perceived adequacy of headache education and any plans to increase headache education. RESULTS: Response rates were 35% to 40%. Medical school lecture hours ranged from 0 (4%) to >5 (24%) with 92% having no plans for an increase in headache education. Family Medicine residency lecture hours ranged from 1--3 (30%) to >5 (34%) and case presentations from 1--5 (23%) to >5 (41%), with 88% of program directors having no plans for increase. Neurology residency lecture hours ranged from 1--3 (11%) to >5 (64%) and case presentations from 1--5 (23%) to>0 (57%), with 80% having no plans for increase. CONCLUSION: Undergraduate medical education in headache is limited. Despite medical schools perceiving their training as adequate, both neurology and family practice residency program directors believe entering residents are inadequately prepared in headache upon entering the program.