Ageing and chronic obstructive pulmonary disease: interrelationships.

PURPOSE OF REVIEW: As life expectancy increases, the ageing population accrues an increasing burden of chronic conditions and functional compromise. Some conditions that lead to compromise are deemed part of 'natural ageing,' whereas others are considered to represent disease processes. Ageing ('a natural process') and chronic obstructive pulmonary disease ('a disease') share many common features, both pulmonary and systemic. At times, the pathways of injury are the same, and at times they are concurrent. In some cases, age and disease are separated not by the presence but by the severity of a finding or condition. This brief review aims to compare some of the similarities between ageing and COPD and to compare/contrast mechanisms for each. RECENT FINDINGS: At the cellular level, the natural process of ageing includes multiple systemic and molecular mechanisms. COPD, though defined by progressive pulmonary compromise, can also be a systemic disease/process. It has become evident that specific senescence pathways like p-16 and the sirtuin family of proteins are implicated both in ageing and in COPD. Also common to both ageing and COPD are increased inflammatory markers, leucocyte response abnormalities, and DNA-level abnormalities. SUMMARY: The prevalence of COPD increases with increasing age. COPD contributes to the accrued burden of chronic disease and is a significant contributor to morbidity and mortality in this population. This review attempts to summarize some of similarities between ageing and COPD and their underlying mechanisms.

An Uncommon Case of Secondary Organizing Pneumonia Due to Influenza Type B.

Secondary organizing pneumonia refers to a disease process caused by pulmonary tissue injury. Various insults can cause secondary organizing pneumonia, including multiple types of infections and cancer. The mainstay of diagnosis is a combination of imaging and lung biopsy showing inflammatory changes, specifically plugs with granulated tissue and fibrosis. Clinical suspicion needs to be raised for secondary organizing pneumonia when a patient is requiring increasing amounts of oxygen in the presence of treatment for pneumonia or another underlying lung disease. Here, we present the case of a 65-year-old male who presented with acute hypoxemic respiratory failure in the setting of previously having been tested positive for influenza B. Aggressive steroids with eventual tapering of his O2 requirements led to a successful outcome. While influenza has been reported as a cause of secondary organizing pneumonia after proceeding infection, these cases are usually represented by type A, rather than B.

Acute Respiratory Failure From Hypermagnesemia Requiring Prolonged Mechanical Ventilation.

Electrolyte abnormalities are an underrecognized cause of respiratory failure in the intensive care unit. One such abnormality is a relatively rare phenomenon of hypermagnesemia resulting in paralysis. A 73-year-old Caucasian male patient presented to the emergency department with diffuse abdominal pain of 2-day duration. He received magnesium citrate and gastrointestinal cocktail for his constipation after initial imaging showed constipation. In view of acute worsening, follow-up computed tomography of the abdomen was done, which showed free air in upper abdomen along with free fluid. Hence, he was taken for emergent laparotomy with repair of pyloric ulcer perforation with omental patch. Post procedure course was complicated by sepsis, acute kidney injury, and respiratory failure with hypoxemia and hypercapnia. On physical examination the patient had flaccid paralysis in all his extremities along with absent brain stem reflexes. Extensive workup including imaging of brain failed to reveal diagnosis. On postoperative day 1, the patient was noted to have magnesium level of 9.2 mg/dL (1.6-2.3 mg/dL), which was thought to be cause of flaccid paralysis and respiratory failure. In view of his acute oliguric kidney injury, he was initiated on intermittent hemodialysis, until his magnesium levels were back to its physiologic limits. His paralysis gradually improved over next 48 to 72 hours and he was liberated from ventilator successfully.

Identifying asymptomatic healthcare workers with COVID-19 in a community hospital: an institution's experience.

The outbreak related to SARS-CoV-2 or COVID-19 has been classified as a pandemic. Many healthcare institutions enacted policies to limit the spread within their facility. As hospitals begin to return to normal particularly with elective procedures, a common concern is how an organization should react in the event that healthcare workers test positive for COVID-19. When our organization had a cluster of positive inpatient healthcare workers, we elected to test all direct patient care healthcare workers. Through this process we learned two valuable lessons that have redefined our practice: 1) the recognition that aggressive contact tracing provides greater yield than testing everyone and 2) organizations must implement effective social distancing both within each department and how departments interact with each other to limit the scope of contract tracing.

A Rare Case of Hemophagocytic Lymphohistiocytosis Triggered by Sepsis Due to Methicillin-Resistant Staphylococcus aureus Bacteremia.

Hemophagocytic lymphohistiocytosis (HLH) is a rare disease that occurs due to unregulated immune system activation induced by various causes including infection and cancer. In this article, we report a case of a 67-year-old male with history of small cell lung cancer who developed HLH triggered by methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. The patient was initially admitted for septic shock and gastrointestinal bleed. Further workup showed that the patient met criteria for HLH diagnosis as he was positive for 5 of the 8 parameters. Unfortunately, the patient's condition worsened and he eventually expired. With this case, we wish to draw attention to the fact that sepsis due to MRSA bacteremia can be a trigger for HLH.

Not All That Shines on a PET Scan Is Cancer: A Silicone-Induced Granuloma Masquerading as Malignancy.

PET/CT scans are frequently used in the initial workup of suspicious lesions but not all that lights up on a PET is cancerous. We wish to discuss a case of silicone-induced granuloma mimicking malignancy and the role of other imaging modalities for further workup.

National Trends (2009-2013) for Palliative Care Utilization for Patients Receiving Prolonged Mechanical Ventilation.

OBJECTIVES: Patients requiring mechanical ventilation have high morbidity and mortality. Providing palliative care services has been suggested as a way to improve comprehensive management of critically ill patients. We examined the trend in the utilization of palliative care among adults who require prolonged mechanical ventilation. Primary objectives were to determine the trend in palliative care utilization over time, predictors for palliative care utilization, and palliative care impact on hospital length of stay. DESIGN: Retrospective, cross-sectional study. SETTING: The National Inpatient Sample data between 2009 and 2013 was used for this study. PATIENTS: Adults (age ≥ 18 yr) who underwent prolonged mechanical ventilation (≥ 96 consecutive hr) were studied. MEASUREMENTS AND MAIN RESULTS: Palliative care and mechanical ventilation were identified using the corresponding International Classification of Diseases, 9th revision, Clinical Modification, codes. A total of 1,751,870 hospitalizations with prolonged mechanical ventilation were identified between 2009 and 2013. The utilization of palliative care increased yearly from 6.5% in 2009 to 13.1% in 2013 (p < 0.001). Among the mechanically ventilated patients who died, palliative care increased from 15.9% in 2009 to 33.3% in 2013 (p < 0.001). Median hospital length of stay for patients with and without palliative care was 13 and 17 days, respectively (p < 0.001). Patients discharged to either short- or long-term care facilities had a shorter length of stay if palliative care was provided (15 vs 19 d; p < 0.001). The factors associated with a higher palliative care utilization included older age, malignancy, larger hospitals in urban areas, and teaching hospitals. Non-Caucasian race was associated with lower palliative care utilization. CONCLUSIONS: Among patients who undergo prolonged mechanical ventilation, palliative care utilization is increasing, particularly in patients who die during hospitalization. Using palliative care for mechanically ventilated patients who are discharged to either short- or long-term care facilities is associated with a shorter hospital length of stay.

Prospective Open-label Trial of Early Concomitant Vasopressin and Norepinephrine Therapy versus Initial Norepinephrine Monotherapy in Septic Shock.

PURPOSE: Delays in achieving target mean arterial pressure (MAP) are associated with increased morbidity and mortality in patients with septic shock. This trial was conducted to test the hypothesis that early concomitant treatment with vasopressin and norepinephrine reduces the time to achieve and maintain target MAP compared with initial norepinephrine monotherapy. METHODS: A single-center prospective open-label trial was conducted in patients with septic shock between November 2015 and June 2016 at a medical intensive care unit in an academic medical center. Initial norepinephrine monotherapy was initiated between November 2015 and February 2016. Between March and June 2016, vasopressin was initiated within 4 hours of norepinephrine. The primary outcome was time to achieving and maintaining MAP of 65 mm Hg for at least 4 hours that was compared between groups using the Student t test and examined using the Kaplan-Meier curve (Clinical Trials registration: NCT02454348). RESULTS: Eighty-two patients were included (41 in each group). Patients treated with early concomitant vasopressin and norepinephrine more frequently had a positive culture (59% vs 37%, p=0.05) and grew nonlactose fermenting gram-negative bacilli (34% vs 10%, p=0.01) compared with patients treated with norepinephrine monotherapy, respectively. The median time to achieve and maintain MAP occurred faster in the early concomitant vasopressin and norepinephrine group, at 5.7 hours (interquartile range [IQR] 1.7-10.3 hrs), compared with 7.6 hours (IQR 3.6-16.7 hrs, p=0.058) in the norepinephrine group. Durations of therapy for norepinephrine or vasopressin, amount of norepinephrine received in the first 24 hours, norepinephrine dosage when MAP was achieved and maintained, maximum norepinephrine dosage, and mortality were similar between groups. CONCLUSION: Patients treated with early concomitant vasopressin and norepinephrine achieved and maintained MAP of 65 mm Hg faster than those receiving initial norepinephrine monotherapy, suggesting that overcoming vasopressin deficiency sooner may reduce the time patients spend in the early phase of septic shock.

Association of chronic obstructive pulmonary disease with mild cognitive impairment and dementia.

PURPOSE OF REVIEW: As age expectancy increases, both dementia and chronic obstructive pulmonary disease (COPD) have become more prevalent. Dementia and COPD together, however, occur more commonly than would be predicted from the incidence of either alone, suggesting a link between these two common senescent diseases. The purpose of this article is to review the extant literature and report findings in a clinically meaningful manner. We will look at the level of evidence, the risk factors for co-occurrence of the two diseases and the differential effects upon cognitive domains in the population with dementia and COPD. RECENT FINDINGS: Cognitive impairment in patients with COPD may be 'dose-dependent' with the duration of COPD. Patients with COPD appear to develop nonamnestic mild cognitive impairment (MCI) as opposed to amnestic MCI. Newer studies exploring the impact of oxygen therapy and pulmonary rehabilitation upon cognitive function have reported some positive findings. SUMMARY: Higher prevalence of MCI/dementia is seen in patients with COPD compared with age-matched controls. Imaging findings and dementia/MCI biomarkers provide preliminary evidence for an indirect association of the two conditions. Although no causality can be drawn with the available data, there is some indication that the severity of hypoxemia correlates with the severity of cognitive dysfunction.

National Trends (2007-2013) of Clostridium difficile Infection in Patients with Septic Shock: Impact on Outcome.

BACKGROUND: Clostridium difficile is the most common infectious cause of healthcare-associated diarrhea and is associated with worse outcomes and higher cost. Patients with septic shock (SS) are at increased risk of acquiring C. difficile infections (CDIs) during hospitalization, but little data are available on CDI complicating SS. OBJECTIVE: Prevalence of CDI in SS between 2007-2013 and impact of CDI on outcomes in SS. METHODS: Outcomes were prevalence of CDI in SS, effect on mortality, length of stay (LOS), and 30-day readmission. RESULTS: There were 2,031,739 hospitalizations with SS (2007-2013). CDI was present in 8.2% of SS. The in-hospital mortality of SS with and without CDI were comparable (37.1% vs 37.0%; 𝑃 = 0.48). Median LOS was longer for SS with CDI (13 days vs 9 days; 𝑃 < 0.001). LOS >75th percentile (>17 days) was 36.9% in SS with CDI vs 22.7% without CDI (𝑃 < 0.001). Similarly, LOS > 90th percentile (> 29 days) was 17.5% vs 9.1%, 𝑃 < 0.001. Odds of LOS >75% and >90% in SS were greater with CDI (odds ratio [OR] 2.11; 95% confidence interval [CI], 2.06-2.15; 𝑃 < 0.001 and OR 2.25; 95% CI, 2.22-2.28; 𝑃 < 0.001, respectively). Hospital readmission of SS with CDI was increased, adjusted OR 1.26 (95% CI, 1.22-1.31; 𝑃 < 0.001). CONCLUSIONS: CDI complicating SS is common and is associated with increased hospital LOS and 30-day hospital readmission. This represents a population in which a focus on prevention and treatment may improve clinical outcomes.

Central Venous Line Insertion Revealing Partial Anomalous Pulmonary Venous Return: Diagnosis and Management.

Central venous line malposition is a well-known complication of line insertion. Rarely, it can be mal-positioned in an anomalous pulmonary vein. We present an unusual case of a 56-year-old woman that was found to have partial anomalous pulmonary venous return on central venous line insertion. In this report, we describe a systematic approach to diagnosis and management of this unusual situation.

Contemporary national trends of cystic fibrosis hospitalizations and co-morbidities in the United States.

INTRODUCTION: Cystic fibrosis (CF) is a life-limiting multisystemic genetic disease. Patients with CF have a high rate of hospitalization. We attempt to ascertain national trends of inpatient stays, prevalence of various co-morbidities during hospitalizations, outcomes and discharge disposition among CF patients. MATERIAL AND METHODS: Data from the National Inpatient Sample (NIS) was used to identify all hospitalizations of patients with CF and their demographic characteristics from 2003 to 2013. Prevalence and effects of various co-morbidities like acute kidney injury (AKI) were determined. Detailed sub-group analysis was performed for individuals with lung transplant. RESULTS: The annual rate of hospitalization per 1,000 CF patients in the U.S. increased from 994 in 2003 to 1,072 in 2013. The overall in-hospital mortality was 1.5%; median age at death was 27 years. In-hospital mortality trended down from 1.9% to 1.2% from 2003 to 2013 (p-value for trend: 0.002). The median length of stay was 7 days. The prevalence of chronic liver disease and AKI was 3.7% and 3.8% respectively. Multivariate adjusted odds of mortality for AKI was 1.74 (95% CI 1.57-1.93, p < 0.001). Patients with prior lung transplantation accounted for 6.5% of hospitalizations. These patients had a significantly higher prevalence of AKI. CONCLUSIONS: The annual hospitalization rates of CF patients is increasing over the years. Females with CF constitute a higher proportion of hospitalized patients despite a higher male preponderance of males with CF in the community. AKI is associated with a significantly higher in-hospital mortality. Lung transplant recipients have a higher prevalence of AKI and mortality.

Successful Management of Neobladder Variceal Bleeding.

Hematuria from a neobladder can occur due to a variety of pathologies including tumors, stones, and fistulas. Variceal bleeding in a neobladder is a very rare condition with only one case reported in literature. We present a case of a patient with cirrhosis and portal hypertension and an ileocolic orthotopic neobladder presenting with hematuria. Computed tomographic angiography showed dilated varices around the neobladder which were successfully embolized. To the best of our knowledge, this is the first report case of variceal bleeding in a neobladder successfully managed with the combination of TIPS (transjugular intrahepatic portosystemic shunt) procedure and embolization.