Interventional Pulmonology and the Esophagus: Tracheostomy and Percutaneous Endoscopic Gastrostomy Placement.

Tracheostomy is a procedure commonly performed in intensive care units (ICU) for patients who are unable to be weaned from mechanical ventilation. Both percutaneous and surgical techniques have been validated and are chosen based on the local expertise available. A primary advantage to the percutaneous technique is the ability to perform this procedure in the ICU without transporting the patient to a procedure suite or operating room; this has become particularly important with the novel coronavirus disease 2019 (COVID-19) pandemic. An additional advantage is the ability to perform both the tracheostomy and the gastrostomy tube placement, if needed, during the same anesthetic episode. This decreases the need for additional sedation, interruption of anticoagulation, repeat transfusion, and coordination of care between multiple services. In the context of COVID-19, combined tracheostomy and gastrostomy placement exposes less health care providers overall and minimizes transportation needs.

Necrotizing Pancreatitis: To Anticoagulate or Not to Anticoagulate?

Necrotizing pancreatitis is an inflammatory process that poses a strong risk of systemic venous thromboembolism. However, it is often challenging to opt for systemic anticoagulation since the disease is also associated with an increased risk of hemorrhage. Given these opposing complications, a risk versus benefit analysis has to be employed in the management of necrotizing pancreatitis on a case-by-case basis. We discuss a case where the team was faced with a dilemma regarding anticoagulation in a patient with newly developed atrial fibrillation in the setting of necrotizing pancreatitis. We found that there is a lack of guidelines that address the time of initiation and the type of systemic anticoagulation that should be administered in such patients.

Quality of life in patients with bronchiectasis: a 2-year longitudinal study.

BACKGROUND: Bronchiectasis is a condition of increasing incidence and prevalence in the United States, defined by the presence of bronchial dilatation on chest-computed tomography. Most patients suffer from chronic daily cough and sputum production. Patients suffering from this disease often have a poor health-related quality of life (HRQoL), with increased morbidity and mortality, and increased health care burden. Little is known about trends in HRQoL among patients with bronchiectasis, therefore, we examined these trends over 2 years using a bronchiectasis-specific HRQoL instrument. METHODS: We present data obtained from administering the Quality of Life-Bronchiectasis (QOL-B) questionnaires at three time points: (I) baseline at the time of first visit to the University of Connecticut Center for Bronchiectasis Care; (II) 1 year follow-up; and (III) a 2-year follow-up. Responses from the 36-item questionnaire evaluate eight scales (Physical Functioning, Role Functioning, Vitality, Emotional Functioning, Social Functioning, Treatment Burden, Health Perceptions, and Respiratory Symptoms); scores are standardized on a 0-100 point scale with higher scores indicating better HRQoL. RESULTS: Twenty-six patients provided baseline QOL-B data, with seven lost to follow-up, leaving nineteen patients in the longitudinal study. Statistically significant improvement between the initial visit and the one-year follow-up visit was shown in three of the eight domains: Physical Functioning, Role Functioning, and Health Perceptions. At 2 years, these improved HRQoL scores were generally maintained. CONCLUSIONS: This study demonstrates patients with bronchiectasis can demonstrate improved HRQoL after treatment at a specialized care center and these improvements are maintained for most patients 2 years after the initial visit.

Mortality risk from comorbidities independent of triple-negative breast cancer status: NCI-SEER-based cohort analysis.

PURPOSE: A comparatively high prevalence of comorbidities among African-American/Blacks (AA/B) has been implicated in disparate survival in breast cancer. There is a scarcity of data, however, if this effect persists when accounting for the adverse triple-negative breast cancer (TNBC) subtype which occurs at threefold the rate in AA/B compared to white breast cancer patients. METHODS: We reviewed charts of 214 white and 202 AA/B breast cancer patients in the NCI-SEER Connecticut Tumor Registry who were diagnosed in 2000-2007. We employed the Charlson Co-Morbidity Index (CCI), a weighted 17-item tool to predict risk of death in cancer populations. Cox survival analyses estimated hazard ratios (HRs) for all-cause mortality in relation to TNBC and CCI adjusting for clinicopathological factors. RESULTS: Among patients with SEER local stage, TNBC increased the risk of death (HR 2.18, 95 % CI 1.14-4.16), which was attenuated when the CCI score was added to the model (Adj. HR 1.50, 95 % CI 0.74-3.01). Conversely, the adverse impact of the CCI score persisted when controlling for TNBC (Adj. HR 1.49, 95 % CI 1.29-1.71; per one point increase). Similar patterns were observed in SEER regional stage, but estimated HRs were lower. AA/B patients with a CCI score of ≥3 had a significantly higher risk of death compared to AA/B patients without comorbidities (Adj. HR 5.65, 95 % CI 2.90-11.02). A lower and nonsignificant effect was observed for whites with a CCI of ≥3 (Adj. HR 1.90, 95 % CI 0.68-5.29). CONCLUSIONS: comorbidities at diagnosis increase risk of death independent of TNBC, and AA/B patients may be disproportionately at risk.

Role of dipicolinic acid in the germination, stability, and viability of spores of Bacillus subtilis.

Spores of Bacillus subtilis spoVF strains that cannot synthesize dipicolinic acid (DPA) but take it up during sporulation were prepared in medium with various DPA concentrations, and the germination and viability of these spores as well as the DPA content in individual spores were measured. Levels of some other small molecules in DPA-less spores were also measured. These studies have allowed the following conclusions. (i) Spores with no DPA or low DPA levels that lack either the cortex-lytic enzyme (CLE) SleB or the receptors that respond to nutrient germinants could be isolated but were unstable and spontaneously initiated early steps in spore germination. (ii) Spores that lacked SleB and nutrient germinant receptors and also had low DPA levels were more stable. (iii) Spontaneous germination of spores with no DPA or low DPA levels was at least in part via activation of SleB. (iv) The other redundant CLE, CwlJ, was activated only by the release of high levels of DPA from spores. (v) Low levels of DPA were sufficient for the viability of spores that lacked most alpha/beta-type small, acid-soluble spore proteins. (vi) DPA levels accumulated in spores prepared in low-DPA-containing media varied greatly between individual spores, in contrast to the presence of more homogeneous DPA levels in individual spores made in media with high DPA concentrations. (vii) At least the great majority of spores of several spoVF strains that contained no DPA also lacked other major spore small molecules and had gone through some of the early reactions in spore germination.