Periprocedural Complications With Balloon Pulmonary Angioplasty: Analysis of Global Studies.

BACKGROUND: Balloon pulmonary angioplasty (BPA) was introduced as a treatment modality for patients with inoperable, medically refractory chronic thromboembolic pulmonary hypertension decades ago; however, reports of high rates of pulmonary vascular injury have led to considerable refinement in procedural technique. OBJECTIVES: The authors sought to better understand the evolution of BPA procedure-related complications over time. METHODS: The authors conducted a systematic review of original articles published by pulmonary hypertension centers globally and performed a pooled cohort analysis of procedure-related outcomes with BPA. RESULTS: This systematic review identified 26 published articles from 18 countries worldwide from 2013 to 2022. A total of 1,714 patients underwent 7,561 total BPA procedures with an average follow up of 7.3 months. From the first period (2013-2017) to the second period (2018-2022), the cumulative incidence of hemoptysis/vascular injury decreased from 14.1% (474/3,351) to 7.7% (233/3,029) (P < 0.01); lung injury/reperfusion edema decreased from 11.3% (377/3,351) to 1.4% (57/3,943) (P < 0.01); invasive mechanical ventilation decreased from 0.7% (23/3,195) to 0.1% (4/3,062) (P < 0.01); and mortality decreased from 2.0% (13/636) to 0.8% (8/1,071) (P < 0.01). CONCLUSIONS: Procedure-related complications with BPA, including hemoptysis/vascular injury, lung injury/reperfusion edema, mechanical ventilation, and death, were less common in the second period (2018-2022), compared with first period (2013-2017), likely from refinement in patient and lesion selection and procedural technique over time.

Pneumothorax in Intubated Patients With COVID-19: A Case Series.

Pneumothorax is a rare complication among mechanically ventilated patients since low tidal volumes are used nowadays instead of traditional high tidal volumes, but the incidence is slightly higher in patients with high positive end-expiratory pressure (PEEP). Herein we describe a case series of nine patients who were on mechanical ventilation due to acute respiratory distress syndrome (ARDS) secondary to coronavirus disease 2019 (COVID-19) and developed pneumothorax in due course. A retrospective analysis was done on COVID-19 intubated patients from March 2020 to June 2020 in a community hospital in Central New Jersey, which was one of the early hit states in the United States at the beginning of the pandemic. Outcomes were studied. The demographics of patients like age, gender, and body mass index (BMI); risk factors like smoking, comorbidities especially chronic lung disease, and the treatment they received were compared. We compared the total number of days on the ventilator, the highest PEEP they received, and the ventilator day when pneumothorax developed. All the patients who developed pneumothorax had a chest tube inserted to treat it. The mortality was noted to be 100% indicating that pneumothorax is a life-threatening complication of COVID-19 and COVID-19 by itself is a risk factor for pneumothorax likely due to a change in lung mechanics. There is a need for large-scale studies to confirm that these outcomes are related to COVID-19.

Hemodynamic indices in pulmonary hypertension: a narrative review.

Background and Objective: Pulmonary hypertension (PH) is defined as a mean pulmonary artery pressure (mPAP) >20 mmHg and its presence is associated with worse outcomes. A comprehensive hemodynamic evaluation of the pulmonary circulation is essential for diagnosis, hemodynamic classification, and prognostication. A multitude of indices assess different aspects of the pulmonary circulation but there are no reviews that describe their specific value in PH. Methods: We performed a thorough literature search of relevant articles in English from 1970-2021 using PubMed. Key Content and Findings: In this article, we present both static and dynamic indices used for the hemodynamic assessment of PH. While some of these indices are routinely used in clinical practice, including cardiac index (CI), stroke volume (SV), and pulmonary vascular resistance (PVR); others such as pulmonary artery compliance (PAC), pulmonary effective arterial elastance (Ea), and pulmonary artery pulsatility index (PAPi) are gaining popularity by enhancing the understanding of different aspects of the pulmonary circulation. We described the advantages and pitfalls of various indices, including when to use them in the hemodynamic evaluation of patients with PH. Conclusions: A variety of indices measuring different aspects of the right ventricle (RV)-pulmonary arteries (PA) system provide valuable information in patients with PH. However, it remains important to develop and validate indices that provide a comprehensive hemodynamic evaluation to improve outcomes in patients with PH.

Solitary fibrous tumor of the urinary bladder: An unusual case report with literature review.

Solitary fibrous tumor is neoplasm of mesenchymal origin commonly involving visceral pleura however we are presenting an unusual case with involvement of urinary bladder. It is generally indolent in nature therefore proper diagnosis is required for complete characterization to avoid unnecessary extensive surgical resection. Our patient was a 64-year-old female who presented with lower abdominal fullness with change in her bowel movement pattern. On imaging partially necrotic mass with heterogenous enhancement was found which was later biopsied and resected with clean surgical margin. Solitary fibrous tumor is overall a benign tumor with satisfactory outcome. Physicians should keep it in a differential of pelvic masses and with the risk recurrence, 6 monthly follow up imaging are usually required after resection.

Foreign body aspiration.

The clinical manifestations of foreign body (FB) aspiration can range from an asymptomatic presentation to a life-threatening emergency. Patients may present with acute onset cough, chest pain, breathlessness or sub-acutely with unexplained hemoptysis, non-resolving pneumonia and at times, as an incidental finding on imaging. Patients with iatrogenic FB such as an aspirated broken tooth during difficult intubation or a broken instrument are more common scenarios in the intensive care unit (ICU). Patients with post-obstructive pneumonia with or without sepsis, or variable degree of hemoptysis often require ICU level of care and bronchoscopic interventions. Rigid bronchoscopy has traditionally been the modality of choice; however, with the innovation in instrumentation and wider availability of flexible bronchoscopes, most of the FB removal is now successfully performed using flexible bronchoscopy. Proceduralists choose instruments in accordance with their training and expertise. We describe the use of most common instruments including forceps, balloon catheters, and baskets. Role of cryoprobe and LASER in FB removal is reviewed as well. In general, larger working channel bronchoscopes are preferred; however, smaller working channel bronchoscopes may be used in situations when the patients are intubated with a smaller diameter endotracheal or tracheostomy tubes. Large size FB are removed en bloc with the grasping tool, bronchoscope, and endotracheal or tracheostomy tube, requiring preparation to safely re-establish the airway. After FB removal, bronchoscopy is re-performed to identify any residual FB, assess any injury to the airway, suction post-obstructive secretions or pus, control any active bleeding and remove granulation tissue that may be obstructing the airway. Additional interventions like balloon dilatation may be required to dislodge an impacted FB or to maintain patency of bronchial lumen. If bronchoscopic methods fail, surgery may be required for retrieval of FB in symptomatic patients or to resect suppurative or necrotizing lung process. Multidisciplinary approach involving intensivists, surgeons, and anesthesiologists is the key to optimal patient outcomes.

Pneumothorax in critically ill patients with COVID-19 infection: Incidence, clinical characteristics and outcomes in a case control multicenter study.

BACKGROUND: The clinical features and outcomes of mechanically ventilated patients with COVID-19 infection who develop a pneumothorax has not been rigorously described or compared to those who do not develop a pneumothorax. PURPOSE: To determine the incidence, clinical characteristics, and outcomes of critically ill patients with COVID-19 infection who developed pneumothorax. In addition, we compared the clinical characteristics and outcomes of mechanically ventilated patients who developed a pneumothorax with those who did not develop a pneumothorax. METHODS: This study was a multicenter retrospective analysis of all adult critically ill patients with COVID-19 infection who were admitted to intensive care units in 4 tertiary care centers in the United States. RESULTS: A total of 842 critically ill patients with COVID-19 infection were analyzed, out of which 594 (71%) were mechanically ventilated. The overall incidence of pneumothorax was 85/842 (10%), and 80/594 (13%) in those who were mechanically ventilated. As compared to mechanically ventilated patients in the non-pneumothorax group, mechanically ventilated patients in the pneumothorax group had worse respiratory parameters at the time of intubation (mean PaO2:FiO2 ratio 105 vs 150, P<0.001 and static respiratory system compliance: 30ml/cmH2O vs 39ml/cmH2O, P = 0.01) and significantly higher in-hospital mortality (63% vs 49%, P = 0.04). CONCLUSION: The overall incidence of pneumothorax in mechanically ventilated patients with COVID-19 infection was 13%. Mechanically ventilated patients with COVID-19 infection who developed pneumothorax had worse gas exchange and respiratory mechanics at the time of intubation and had a higher mortality compared to those who did not develop pneumothorax.

Isolated Pauci-Immune Pulmonary Capillaritis Associated with Hydrocarbon Inhalation and Marijuana Smoking: An Unusual Case of Severe Hypoxemia.

We present a case report of a patient with Isolated pauci-immune pulmonary capillaritis (IPIPC). A 40-year-old male presented with acute onset severe hypoxemic respiratory failure. He had just returned home from work as a cabinetmaker, where he experienced inhalational exposure to hydrocarbons and solvents, and had smoked a marijuana cigarette. He was hypotensive, and his chest imaging showed bilateral dependent infiltrates. His hypoxemia made little improvement after conventional ventilator support and broad-spectrum antibacterial therapy and he was considered too unstable to tolerate diagnostic bronchoscopy with bronchoalveolar lavage. His laboratory evaluation initially showed microscopic hematuria which later cleared, but other tests including serologic autoimmune assessment were negative, and he did not have any traditional risk factors for vasculitis. A video-assisted thoracoscopic lung biopsy revealed diffuse alveolar hemorrhage with pulmonary capillaritis on histopathology. He was diagnosed with IPIPC and initiated on immunosuppressive therapy. He was soon liberated from mechanical ventilation and improved to hospital discharge. Diffuse alveolar hemorrhage from Goodpasture's Syndrome has manifested following inhalation of hydrocarbons and following smoking. This has not previously been reported with IPIPC. Given the lack of other findings and risk factors, his IPIPC was likely associated with occupational exposures to hydrocarbons as a cabinetmaker compounded by marijuana smoking.

A pictorial review of gall stones and its associated complications.

Gallstone disease is the term commonly used to refer to gallstones that cause symptoms. There is a myriad of complications that can arise from gallstones: acute cholecystitis, xanthogranulomatous cholecystitis, emphysematous cholecystitis, gallbladder wall perforations, pericholecystic abscesses, Mirizzi syndrome, cholecystoenteric fistulas, choledocholithiasis, gallstone pancreatitis, porcelain gallbladder, gallbladder malignancies, and many more. The aim of this pictorial review is to revisit how multimodality imaging can help with the diagnosis of gallstone disease. We review the classic imaging findings on different imaging modalities for gallstone disease and its associated complications and how it is useful in early diagnosis for timely management of complications as well as surgical planning.

Incidence of pancreatitis with the use of immune checkpoint inhibitors (ICI) in advanced cancers: A systematic review and meta-analysis.

BACKGROUND: Systemic immune side effects including pancreatitis have been reported with the use of Immune Checkpoint Inhibitors (ICI) (CTLA-4, PD-1 and PDL-1). However, the true incidence, risk, causes (tumor or drug specific) of pancreatitis and relation to other immune side effects, especially diabetes mellitus (DM) are unknown. METHODS: We performed a systematic review and meta-analysis of all clinical trials using ICI for the incidence of any grade lipase elevation, pancreatitis or DM. RESULTS: The incidence of asymptomatic lipase elevation after ICI use is 2.7% (211/7702) and grade 2 pancreatitis is 1.9% (150/7702). No pancreatitis related mortality has been reported in these clinical trials. Patients treated with CTLA-4 inhibitors have increased incidence of pancreatitis when compared to patients treated with PD1 inhibitors 3.98% (95% CI: 2.92 to 5.05) vs 0.94% (95% CI: 0.48 to 1.40); P value < 0.05. Patients treated with ICI for melanoma have increased incidence of pancreatitis when compared to non-melanoma cancers. We also noted an additive increase in incidence of pancreatitis with combination of CTLA4 and PD-1 inhibitors (10.60; 95% CI: 7.89 to 13.32) compared with either CTLA-4 or PD-1 inhibitors alone. CONCLUSIONS: Our study provides precise data for the incidence of pancreatitis among patients using ICI based on tumor types and ICI regimens. ICI use for solid tumors is associated with increased incidence of all grades of lipase elevation and pancreatitis, especially for CTLA-4 agents and ICI combination. Although it does not appear to be associated with mortality, ICI related pancreatitis should be recognized early for appropriate treatment and to potentially reduce long term complications.

Idiopathic Internal Jugular Vein and Subclavian Vein Thrombosis: A Rare Case Report.

Venous thrombosis is a vascular disorder which is a consequence of Virchow's triad: hypercoagulability, venous stasis, and endothelial injury. While lower extremity deep venous thrombosis is common, upper torso thrombosis is a rare clinical condition and usually a complication of central venous catheterization or malignancy-related paraneoplastic syndromes. Herein, we present a rare case of a 64-year-old male who presented with right upper extremity and right facial swelling who was found to have a thrombus in the right internal jugular vein and right subclavian vein with no predisposing factors. He was successfully treated with anticoagulation without any complications.

Organizing pneumonia co-existing with carcinoid tumour: complete resolution with bronchoscopic tumour resection.

Organizing pneumonia is a well-known clinical entity resulting in response to noxious stimuli causing lung injury. It is known to occur with infectious disease processes, neoplasms, post lung surgery or radiation therapy and when idiopathic, is called cryptogenic organizing pneumonia. We present an unusual case of a 48-year-old woman who presented with chronic cough and progressive dyspnoea while being on macrolide therapy for Lyme disease. Computerized tomography of chest demonstrated a well-circumscribed nodule in the lingula and bilateral central ground glass opacities. Transbronchial biopsies were consistent with carcinoid tumour in the lingula and organizing pneumonia in bilateral lung fields. Bronchoscopic relief of obstruction was performed by mechanical debulking of the tumour, with subsequent complete resolution of bilateral opacities, consistent with resolution of organizing pneumonia without the need for steroid therapy.

Intraventricular empyema caused by Neisseria meningitidis.

Meningitis is defined as an inflammation of the protective covering of brain and spinal cord collectively called as meninges. Meningeal infection can be complicated by intraventricular empyema. There are 9 cases of intraventricular empyema described in the literature out of which only three are described to be caused by Neisseria meningitidis. We report the fourth rare case. A 61-year-old female with past medical history of diabetes and hypertension presented with the chief complaint of fever with chills and headache of 1-day duration. CT head did not reveal any acute abnormalities. Lumbar puncture was obtained and empiric IV antimicrobial agents were started. CSF analysis showed gram negative diplococci with culture growing Neisseria meningitidis suggesting meningococcal meningitis. Due to persistent headache and lethargy after complicated meningitis was suspected and MRI of brain was obtained which reflected a diagnosis of intraventricular empyema. Pyogenic ventriculitis also known as intraventricular empyema or ependymitis, is a defined as an inflammation of the ependymal lining of the cerebral ventricular system and is characterized by the presence of suppurative fluid in the ventricles. It is a health care associated complication and is often confused with meningitis due to the similar presentation. Therefore, persistent symptoms despite optimal antimicrobial therapy (therapeutic failure) should alarm the presence of pyogenic ventriculitis. This is the fourth case of intraventricular empyema reported secondary to Neisseria meningitidis. Our case reiterates that clinicians should maintain an index of suspicion for complicated meningitis in patients not responding to standard antimicrobial therapy.