Effects of Concurrent Dosing on the Efficacy of Tissue Plasminogen Activator and Deoxyribonuclease in the Treatment of Pleural Infection.

BACKGROUND: The goal of this study was to evaluate how the administration of concurrent tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) therapy with variable dosing for complicated parapneumonic effusions and empyema affects patient outcomes in an inner-city community hospital. METHODS: This retrospective analysis was performed at an inner-city hospital located in Raleigh, North Carolina. A list of all patients treated with tPA and DNase between July 1, 2015, and December 31, 2017, was generated and screened. Data were collected through a review of past medical records, including demographics, past medical history, and details about their hospital course. RESULTS: A total of 38 patients were found to have been treated with concurrent tPA and DNase for complicated parapneumonic effusion or empyema. Twenty (52.6%) patients received the full six doses of combined concurrent tPA/DNase. Of the 18 (47.4%) patients who did not receive the full six doses, 11 did not require the full six doses for effusion resolution, and seven had to discontinue therapy due to tube blockage or pain. Only seven (18.4%) patients had complications related to tPA/DNase administration, most commonly pain. Nineteen (50%) patients had complete radiological clearance of effusion, with 13 (34.2%) having partial clearance, and six (15.8%) having no change or worsening of their effusion. Eight (21.1%) patients needed further surgical management of their effusion. CONCLUSIONS: The current most common dosing pattern for combined tPA and DNase therapy of twice daily for three days may not be optimal for all patients. The dosing regimen should be individualized depending on clinical response. Concurrent dosing is safe.

Pleural Epithelioid Hemangioendothelioma (EHE): A Case Report.

Pleural epithelioid hemangioendothelioma (EHE) is a rare malignancy of vascular origin. It can affect various organs; pleural involvement is rare and lack of suspicion leads to delay in diagnosis. We present a case of pleural EHE with metastasis to lung parenchyma that presents with chest pain and dyspnea. Chest imaging showed loculated pleural effusion, pleural thickening, mediastinal lymphadenopathy, and pulmonary nodules.

Management of Isolated Thoracic Lymphadenopathy of Unclear Etiology: A Survey of Physicians and Literature Review.

Background After identifying incidental mediastinal lymph nodes, decisions need to be made regarding the required follow-up imaging, the intervals at which this imaging should be performed, the types of imaging and procedures needed, and when to discontinue the follow-up. The purpose of this study is to determine the majority opinion on the management of these findings and provide recommendations for future management of incidental mediastinal lymphadenopathy.  Methodology Sixty-two healthcare providers from a variety of specializations were surveyed on their preference for diagnostic workup and subsequent follow-up following the finding of incidental mediastinal lymphadenopathy on computed tomography (CT) of the chest. Results For thoracic lymphadenopathy of unclear etiology and patients who are not offered endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), most providers (47/62, 75.8%) initiate the CT scan follow-up at size 10 to 14 mm. Of those patients, 51.6% (32/62) of providers repeat the initial CT scan in three months and 41.9% (26/62) repeat the initial CT scan in six months. If the follow-up CT chest shows stable lymphadenopathy, 47.5% (29/62) repeat a CT chest every six months and 37% (23/62) repeat a CT chest every 12 months. The majority of providers (42/62, 67.7%) do not use positron emission tomography (PET)-CT for the initial evaluation of isolated thoracic lymphadenopathy and follow-up of lymphadenopathy with increasing size. For thoracic lymph nodes with a maximum diameter of 10 mm, only 4.8% (3/62) of providers continue CT screening after 24 months, while 24.6% (15/62) of providers continue CT screening after 24 months for sizes greater than 20 mm. Regarding the timing of EBUS-TBNA, 40.3% (25/62) of providers consider referring/performing this procedure at lymph nodes of size 11-15 mm, followed by 21% (13/62) of providers referring/performing the procedure at size 10 mm. Conclusions The majority of providers initiate CT scan follow-ups at 10 to 14 mm size for patients with isolated thoracic lymphadenopathy. The majority of providers do not use PET-CT for the initial evaluation of isolated thoracic lymphadenopathy. We found variable responses from providers regarding the timing of follow-up intervals and total duration. There is a need for consensus guidelines regarding the management of thoracic lymphadenopathy of unclear etiology.

Fatal Allergic Reaction to Gadolinium Contrast.

Gadolinium-based contrast agents (GBCA) have been used to enhance the sensitivity and specificity of disease diagnoses. They have excellent safety profiles. However, rare adverse events may happen. We present a case of severe fatal allergic reaction to GBCA in a 35-year-old patient.

The Utility of EBUS-Guided Transbronchial Forceps Biopsy With or Without an Electrocautery Knife for the Diagnosis of Mediastinal and Hilar Lymphadenopathy.

INTRODUCTION: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been shown to have a high diagnostic yield for mediastinal and hilar lymph node sampling, particularly in diagnosing and staging non-small cell lung cancer. However, the diagnostic yield is lower in patients with granulomatous and lymphoproliferative disorders. We prospectively compared the feasibility, safety, and diagnostic yield of EBUS-guided lymph node forceps biopsy (EBUS-TBFB) with electrocautery knife compared to EBUS-TBNA of lymph nodes in patients with suspected granulomatous and lymphoproliferative disease. METHODS: Patients over 18 years of age with mediastinal/hilar lymph node >10 mm in size in short axis (on CT chest) who had suspected sarcoidosis/lymphoma radiologically/clinically were included in the study. Patients had EBUS-TBNA first with 21 or 22G needles which were followed by biopsy of the node with small forceps (EBUS-TBFB) through the same aspiration site to obtain samples. Electrocautery knife at 20W was used in patients where mucosal penetration was difficult, followed by passage of forceps through that site. RESULTS: A total of 30 patients were enrolled in the study, of which 25 patients underwent EBUS-TBFB. Eight patients had a history of lymphoma, one patient had history of squamous cell carcinoma, and one patient had history of chronic lymphocytic leukemia. A 22 gauge needle was used for aspiration in all the cases that were performed, and 1.5 mm or 1.8 mm forceps were used for the biopsy. The use of electrocautery knife at 20W (Olympus America Inc.) was required in 10/25 patients. The EC knife allowed all 10 of those to have successful entry of forceps into the lymph node. The cytology (aspiration from EBUS needle) and histopathology (from forceps) were concordant in 17 patients while it was discordant in eight patients. One patient developed pneumomediastinum after needle and forceps biopsy that required no intervention. CONCLUSION: EBUS-guided forceps biopsy is a safe procedure. EC knife did successfully allow forceps entry into the lymph node in all EC knife procedures. The diagnostic yield was 73% (22/30) which improved to 86% (26/30) when both techniques were combined (TBNA and TBFB).

Methylene Blue in Refractory Shock.

Many patients suffer shock in intensive care units (ICU). The majority of the patients with shock respond to standard treatment with vasopressors in addition to the treatment of underlying etiology. Some may not respond to vasopressors and have high mortality. To those patients who do not respond, methylene blue has been used in the past with some success. We present a case report on the use of methylene blue along with a brief literature review.

Outcomes of Early Versus Late Tracheostomy in Patients With COVID-19: A Multinational Cohort Study.

Timing of tracheostomy in patients with COVID-19 has attracted substantial attention. Initial guidelines recommended delaying or avoiding tracheostomy due to the potential for particle aerosolization and theoretical risk to providers. However, early tracheostomy could improve patient outcomes and alleviate resource shortages. This study compares outcomes in a diverse population of hospitalized COVID-19 patients who underwent tracheostomy either "early" (within 14 d of intubation) or "late" (more than 14 d after intubation). DESIGN: International multi-institute retrospective cohort study. SETTING: Thirteen hospitals in Bolivia, Brazil, Spain, and the United States. PATIENTS: Hospitalized patients with COVID-19 undergoing early or late tracheostomy between March 1, 2020, and March 31, 2021. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: A total of 549 patients from 13 hospitals in four countries were included in the final analysis. Multivariable regression analysis showed that early tracheostomy was associated with a 12-day decrease in time on mechanical ventilation (95% CI, -16 to -8; p < 0.001). Further, ICU and hospital lengths of stay in patients undergoing early tracheostomy were 15 days (95% CI, -23 to -9 d; p < 0.001) and 22 days (95% CI, -31 to -12 d) shorter, respectively. In contrast, early tracheostomy patients experienced lower risk-adjusted survival at 30-day post-admission (hazard ratio, 3.0; 95% CI, 1.8-5.2). Differences in 90-day post-admission survival were not identified. CONCLUSIONS: COVID-19 patients undergoing tracheostomy within 14 days of intubation have reduced ventilator dependence as well as reduced lengths of stay. However, early tracheostomy patients experienced lower 30-day survival. Future efforts should identify patients most likely to benefit from early tracheostomy while accounting for location-specific capacity.

Identification of characteristics frequency and hot-spots in protein sequence of COVID-19 disease.

COVID-19 has threatened the whole world since December 2019 and has also infected millions of people around the globe. It has been transmitted through the SARS CoV-2 virus. Various proteins of the SARS CoV-2 virus have an important role in its interaction with human cells. Specifically, the interaction of S-protein with human ACE-2 protein helps in entering of SARS CoV-2 virus into a human cell. This interaction take-place at some specific amino-acid locations called as hot-spots. Understanding of this interaction is helpful for drug designing and vaccine development for new variants of COVID-19 disease. An attempt has been made in this paper for understanding this interaction by finding the characteristics frequency of SARS-related protein families using the resonance recognition model (RRM). Hardware implementation of Bandpass notch (BPN) lattice IIR filter system architecture is also carried out, which is used for hot-spots identification in SARS CoV-2 proteins. Various signal processing techniques like retiming, pipelining, etc. are explored for performance improvement. Synthesis of proposed BPN filter system has been done using Xilinx ISE EDA tool on Zynq-series (Zybo-board) FPGA family. It is found that retimed and pipelined architecture of hardware-implemented BPN lattice IIR filter-based hot-spots detection system improves the speed (computational time) by 14 to 31 times for different SARS CoV2 related proteins as compared to its MATLAB simulation with similar functionality.

Adenocarcinoma of the lung with concurrent Mycobacterium avium complex infection.

Nontuberculous mycobacterial infection, particularly Mycobacterium avium complex (MAC), which is also known as Lady Windermere syndrome usually presents with chronic cough, typically seen in elderly caucasian women who chronically suppress the normal cough reflex. Computerized tomography of the chest in patients with MAC infection can present as a tree in bud nodules, pulmonary nodules, cavity, or consolidation. However, other coexisting diseases such as lung cancer should be kept in mind while investigating these radiographic changes in patients with suspected MAC infection, more so if they have underlying risk factors for malignancy. We present a patient with suspected MAC infection who had co-existing lung adenocarcinoma.

Review of Pharmacotherapy Trialed for Management of the Coronavirus Disease-19.

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, there has been substantial progress in the pharmacologic treatment and supportive care of patients hospitalized with active COVID-19 infections. To date there have been numerous medications trialed for COVID-19 management. In this review, our objective is to provide a comprehensive review of the primary literature and clinical applications surrounding some of the prominent drugs and medication classes that have been utilized in those suffering from COVID-19 infections. The medications reviewed in this article include: hydroxychloroquine, remdesivir, azithromycin, dexamethasone, melatonin, tocilizumab, ascorbic acid, and zinc. The medication classes reviewed include: anticoagulation, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, convalescent plasma, non-steroidal anti-inflammatory drugs, human recombinant soluble ACE2, and the BNT162b2 mRNA COVID-19 vaccine.

Palliative medicine in intensive care unit during a pandemic.

The coronavirus disease-2019 (COVID-19) or severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) pandemic has changed the landscape of medical care. Efforts made to limit the spread of the deadly disease have impacted the specialty of palliative medicine in ways that could not have been completely predicted or appreciated. The consequences of these changes have been most evident in the care of COVID-19 patients and families within the intensive care unit. The policies meant to keep staff, patients, and families safe, greatly changed the way that palliative medicine could be provided. This article provides a more in-depth look at how the practice of palliative medicine adapted to such difficult and constantly changing times, particularly in aspects of family meetings, communication, paternalism, managing emotions, death, and grief. Despite the ongoing challenges presented by this virus, the specialty of palliative medicine may be well suited to adapt and flourish.

Development of postgraduate training in critical care medicine for nurse practitioners and physician assistants.

ABSTRACT: Nurse practitioners (NPs) and physician assistants (PA) are increasingly providing care to the critically ill patients in the intensive care unit. We structured a 4-month training program for our existing NPs and PAs and assessed their knowledge and skill pre and post training. The program was composed of blended didactic in critical care medicine topics, critical care simulations in simulation laboratory, and supervised critical care procedures. Formal knowledge and skill assessments were performed before and after the program to assess success in meeting predefined learning objectives. The mean preintervention medical knowledge assessment score was 3.37 ± 0.56 SD, which significantly improved to 3.86 ± 0.46 SD (p < .00001). For clinical skills for critical care procedures, the mean preintervention score was 3.10 ± 0.86 SD, which improved to 3.61 ± 0.92 SD (p < .00001). The overall knowledge (including medical knowledge and clinical skills) improved from mean 3.30 ± 0.86 SD to 3.80 ± 0.42 SD. The improvement was seen regardless of the duration of experience in critical care medicine. We concluded that structured didactics with supervised procedural training along with dedicated training in simulation laboratories, even for a short period, improves the overall knowledge and clinical skills required to work in a critical care setting.

Use of endobronchial valve to treat COVID-19 adult respiratory distress syndrome-related alveolopleural fistula.

Coronavirus disease-2019 (COVID-19) pneumonia is one of the severe and most dreaded forms of illness caused by severe acute respiratory syndrome coronavirus 2. It often progresses to respiratory failure and acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. ARDS can lead to multiple complications while on mechanical ventilation due to positive airway pressures in a fibrotic lung, one such complication is the development of alveolopleural fistula. Alveolopleural fistula has high morbidity and mortality. We used endobronchial valve in a patient with COVID-19-related ARDS with persistent air leak (alveolopleural fistula), which allowed us to remove the chest tube and wean the patient successfully off mechanical ventilation.

Materialization of novel composite bio-based active edible film functionalized with essential oils on antimicrobial and antioxidative aspect of chicken nuggets during extended storage.

The present study was aimed to develop Manihot esculenta and Carrageenan bio-based composite active film functionalized with anise, caraway, and nutmeg essential oils (EOs) and to assess the shelf life of chicken nuggets wrapped with the developed film at refrigeration storage. Overall, the Minimum Inhibitory Concentration (MIC) values of the three EOs ranged from 0.4 to 0.8% v/v of which nutmeg EO was found most effective. Incorporation of EOs in the film resulted in significant (P ˂ 0.05) decrease in tensile strength and water activity while elongation at break was significantly (P ˂ 0.05) increased. No significant (P ˃ 0.05) changes in thickness and Water Vapor Transmission Rate (WVTR) were observed. Based on physicomechanical and sensory evaluation, films incorporated with 0.5, 1, and 1% concentration of anise, nutmeg, and caraway EO were selected. Chicken nuggets overwrapped with aforementioned films were stored aerobically at refrigeration temperature (4 ± 1 °C) to evaluate antimicrobial, antioxidant, and sensory characteristics. The result indicated that pH, peroxide, free fatty acid (FFA), and thiobarbituric acide (TBA) value of treatments were significantly (P ˂ 0.05) lower than controls however significantly (P < 0.05) higher DPPH activity was observed in all treatments. The total plate count, psychrophilic count and, yeast and mold count were also significantly (P ˂ 0.01) lower in treatment groups and were within the permissible limits. The treated samples were well acceptable during whole storage period of 15 days. The application of composite, active edible bio-based film was found proficient in confining product quality attributes throughout storage. PRACTICAL APPLICATION: The majority of films used for packaging of meat and meat products are derived from synthetic "plastic" materials. The demerits associated with plastics have eventually led to explore natural alternatives such as edible films. The composite-active bio-based films have a huge potential to be molded for specific film properties based on requirements of product-specific packaging conditions.

Transbronchial lung cryobiopsy for the diagnosis of lepidic-predominant lung adenocarcinoma.

Lung cancer is one of the most common malignancies globally with lung adenocarcinoma as the most common type of lung cancer. With new classification of lung cancers in 2011, it has become pertinent that adequate tissue is obtained for the diagnosis and subtyping of lung adenocarcinoma particularly for prognostication. Transbronchial cryobiopsy is a minimally invasive procedure which helps obtain adequate tissue and avoid surgical lung biopsy.

Cocaine-Induced Bronchospasm Mimicking Acute Asthma Exacerbation.

Cocaine can cause a myriad of changes in the lung, which can range from bronchoconstriction to destruction of the alveolar-capillary membrane and acute lung injury. Cocaine-induced bronchospasm is a diagnosis of exclusion that should be considered when the clinical presentation of acute hypoxic and hypercapneic respiratory failure cannot be explained by chronic obstructive pulmonary disease or asthma exacerbation, anaphylaxis to food or medications, exercise, or infection. Here, we present two patients with acute hypoxic and hypercapneic respiratory failure that was ultimately attributed to cocaine use shortly prior to symptom onset.

Cavitary lung disease following transbronchial biopsy using cryoadhesion in a patient with diffuse parenchymal lung disease.

Transbronchial lung biopsy using cryoadhesion is a diagnostic technique gaining in popularity. Several studies have been performed on its diagnostic yield and safety profile. However, definitive conclusions are limited due to the heterogeneity of results. The most common complications described in the current literature are pneumothorax and hemorrhage. This case describes a 60-year-old female who developed a cavitary lung lesion shortly after undergoing transbronchial lung cryobiopsy, highlighting the need for further research on the rarer complications that may be associated with this promising procedure.

Delayed breast cancer relapse with pleural metastasis and malignant pleural effusion after long periods of disease-free survival.

Breast cancer relapse remains a common cause of morbidity and mortality in patients who undergo initial treatment with surgery and with or without concurrent chemotherapy or radiation. Relapse rates remain high within the first decade after initial treatment, after which the risk of relapse decreases. While common within the first year of breast cancer diagnosis, pleural metastasis with malignant pleural effusion (MPE) after 10-12 years of a disease-free period is rare. Here, we present two uncommon cases of delayed breast cancer relapses with pleural metastasis, which caused MPEs.

Use of autologous blood patch for prolonged air leak in spontaneous pneumothoraces in the adolescent population.

Instillation of an autologous blood patch for prolonged air leak (PAL) in chest tube system has been studied and determined to be a safe and effective treatment plan for adults. The current recommended treatment guidelines for a PAL in adolescent secondary to a spontaneous pneumothorax are surgical intervention. This paper serves as documentation of two case reports with successful treatment of PALs with autologous blood patch in two adolescent patients.