The Journey for Lung Cancer Screening where we Stand Today.

Background: Lung cancer remains a leading cause of cancer mortality worldwide with many patients presenting with advanced disease. Objective: We reviewed the available literature for lung cancer screening using low dose computed tomography (LDCT). We reviewed the National Lung Screening Trial (NLST), Early Lung Cancer Action Program (ELCAP) and the (Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON) trials. We also look at different lung cancer risk prediction models that may aid in identifying target populations and also discuss the cost-effectiveness of LDCT screening in different groups of smokers and ex-smokers. Lastly, we discuss recent guideline changes that have occurred in line with new and emerging evidence on lung cancer screening. Conclusion: LDCT has been shown reduce lung cancer mortality in certain groups of current and former smokers and should be considered to help in the early diagnosis of lung cancer.

Pulmonary cavitation: an under-recognized late complication of severe COVID-19 lung disease.

BACKGROUND: Pulmonary radiological findings of the novel coronavirus disease 2019 (COVID-19) have been well documented and range from scattered ground-glass infiltrates in milder cases to confluent ground-glass change, dense consolidation, and crazy paving in the critically ill. However, lung cavitation has not been commonly described in these patients. The objective of this study was to assess the incidence of pulmonary cavitation in patients with COVID-19 and describe its characteristics and evolution. METHODS: We conducted a retrospective review of all patients admitted to our institution with COVID-19 and reviewed electronic medical records and imaging to identify patients who developed pulmonary cavitation. RESULTS: Twelve out of 689 (1.7%) patients admitted to our institution with COVID-19 developed pulmonary cavitation, comprising 3.3% (n = 12/359) of patients who developed COVID-19 pneumonia, and 11% (n = 12/110) of those admitted to the intensive care unit. We describe the imaging characteristics of the cavitation and present the clinical, pharmacological, laboratory, and microbiological parameters for these patients. In this cohort six patients have died, and six discharged home. CONCLUSION: Cavitary lung disease in patients with severe COVID-19 disease is not uncommon, and is associated with a high level of morbidity and mortality.

Efficacy and Safety of Biologic Agents in Chronic Urticaria, Asthma and Atopic Dermatitis - A Real-life Experience.

INTRODUCTION: Several biologic agents have been approved for the treatment of asthma, chronic urticaria and atopic dermatitis. These therapeutic agents are especially useful for patients with severe or refractory symptoms. We present the real-life experience of four of the commonly used biologic agents in the United Arab Emirates. METHODS: In this retrospective observational study, we reviewed the demographic, clinical, laboratory and treatment parameters for all patients treated with biologic agents. RESULTS: 270 patients received biologics at our centre between May 2015 and December 2019 with a median age of 36.5 years. Omalizumab was the most prescribed agent (n=183, 67.8%) followed by dupilumab (n=54, 20%), benralizumab (n=22, 8.1%) and mepolizumab (n=11, 4.1%). Urticaria was the commonest treatment indication (n=148, 55%) followed by asthma (n=105, 39%) and atopic dermatitis (n=13, 5%). All chronic urticaria patients were treated with omalizumab and showed improvement in the mean urticaria control test score from 6.7±4.47 to 12.02±4.17, with a p-value of 0.001. Dupilumab was found to be the most commonly prescribed drug for asthma (37%), followed by omalizumab (32%), benralizumab (21%) and mepolizumab (10%). The mean Asthma control test score for all asthmatics combined increased from 17.06 ± 5.4 to 19.44 ± 5.6, with p-value 0.0012 with treatment; FeNO reduced from 60.02 ± 45.74 to 29.11 ± 27.92, with p-value 0.001 and mean FEV1 improved from 2.38L ± 0.8 to 2.67L ± 0.78, with p-value 0.045. Only 4 patients in the entire cohort reported adverse events. CONCLUSION: Our study demonstrated that biological agents are a safe and effective treatment for atopic asthma, chronic urticaria and atopic dermatitis.

Characteristics and Outcomes of Middle East Respiratory Syndrome Coronavirus Patients Admitted to an Intensive Care Unit in Jeddah, Saudi Arabia.

BACKGROUND: An increasing number of patients are being infected with Middle East respiratory syndrome coronavirus (MERS-CoV) since the first case was identified in September 2012. We report the characteristics and outcomes of MERS-CoV-confirmed patients who developed critical illness requiring admission to an intensive care unit (ICU). METHODS: We conducted a prospective cohort study of all MERS-CoV-confirmed cases who were admitted to our ICU from March 20, 2014, till June 1, 2014. Presenting symptoms, comorbid conditions, and details of their ICU stay were recorded. RESULTS: Eight patients were admitted to the ICU with MERS-CoV infection. All had signs of respiratory distress with 7 requiring mechanical ventilation. Three patients were health care workers. In all, 6 patients had comorbid conditions and 5 patients developed multiorgan system failure (MOSF). In all, 5 patients expired, 2 were discharged alive, and 1 remained intubated at the end of the study period. CONCLUSIONS: Middle East respiratory syndrome coronavirus carries a high mortality rate in patients who require ICU admission, with a significant number of patients developing MOSF. Further investigation is needed to determine optimal management guidelines for these patients.

A new pattern of pulmonary graft vs host disease in a hematopoietic stem cell transplant patient.

BACKGROUND: The primary pulmonary manifestation of chronic graft vs host disease (GvHD) is the development of bronchiolitis obliterans. Other pulmonary manifestations of chronic GvHD that have been reported include diffuse alveolar damage, lymphocytic interstitial pneumonia, bronchiolitis organising pneumonia and lymphocytic bronchiolitis/bronchitis. CASE PRESENTATION: We report an unusual case of a 34-year-old patient with acute myeloid leukaemia, status post-allogenic hematopoietic stem cell transplantation who subsequently developed GvHD with skin involvement. He presented to our hospital with new onset respiratory failure and on subsequent surgical lung biopsy was found to have non-specific interstitial pneumonia (NSIP). CONCLUSION: This is the third case of a patient with biopsy-proven GvHD who had NSIP pattern on surgical lung biopsy. We believe this may represent a rare manifestation of pulmonary GvHD.

Survey of academic pulmonologists, oncologists, and infectious disease physicians on the role of bronchoscopy in managing hematopoietic stem cell transplantation patients with pulmonary infiltrates.

BACKGROUND: In the absence of evidence-based guidelines, there is potential for variability in the management of hematopoietic stem cell transplantation (HSCT) patients with pulmonary infiltrates. We decided to perform a nationwide survey of pulmonologists, oncologists, and infectious disease physicians on the role of bronchoscopy in managing HSCT patients. METHODS: An 18-question survey was prepared, and after being internally reviewed it was sent through electronic mail to all hematology oncology, pulmonary and critical care, and infectious disease fellowship programs in the United States. Both faculty and fellows from all training programs were asked to electronically fill out the survey. RESULTS: A total of 167 responses, representing 76 different institutions were collected (62 pulmonary, 49 oncology, 53 infectious disease). Pulmonologists felt that bronchoscopy was less likely to yield a positive result or change pharmacological therapy (P-value=0.02 and 0.02). With regard to timing for bronchoscopy in HSCT recipients, there was consensus between all the 3 groups that patients who are non-neutropenic and do not have cavitating infiltrates on chest computed tomography scan should receive bronchoscopy only after failure of empiric antimicrobial therapy. However, there was no agreement between the 3 groups on when neutropenic patients or those with cavitating lesions should receive bronchoscopy. CONCLUSIONS: In the absence of randomized clinical trials and evidence-based guidelines, disparities exist in the use of bronchoscopy in the management of infiltrates. These differences were observed within and between both specialties. This study reflects the need for further research to better define the role of bronchoscopy in these patients.

Development of massive pneumopericardium after intubation and positive pressure ventilation.

Pneumopericardium is a rare complication of chest trauma, mechanical ventilation and cavitating pneumonia. We report a case of a 7-year-old patient with chronic myeloid leukemia who developed massive pneumopericardium immediately after being electively intubated for a diagnostic radiological procedure in the setting of ongoing Enterococcal pneumonia. As intensive care medicine becomes more prevalent in hospitals, we believe that clinicians need to be aware of this uncommon but potentially fatal condition.

Capsule endoscopy removal through flexible bronchoscopy.

Since its introduction over 9 years ago, capsule video endoscopy has become increasingly popular within the gastroenterology community, leading to its use in a growing number of patients including the elderly. With the widespread adoption of this diagnostic modality within the elderly population comes the added risk of capsule aspiration. We present such a case where a 90-year-old patient was admitted after accidental aspiration of a capsule. Removal of the capsule posed a therapeutic challenge. In the article, we discuss the novel use of a Roth Net expandable foreign body extractor to remove the capsule using a flexible bronchoscope with minimal need for sedation. As video capsule endoscopy is used more routinely in elderly patients and clinical pulmonologists will be more frequently called up to assist in foreign body removal, our experience highlights that it is possible to remove these large capsules with a flexible bronchoscope and avoid the need for rigid bronchoscopy in this high-risk patient group.

Myocardial infarction in thrombotic thrombocytopenic purpura: a single-center experience and literature review.

BACKGROUND: Several case reports and series have described myocardial infarctions (MIs) in patients hospitalized for thrombotic thrombocytopenic purpura (TTP). The exact magnitude and outcome of this complication are unknown. METHODS: Electronic medical records for patients admitted to Wake Forest University Baptist Medical Center were examined from 1996 to 2005. Those patients having a diagnosis of TTP during the hospitalization period were included in the analysis. Only patients' initial episodes of TTP were analyzed. Baseline cardiac and TTP risk factors were documented. Outcomes analyzed included MIs, arrhythmias, development of congestive heart failure and death. RESULTS: Eighty-five patients diagnosed with TTP were identified with 13 (15.3%) having MIs, as defined by an elevation of cardiac enzymes. Median troponin I value was 5.9 ng/mL (range 3.7-8.8 ng/mL). Twelve patients had non-ST segment elevation MIs and one had ST segment elevation. Two of 13 patients who had echocardiographic analysis had documented wall motion abnormalities. There was no difference between non-MI and MI patients in cardiac risk factors, prior cardiac events, history of thromboembolic disease or heart failure. There was no in-hospital mortality difference. CONCLUSION: MI is an important complication of TTP, identified in 15.3% of patients in our study. Routine cardiovascular evaluation with cardiac enzymes, electrocardiography, and telemetry is warranted in acute TTP patients. Appropriate intervention is yet to be determined.