Spontaneous Pneumomediastinum Secondary to Undiagnosed Asthma in Military Adult.

Spontaneous pneumomediastinum (SPM) is a rare but described complication of exercise-induced bronchoconstriction (EIB), more commonly observed in children with asthma. We present a 23-year-old active duty military male and avid distance runner who developed progressive radiating retrosternal chest pain preceded by wheezing and coughing paroxysm. A chest computed tomography revealed extensive pneumomediastinum. SPM results from increased intrathoracic pressure with alveolar rupture and subsequent tracking of air between fascial planes. Like most cases of SPM, our patient remained hemodynamically stable and responded well to conservative therapies with complete resolution. After thorough evaluation, undiagnosed asthma was determined to be the inciting etiology. The patient is now well controlled and symptom free on a daily low-dose inhaled corticosteroid without SPM reoccurrence. In young adult patients presenting with SPM, EIB and asthma should be considered on the differential diagnosis as appropriate medical therapy will improve symptoms and reduce risk of reoccurrence.

Intensivist -Driven Ventilator Management Shortens Duration of Mechanical Ventilation in Coronary Artery Bypass Graft Surgery Patients.

BACKGROUND: Prolonged mechanical ventilation in post Coronary Artery Bypass Graft Surgery (CABG) is associated with deleterious effects including, increased ICU and hospital length of stay (LOS), infectious complications, and mortality. Standardized ventilator weaning protocols and the utilization of critical care physicians in post CABG patient care vary substantially among institutions. The purpose of this study was to evaluate if intensivist consultation in conjunction with a multidisciplinary, standardized ventilator weaning protocol improves outcomes in CABG patients. MATERIALS AND METHODS: We performed a single-center, retrospective, before-after cohort analysis at Miami Valley Hospital in Dayton, OH, a 970-bed community hospital. Patients were divided into two arms: the before cohort or delayed-consult group (critical care consult after six hours on ventilator) and after cohort or immediate-consult group (immediate critical care consult). All patients were weaned from ventilator using a standardized weaning protocol. RESULTS: A total of 764 patients were enrolled, 411 in the delayed-consult group and 353 in the immediate-consult group. The immediate-consult group had less time on initial mechanical ventilation than the delayed-consult group (5.86 ± 4.75 h vs. 6.00 ± 6.64 h, P = 0.038). The small advantages to immediate critical care consultation for higher percent of early extubations, fewer re-intubations, shorter ICU LOS, and lower rate of ICU readmission were not statistically significant. The two groups had similar ventilator free days, prolonged mechanical ventilation, hospital LOS, and in-hospital mortality. CONCLUSION: Our study suggests that intensivist-driven ventilator management in conjunction with a multidisciplinary standardized weaning protocol shortens duration of mechanical ventilation in coronary artery bypass graft surgery patients.

Characteristics, Treatment, and Outcomes of Patients With Severe or Life-threatening COVID-19 at a Military Treatment Facility-A Descriptive Cohort Study.

INTRODUCTION: The treatment of severe and life-threatening COVID-19 is a rapidly evolving practice. The purpose of our study was to describe the characteristics and outcomes of patients with severe or life-threatening COVID-19 who present to a Military Treatment Facility (MTF) with an emphasis on addressing institutional adaptations to rapidly changing medical evidence. MATERIALS AND METHODS: A single-center retrospective study conducted on a prospectively maintained cohort. The MTF is a 52-bed hospital within an urban setting. Patients were included in the cohort if they had laboratory-confirmed severe or life-threatening COVID-19 with positive SARS-CoV-2 reverse transcription polymerase chain reaction. Severe disease was defined as dyspnea, respiratory frequency ≥30/min, blood oxygen saturation ≤93% on ambient air, partial pressure of arterial oxygen to fraction of inspired oxygen ratio <300, or lung infiltrates involving >50% of lung fields within 24-48 hours. Life-threatening COVID-19 was defined as respiratory failure, septic shock, or multiple organ dysfunction. The cohort included patients admitted from June 1 through November 13. Data were collected retrospectively via chart review by a resident physician. RESULTS: In total, our MTF saw 14 cases of severe or life-threatening COVID-19 from June 1 to November 13. Patients had a median age of 70.5 years, with 7% being active duty personnel, 21% dependents, and 71% retired military members. The median time to dexamethasone, remdesivir, and convalescent plasma administration was 4.7, 6.3, and 11.2 hours, respectively. The 28-day in-hospital mortality was 0%. CONCLUSIONS: Patients who present to an MTF with severe or life-threatening COVID-19 are largely retirees, with only a small fraction comprising active duty personnel. The institution of order sets and early consultation can help facilitate prompt patient care for COVID-19.

When Back Pain Turns Deadly: An Unusual Presentation of Lung Cancer.

Back pain is a common presenting concern in physician offices and emergency departments alike, with etiologies ranging from minor injuries to severe life-threatening illnesses. This case details the clinical course of a 68-year-old former smoker with no pulmonary symptoms who presented with back pain multiple times before developing cord compression syndrome and being diagnosed with non-small cell lung cancer (NSCLC). It demonstrates the importance of lung cancer screening and the necessity of monitoring for red flags in cases of back pain.

Congenital pulmonary airway malformation in the asymptomatic adult: A rare presentation.

Congenital Pulmonary Airway Malformation (CPAM) is a rare developmental abnormality of the lower respiratory tract, primarily diagnosed in the neonatal period. The most concerning sequelae for patients with CPAM are recurrent respiratory infections and malignancy. Rarely discovered in asymptomatic adults, CPAM presents challenging questions for management. We describe such a case and discuss the risks and benefits of resection.

Effect of a pulmonary nodule fact sheet on patient anxiety and knowledge: a quality improvement initiative.

INTRODUCTION: The utilisation of chest CT for the evaluation of pulmonary disorders, including low-dose CT for lung cancer screening, is increasing in the USA. As a result, the discovery of both screening-detected and incidental pulmonary nodules has become more frequent. Despite an overall low risk of malignancy, pulmonary nodules are a common cause of emotional distress among adult patients. METHODS: We conducted a multi-institutional quality improvement (QI) initiative involving 101 participants to determine the effect of a pulmonary nodule fact sheet on patient knowledge and anxiety. Males and females aged 35 years or older, who had a history of either screening-detected or incidental solid pulmonary nodule(s) sized 3-8 mm, were included. Prior to an internal medicine or pulmonary medicine clinic visit, participants were given a packet containing a pre-fact sheet survey, a pulmonary nodule fact sheet and a post-fact sheet survey. RESULTS: Of 101 patients, 61 (60.4%) worried about their pulmonary nodule at least once per month with 18 (17.8%) worrying daily. The majority 67/101 (66.3%) selected chemotherapy, chemotherapy and radiation, or radiation as the best method to cure early-stage lung cancer. Despite ongoing radiographic surveillance, 16/101 (15.8%) stated they would not be interested in an intervention if lung cancer was diagnosed. Following review of the pulmonary nodule fact sheet, 84/101 (83.2%) reported improved anxiety and 96/101 (95.0%) reported an improved understanding of their health situation. Patient understanding significantly improved from 4.2/10.0 to 8.1/10.0 (p<0.01). CONCLUSION: The incorporation of a standardised fact sheet for subcentimeter solid pulmonary nodules improves patient understanding and alleviates anxiety. We plan to implement pulmonary nodule fact sheets into the care of our patients with low-risk subcentimeter pulmonary nodules.

Chronic Pulmonary Blastomycosis Mimicking Pulmonary Tuberculosis.

Introduction: Blastomyces dermatitidis is a dimorphic fungus endemic to the Mississippi River valley. We describe a rare case of chronic pulmonary blastomycosis complicated by large pulmonary cavitation in a young service member who was misdiagnosed with active pulmonary tuberculosis. Case Presentation: A 25-year-old active duty male presented to his primary care provider with complaints of hemoptysis, fatigue, weight loss, and fever. Computed tomography chest with contrast identified a large cavitary lesion in the right upper lobe (RUL). The patient was admitted to an outside hospital and he underwent bronchoscopy with transbronchial biopsies and bronchoalveolar lavage of the RUL. Histology and cultures were unremarkable however; Histoplasma serum antigen was positive. The patient was empirically treated for active pulmonary tuberculosis and soon discharged. He returned for medical evaluation 3 mo later with continued hemoptysis. Repeat bronchoscopy with transbronchial biopsies of the RUL cavity grew Blastomyces dermatitidis. The patient's symptoms resolved and chest imaging significantly improved with initiation of itraconazole. Discussion: Chronic pulmonary blastomycosis can present with a constellation of symptoms that may be indistinguishable from chronic pulmonary histoplasmosis, pulmonary tuberculosis, or lung cancer. Knowledge of endemic diseases and a thorough travel history should be an integral part of a military physician's infectious disease evaluation.

Acute pulmonary embolism leading to cavitation and large pulmonary abscess: A rare complication of pulmonary infarction.

Pulmonary infarction is an infrequent complication of pulmonary embolism due to the dual blood supply of the lung. Autopsy studies have reported cavitation to occur in only 4-5% of all pulmonary infarctions with an even smaller proportion of these cases becoming secondarily infected. Patients with infected cavitating pulmonary infarction classically present with fever, positive sputum culture, and leukocytosis days to weeks following acute pulmonary embolism. We describe a rare case of acute pulmonary embolism with pulmonary infarction leading to cavitation and subsequent abscess formation requiring left lower lobe resection.

Effects of cocaine-positive urine screens on serum thyrotropin levels in patients admitted to an inpatient mental health unit.

OBJECTIVE: To assess the effect of a positive urine screen for cocaine on thyrotropin (TSH, also thyroid-stimulating hormone) concentrations. METHODS: In this retrospective cohort study, patients admitted to the mental health unit at an academic inpatient setting with a diagnosis of cocaine dependence or cocaine intoxication were routinely screened with urine drug toxicology tests and TSH concentrations. TSH concentrations from patients who tested positive for cocaine on urine toxicology were compared with patients having negative cocaine screenings. RESULTS: A total of 192 patients were included: 122 with a positive cocaine screen and 70 with a negative cocaine screen. All patients were screened using a highly sensitive TSH assay. A positive cocaine screen was not associated with a statistically significant difference in TSH concentrations compared with a negative cocaine screen. The percentage of patients with hypothyroidism (TSH >4.50 µIU/mL) or hyperthyroidism (TSH <0.40 µIU/mL) were similar in both study groups. CONCLUSIONS: The study failed to show that a positive urine screen for cocaine was associated with a significant effect on serum TSH levels in patients admitted to a mental health unit with a diagnosis of cocaine dependence or cocaine intoxication. Our findings support those of a prior study that cocaine use does not affect routine thyroid function tests. The present study does not support the clinical practice of ordering a serum TSH screening test on patients admitted to inpatient psychiatry units soley because the urine screen is positive for cocaine.