Outcomes of patients with elevated pulmonary artery systolic pressure on echocardiography due to chronic lung diseases.

BACKGROUND: Pulmonary hypertension is associated with increased mortality, and lung diseases are the second most common cause of pulmonary hypertension. We aimed to evaluate the prognostic value of echocardiography in low-middle income countries where right heart catheterization is difficult to perform. METHODS: This retrospective chart review study included adult patients hospitalized from June 2012 to May 2021, with a pulmonary artery systolic pressure (PASP) of ≥35 mmHg on echocardiography. The control arm consisted of patients with similar lung diseases who did not have an elevated PASP. RESULTS: The study and control arm consisted of 128 patients each, with both groups having similar lung diseases. Obesity hypoventilation syndrome was the most common etiology of elevated PASP (28.1 %), followed by pulmonary embolism (20.3 %). The overall 1-year mortality of the study cohort, after diagnosis of elevated PASP, was 20.3 %. The control cohort with normal PASP had a 1-year mortality of 4.7 %. In the study cohort, patients with bronchiectasis had the highest cause-specific 1-year mortality (45.5 %). In the normal PASP cohort, the highest cause-specific 1-year mortality was observed in patients with interstitial lung disease (13.0 %). One-year hospital readmission was observed in 46.9 % and 33.6 % of patients in the study and control arms, respectively. On multivariate analysis, increased odds of 1-year mortality were observed in patients with elevated PASP, patients with 1-year hospital readmission, and in patients with interstitial lung disease or bronchiectasis. CONCLUSION: Elevated PASP on echocardiography may be a prognostic factor for mortality in patients with chronic lung diseases.

Clinical Risk Factors for Death in Patients With Empyema and Active Malignancy.

Background Pleural infection is a common clinical problem resulting in prolonged hospitalization and increased mortality. In patients with active malignancy, management decisions are based on the need for further immunosuppressive therapies, the ability to tolerate surgery, and consideration of the limited life expectancy. Identifying patients at risk for death or poor outcomes is very important as it will guide care. Study design and methods This is a retrospective cohort study of all patients with active malignancy and empyema. The primary outcome was time to death from empyema at three months. The secondary outcome was surgery at 30 days. Standard Cox regression model and cause-specific hazard regression model were used to analyze the data. Results A total of 202 patients with active malignancy and empyema were included. The overall mortality rate at three months was 32.7%. On multivariable analysis, female gender and higher urea were associated with an increased risk of death from empyema at three months. The area under the curve (AUC) of the model was 0.70. The risk factors for surgery at 30 days included the presence of frank pus and postsurgical empyema. The AUC of the model was 0.76. Interpretation Patients with active malignancy and empyema have a high probability of death. In our model, the risk factors for death from empyema included female gender and higher urea.

Mobile Cone-Beam CT-Assisted Bronchoscopy for Peripheral Lung Lesions.

Peripheral bronchoscopy with the use of thin/ultrathin bronchoscopes and radial-probe endobronchial ultrasound (RP-EBUS) has been associated with a fair diagnostic yield. Mobile cone-beam CT (m-CBCT) could potentially improve the performance of these readily available technologies. We retrospectively reviewed the records of patients undergoing bronchoscopy for peripheral lung lesions with thin/ultrathin scope, RP-EBUS, and m-CBCT guidance. We studied the performance (diagnostic yield and sensitivity for malignancy) and safety (complications, radiation exposure) of this combined approach. A total of 51 patients were studied. The mean target size was 2.6 cm (SD, 1.3 cm) and the mean distance to the pleura was 1.5 cm (SD, 1.4 cm). The diagnostic yield was 78.4% (95 CI, 67.1-89.7%), and the sensitivity for malignancy was 77.4% (95 CI, 62.7-92.1%). The only complication was one pneumothorax. The median fluoroscopy time was 11.2 min (range, 2.9-42.1) and the median number of CT spins was 1 (range, 1-5). The mean Dose Area Product from the total exposure was 41.92 Gy·cm2 (SD, 11.35 Gy·cm2). Mobile CBCT guidance may increase the performance of thin/ultrathin bronchoscopy for peripheral lung lesions in a safe manner. Further prospective studies are needed to corroborate these findings.

Spontaneous large volume hemothorax managed with a small-bore chest tube.

A 67-year-old male with metastatic lung cancer presented with acute shortness of breath and increasing oxygen requirements. He had a decreasing hemoglobin for which he required red blood cell transfusions. His chest X-ray showed near complete white-out of the left lung. Bedside ultrasound (Handheld Sonostar C4PL) showed a large pleural effusion with swirling echogenic material suggestive of plankton sign. The pleural effusion was aspirated and showed frank blood, after which a small-bore chest tube (SBCT) was inserted. A total of 3200 mL of blood was drained with the SBCT. There was complete clearance of the pleural space, and no further blood product transfusions were needed. This case highlights that conservative management can be considered in patients with spontaneous hemothorax due to metastatic disease.

Control of bleeding from intercostal artery laceration.

Laceration of an intercostal artery is a rare but potentially catastrophic complication of pleural procedures such as thoracentesis. Recognition of this problem often occurs late in the bleeding process, only after hemodynamic decompensation has occurred. Aggressive and emergent measures are usually undertaken such as angiographic embolization or thoracotomy. In our review of the literature, manual pressure over the pleural space is not described as an intervention in case reports or case series. We demonstrate the first video proof of the immediate success of direct pressure over an intercostal site as a simple, rapid, and effective method for definitively stopping intercostal arterial hemorrhage after a pleural procedure.

Ventilatory Strategy to Prevent Atelectasis During Bronchoscopy Under General Anesthesia: A Multicenter Randomized Controlled Trial (Ventilatory Strategy to Prevent Atelectasis -VESPA- Trial).

BACKGROUND: Atelectasis negatively influences peripheral bronchoscopy, increasing CT scan-body divergence, obscuring targets, and creating false-positive radial-probe endobronchial ultrasound (RP-EBUS) images. RESEARCH QUESTION: Can a ventilatory strategy reduce the incidence of atelectasis during bronchoscopy under general anesthesia? STUDY DESIGN AND METHODS: Randomized controlled study (1:1) in which patients undergoing bronchoscopy were randomized to receive standard ventilation (laryngeal mask airway, 100% Fio2, zero positive end-expiratory pressure [PEEP]) vs a ventilatory strategy to prevent atelectasis (VESPA) with endotracheal intubation followed by a recruitment maneuver, Fio2 titration (< 100%), and PEEP of 8 to 10 cm H2O. All patients underwent chest CT imaging and a survey for atelectasis with RP-EBUS bilaterally on bronchial segments 6, 9, and 10 after artificial airway insertion (time 1) and 20 to 30 min later (time 2). Chest CT scans were reviewed by a blinded chest radiologist. RP-EBUS images were assessed by three independent, blinded readers. The primary end point was the proportion of patients with any atelectasis (either unilateral or bilateral) at time 2 according to chest CT scan findings. RESULTS: Seventy-six patients were analyzed, 38 in each group. The proportion of patients with any atelectasis according to chest CT scan at time 2 was 84.2% (95% CI, 72.6%-95.8%) in the control group and 28.9% (95% CI, 15.4%-45.9%) in the VESPA group (P < .0001). The proportion of patients with bilateral atelectasis at time 2 was 71.1% (95% CI, 56.6%-85.5%) in the control group and 7.9% (95% CI, 1.7%-21.4%) in the VESPA group (P < .0001). At time 2, 3.84 ± 1.67 (mean ± SD) bronchial segments in the control group vs 1.21 ± 1.63 in the VESPA group were deemed atelectatic (P < .0001). No differences were found in the rate of complications. INTERPRETATION: VESPA significantly reduced the incidence of atelectasis, was well tolerated, and showed a sustained effect over time despite bronchoscopic nodal staging maneuvers. VESPA should be considered for bronchoscopy when atelectasis is to be avoided. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT04311723; URL: www. CLINICALTRIALS: gov.

Giant Cell Arteritis as an Uncommon Cause of Chronic Cough: A Case Report.

BACKGROUND Chronic cough is a common medical concern. Giant cell arteritis (GCA) is an uncommon cause of chronic cough and is not usually suspected since symptoms can be non-specific. We present a case of chronic cough due to GCA in which symptoms were subtle but imaging was remarkable and clearly disclosed the diagnosis. CASE REPORT A 71-year-old woman presented to the pulmonary clinic with a concern of worsening cough for 4 months. She had been treated with proton pump inhibitor, intranasal steroids, and antibiotics, without improvement. Other symptoms were an occasional headache for the prior 5 months, but this had resolved. She had a history of early-stage breast and thyroid cancers, both of which were treated surgically several years earlier and were in remission. Results of a physical examination including flexible video laryngoscopy of the upper airway were completely normal. Laboratory investigations showed normal blood chemistries and blood cell counts. Her C-reactive protein level was 1 mg/L (upper limit of normal <10) but her erythrocyte sedimentation level was 121 mm/hr (upper limit of normal <30). A positron emission tomography (PET) scan was performed as surveillance for her prior cancers. This showed diffuse tracer uptake in the aorta as well as bilateral common carotid, subclavian, and common iliac arteries, revealing GCA as the underlying diagnosis. CONCLUSIONS Giant cell arteritis is a rare cause of chronic cough. Other symptoms can be subtle or non-specific as in our case, and a high index of suspicion is needed to obtain a temporal artery biopsy. In these cases, imaging adjuncts can provide a non-invasive diagnosis.

Safety and incidence of complications associated with bronchoscopy in an obese population.

INTRODUCTION: The safety of bronchoscopy in obese patients and those with obstructive sleep apnea (OSA) is unclear. Our objective was to evaluate the incidence of complications during bronchoscopy under moderate sedation in obese patients and to assess the impact of OSA, body mass index (BMI), and duration of the procedure. METHODS: We performed a retrospective study in adult patients undergoing bronchoscopy from January 2010 to August 2019. All patients with BMI > 30 kg/m2 were included. Logistic regression analyses were used to identify the factors associated with all-complications and respiratory complications. RESULTS: A total of 345 obese patients were identified. The average BMI in our cohort was 35.3 ± 5.1 kg/m2 . During the pre-procedure risk assessment, 165 (47.8%) patients were labelled as "suspected OSA." The most common doses of sedation given during the bronchoscopies were fentanyl 50 mcg (34.5%) and midazolam 3 mg (33.6%). The incidence of major complications was 0.6% and minor complications were 41.2%. Minor respiratory (22.9%) and cardiac (26.4%) complications were common. No deaths occurred due to bronchoscopy. Factors that were associated with increased respiratory complications were female gender, suspected OSA, and bronchoscopy duration 20-30 minutes and bronchoscopy duration greater than 1 hour. CONCLUSION: Bronchoscopy under moderate sedation performed in obese patients is safe; however, increased risk may exist with females, increased procedure time, and suspected OSA.

Pediatric size phlebotomy tubes and transfusions in adult critically ill patients: a pilot randomized controlled trial.

BACKGROUND: Transfusion of red blood cells (RBC) is common, can have adverse effects, and is a costly and limited resource. Interventions that reduce iatrogenic blood losses could reduce transfusions. The objectives of this pilot trial were to assess the feasibility (acceptability of the intervention and suitability of eligibility criteria) and potential effectiveness of pediatric size phlebotomy tubes in adult critically ill patients. METHODS: We conducted a pilot, randomized controlled trial in the medical intensive care unit (ICU) of a university-affiliated, tertiary care referral hospital from November 2017 to September 2018. A total of 200 patients with hemoglobin of at least 7 g/dL and without bleeding were randomized to pediatric or adult size phlebotomy tubes. Stratification was according to baseline hemoglobin (7-9.49 g/dL, 9.5-11.99 g/dL, and 12 g/dL or greater). Acceptability was measured via the number of blood test recollections and the number of patients that discontinued the use of pediatric tubes. The suitability of patient eligibility criteria was determined by identifying baseline characteristics associated with RBC transfusions. Potential effectiveness was estimated from the time to RBC transfusion or to hemoglobin level below 7 g/dL. RESULTS: The use of pediatric tubes was acceptable as patients experienced a low number of tests recollections (on average 1 every 57 days), and none of the participants discontinued their use. The baseline hemoglobin category was the only factor that appeared to be independently associated with RBC transfusions. A total of 6 patients (6%) in the pediatric tube group and 11 patients (11%) in the adult tube group (hazard ratio, 0.69; 95% CI, 0.25 to 1.9) received an RBC transfusion or reached hemoglobin below 7 g/dL. Almost all of these patients (16 of 17 participants) had baseline hemoglobin of 7-9.49 g/dL. CONCLUSIONS: This pilot study suggests that pediatric phlebotomy tubes are acceptable to patients and can therefore be used in adult ICU patients. A future study should focus on patients with hemoglobin levels below 9.5 g/dL, as these patients have a high risk of transfusions. This intervention has the potential of being successful in selected patients. A definitive trial is warranted. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03286465. Retrospectively registered on September 18, 2017.

Clinical Characteristics and Etiologies of Miliary Nodules in the US: A Single-Center Study.

BACKGROUND: Miliary nodules have been typically described as a radiological manifestation of disseminated tuberculosis. However, miliary nodules are known to occur in a wide variety of conditions. The primary objective of the study was to identify clinical characteristics and etiologies of miliary nodules within our institution. METHODS: Using International Classification of Diseases, Ninth and Tenth Revision codes, electronic medical records were used to retrospectively identify 53 patients who fulfilled criteria of miliary nodules over the last 10 years. Demographic and clinical data were extracted for all the patients in this cross-sectional study. RESULTS: The diagnosis of tuberculosis was made in 15 (28.3%) patients, sarcoidosis in 12 (22.6%), silicosis in 7 (13.2%), extrathoracic malignancy in 5 (9.4%), and histoplasmosis in 4 (7.6%) patients. Four of 9 HIV patients had histoplasmosis. There was 1 case each of hypersensitivity pneumonitis, Pneumocystis jiroveci pneumonia, Mycobacterium-avium complex, Epstein-Barr virus pneumonia, cryptococcosis, aspergillosis, and primary lung cancer. Sputum was positive for acid fast bacilli in 4 cases (28%), and bronchoscopy had a 57% successful yield in miliary tuberculosis. CONCLUSION: Our study is the largest single-center data review evaluating the etiology of miliary nodules within the United States; most of the data exist in case reports.

Ventricular Assist Device-Related Haemolysis Presenting with Acute Pancreatitis.

Acute pancreatitis is one of the rare complications in patients fitted with a left ventricular assist device (LVAD). We herein report a case of acute pancreatitis in a patient with LVAD triggered by intravascular haemolysis. A 44-year-old man with non-ischaemic cardiomyopathy (NICM) after VAD implantation presented with epigastric pain. Laboratory work-up showed acute pancreatitis and haemolysis. As there was concern that device thrombosis was causing haemolysis, the patient was started on unfractionated heparin infusion. The patient was discharged when haemolysis and pancreatitis had resolved. To our knowledge, VAD-associated haemolysis presenting with acute pancreatitis is infrequently described in the literature. LEARNING POINTS: Our case report highlights a rare presentation of device thrombosis presenting as haemolysis and pancreatitis in a patient fitted with a ventricular assist device (VAD).Our case report aims to educate internists to keep in mind a potentially life-threatening condition when taking care of patients with VAD.Our case report highlights haemolysis as a rare cause of acute pancreatitis.

A Unique Case of Mycophenolate Induced Colitis after 10 Years of Use.

A 31-year-old female with a history of lupus nephritis on Hydroxychloroquine, Prednisone, and Mycophenolate Mofetil (MMF) for 10 years presented to the hospital for ankle swelling. On day four, she started to have severe, nonbloody, watery diarrhea with abdominal distension and tenderness. Stool PCR was negative for C. difficile. CT abdomen/pelvis showed gaseous distension of the colon without any obstruction. Flexible sigmoidoscopy revealed a normal looking mucosa. Histopathology showed crypt atrophy and increased crypt apoptosis, consistent with MMF colitis. The diarrhea resolved three days after stopping MMF. Although generally well tolerated, diarrhea is a common side effect of MMF. Most cases occur in the first six months of starting MMF. This case is unique because it describes MMF colitis in lupus after more than 10 years. Thus, MMF colitis should be considered as a differential in patients taking it, regardless of the duration of use.