Tussis for Obstructive Stridor, an Impromptu Cure: A Rare Case of Spontaneous Resolution of Obstructive Fibrinous Tracheal Pseudomembrane (OFTP).

Obstructive fibrinous tracheal pseudomembrane (OFTP) is a relatively rare complication of endotracheal intubation. OFTP, which may cause fatal airway obstruction, is perhaps more common than reported in the literature. Although little is known about the mechanisms that play a role in the development of OFTP, it is hypothesized that OFTP results from ischemic injury to tracheal mucosa. Diagnosis is made using rigid bronchoscopy, which is also used for excision and removal of the pseudomembrane. Here we present a case of OFTP in a patient who was intubated for three days, developed symptoms three days after extubation, and ultimately spontaneously expelled the tracheal pseudomembrane.

Impact of COVID19 on resident physicians of a community hospital in New York city.

Introduction: Novel Corona Virus Disease 19 has created unforeseen burden on health care. New York city is one of the epicenters of pandemic and here we explore physical, mental and social impact of COVID 19 on Resident Physicians (RP) working within the center of this epicenter. Methods: This is a single-center cross-sectional web-based survey involving RP of a community hospital in Brooklyn, New York. Questionnaire was formulated in online platform. We used a convenient sampling method. Univariate analysis was conducted and presented the distribution of qualitative responses as frequency and percentages. Result: COVID19 related symptoms were reported by 39.8% RP. COVID19 IgG and IgM antibodies, both negative were reported by 34.9%, while only 6% RPs were IgG antibody positive. Symptomatic RP tested for COVID19-PCR was positive in 42.42%. Self-isolation from family during the pandemic was reported by only 14.5%. Financial constraints, lack of accommodation, and emotional reasons were main reasons of not being able to self isolate. Being bothered by 'Anxiety' and 'Nervousness' were reported by 8.5% on 'Almost every day' while 46.3% reported on 'several days in the two weeks duration'. 'Uncontrollable worrying', 'Feeling down', 'Depressed,' or 'Hopeless' was reported as 'Not at all' by 78.8% and 3.7% reported it to 'occur nearly every day for the last two weeks'. Conclusion: Aftermath of fight against pandemic has left RP with significant physical, mental, and social impact. Appropriate stress management and safety interventions are urgently needed. Further studies are needed to explore the detailed impact of COIV19 on RP.

Pulmonary Kaposi Sarcoma: an uncommon presentation in HIV heterosexual female on antiretroviral therpay.

Kaposi sarcoma (KS) is caused by Human Herpesvirus 8 (HHV-8), and it affects 15 times more common in men than women. It has varied clinical presentation from classic, endemic, organ transplant-related, and acquired immunodeficiency syndrome (AIDS)-related. Clinical features of pulmonary KS might be challenging to distinguish from pneumonia in immunocompromised patients and could lead to diagnostic challenges. Hence Pulmonary KS should also be considered in the differential when HIV-infected patients develop rapidly progressive respiratory symptoms after the initiation of glucocorticoid therapy and immunocompromised not responding to antibiotic treatment for pneumonia, especially when CD4 < 100 and viral load >10,000. Early diagnosis and treatment are essential for a better outcome and prevent morbidity and mortality. Highly active antiretroviral therapy (HAART) is the only proven therapy to prevent Kaposi sarcoma. We report the case of a young woman who presented with symptoms of pneumonia and was later found to have pulmonary KS (PKS).

Using Video-Assisted Laryngoscope (GlideScope®) to Insert a Nasogastric Tube and Prevent Pneumothorax From Incorrectly Inserted Nasogastric Tubes.

When indicated, nasogastric tubes (NGT) are often inserted blindly, and the positioning is later confirmed using a chest X-ray (CX-ray). This case describes the blind insertion of an NGT in an 85-year-old nonverbal woman with advanced dementia who developed a pneumothorax (PTX) following NGT insertion. The patient had sepsis due to pneumonia and an infected decubitus ulcer. Because the patient had difficulty swallowing, NGT insertion was blindly performed by a house staff resident, and the tube entered the left lung. A portable bedside CX-ray was performed post-insertion and confirmed that the NGT was in the left lung, with left-sided PTX. An immediate CT of the chest revealed a partial collapse of the left lung. The patient was placed on a nonrebreather mask with 80% oxygen, and immediate insertion of a chest tube (12 Fr catheter) resulted in a subcomplete resolution of the PTX on the left side, with remaining apical PTX. Because an NGT was still required to feed the patient, we used a video-assisted laryngoscope (VAL) to assist with the insertion of the NGT the second time and prevent insertion in the incorrect location. We encourage physicians to consider the insertion of NGT under direct observation using VAL.

Incidence, Predictors, Causes, and Cost of 30-Day Hospital Readmission in Chronic Obstructive Pulmonary Disease Patients Undergoing Bronchoscopy.

Introduction Chronic obstructive pulmonary disease (COPD) has a significant disease burden and is among the leading causes of hospital readmissions, adding a significant burden on healthcare resources. The association between 30-day readmission in a COPD patient undergoing bronchoscopy and a wide range of modifiable potential risk factors, after adjusting for sociodemographic and clinical factors, has been assessed, and comparison has been made with COPD patients not undergoing bronchoscopy. Methods We conducted a comprehensive analysis of the 2016 Nationwide Readmission Database (NRD) of 30-day all-cause readmission among COPD patients undergoing bronchoscopy. A Cox's proportional hazards model was used to obtain independent relative risks of readmission following bronchoscopy in COPD patients as compared to patients not undergoing bronchoscopy. Our primary outcome was the 30-day all-cause readmission rate in both groups. Other secondary outcomes of interest were the 10 most common reasons for readmission, resource utilization, independent predictors of readmission, and relative proportion of comorbidities between the index admission (IA) and the readmission in both groups. Results The overall rate of readmission following bronchoscopy in COPD patients as compared to patients not undergoing bronchoscopy was 17.32% and 15.87%, respectively. The final multivariate model in the bronchoscopy group showed that the variables found to be an independent predictor of readmission were: pulmonary hypertension (hazard ratio [HR] 2.35; 95% confidence interval [CI] 1.26-4.25; P < .01), adrenal insufficiency (HR 4.47; 95% CI 1.44-13.85; P = .01) and discharge to rehab status. Independent predictor variables of admission in Group B were gender (women < men; HR 0.91; 95% CI 0.88-0.93; P < .01), and type of insurance (Medicaid > Medicare > private insurance). For all patients undergoing bronchoscopy, the mean length of stay (LOS) for IA was 11.91 ± 20.21 days, and LOS for readmission was 5.87 ± 5.48 days. The mean total cost of IA for patients undergoing bronchoscopy was much higher than that of readmission ($26,916 vs. $12,374, respectively). The entire LOS for readmission was 1,265 days, with a total cost of $2.66 million. For patients not undergoing bronchoscopy during the IA, mean LOS for IA was 4.26 ± 4.27 days, and mean LOS for readmission was 5.39 ± 5.51 days, which was longer than the IA in Group B but still shorter than LOS for readmission in Group A (patients undergoing bronchoscopy). The mean total cost of readmission was higher than the IA ($8,137 for IA vs. $10,893 for readmission). The total LOS in this group of patients was 313,287 days, with the total cost of readmission at $628 million. Conclusions Patients undergoing bronchoscopy have a slightly higher rate of 30-day readmissions as compared to patients not undergoing bronchoscopy, and the LOS is also slightly higher in this group during subsequent readmissions as compared to readmission in patients not undergoing bronchoscopy in IA. The readmission rate in COPD patients is impacted by a variety of social, personal, and medical factors. Patients with multiple medical comorbidities have a higher risk of readmission. In our understanding, bronchoscopy in a patient with acute exacerbation of COPD should be reserved for selected patients, and the rationale should be clarified, as it affects the overall LOS and healthcare expenditure.

A symptomatic gastric sarcoidosis and asymptomatic pulmonary sarcoidosis: a rare manifestation.

Sarcoidosis is a granulomatous disease of unknown etiology which may present with systemic manifestations. The diagnosis of gastric sarcoidosis needs much effort to accomplish as it is exceedingly rare, and the treatment is usually recommended exclusively for symptomatic disease. Here, we present a case of gastric sarcoidosis in a 31-year old black female patient with symptoms of nausea and epigastric pain. A diagnosis of gastric sarcoidosis was mainly based on the presence of non-necrotizing granulomas on biopsy following esophagogastroduodenoscopy (EGD). She was treated with steroid with high dose at first, followed by a slow taper and the symptoms responded to the treatment.

Polysomnographic variables in Alternate overlap syndrome: data from sleep heart health study.

Objective: To evaluate influence of asthma on polysomnographic variables of patients with obstructive sleep apnea (OSA).Methods: A longitudinal retrospective study using data collected from the Sleep Heart Health Study (SHHS).Results: All 2822 patients included had OSA, 2599 were non-asthmatic whereas 223 were asthmatics. Average BMI for non-asthmatics was 28.8 kg/m2 whereas asthmatics had 29.5 kg/m2. Median pack-years of smoking was 1.42 vs. 1.98 in non-asthmatic and asthmatic groups, respectively. Sex distribution, age (in years), BMI, FEV1, FVC, AHI ≥ 4% (all apneas, hypopneas with ≥4% oxygen desaturation or arousal per hour of sleep), RDI ≥ 3% (overall respiratory distribution index at ≥3% oxygen desaturation or arousal), sleep latency, percentage of sleep time in apnea/hypopnea and Epworth sleep scale score were all statistically significant. Non-asthmatics had greater AHI (12.63/hr) compared to asthmatics (11.34/hour), p = 0.0015. RDI in non-asthmatics and asthmatics was (23.07 vs 20.53; p = 0.009). Sleep latency was found to be longer in asthmatics 19.8 minutes vs. 16 minutes (p = 0.008). Epworth sleepiness scale score was high in asthmatics (9 vs. 8, p = 0.002).Conclusion: OSA was found more severe in non-asthmatic subgroup, but asthmatics had statistically significant higher Epworth sleepiness scale score and sleep latency. Clinicians should be vigilant and keep low threshold to rule out OSA particularly on patients with difficult to control asthma, smoker, GERD, obese and nasal disease.

Predictors of hospital stay in normotensive acute pulmonary embolism: a retrospective pilot study.

Introduction: The aim of our study is to determine the clinical, biochemical, and imaging factors that affect the duration of hospital stay in patients admitted with normotensive acute pulmonary embolism. Methods: This was a single-center retrospective study conducted in a community hospital in New York metropolitan area for patients admitted from October 2015 to October 2017. Results: A total of 79 patients were included, the mean age was 55.76 (SD = 17.33), 29 cases were males (37%) and 50 cases were females (63%). Among all patients, 17 cases had short length of stay (LOS) (≤2 days) and 62 cases had long LOS (>2 days). There were statistically significant differences in age (p = .041), presence of lung disease (p = .036), number of comorbidities (p = .043), and pulmonary embolism severity index (PESI) scores (original and simplified; p = .002 and .001, respectively). Logistic regression analysis showed that PESI score significantly predicted long LOS (OR 1.067, 95% CI [1.001, 1.137], p = .048). Similarly, sPESI significantly predicted long LOS (OR 0.223, 95% CI [0.050, 0.999], p = .050). Both regression models were adjusted for age, lung disease, and number of comorbidities. Conclusion: Both original and simplified PESI scores were statistically significant predictors of duration of hospital stay. Patients with multiple comorbidities or with chronic lung disease were also likely to have prolonged hospital stay. None of the cardiac biomarkers affected the duration of hospital stay, neither did the presence of right ventricular dysfunction nor treatment modality.