Differentiating Lung Nodules Due to Coccidioides from Those Due to Lung Cancer Based on Radiographic Appearance.

BACKGROUND: Coccidioidomycosis (cocci) is an endemic fungal disease that can cause asymptomatic or post-symptomatic lung nodules which are visible on chest CT scanning. Lung nodules are common and can represent early lung cancer. Differentiating lung nodules due to cocci from those due to lung cancer can be difficult and lead to invasive and expensive evaluations. MATERIALS AND METHODS: We identified 302 patients with biopsy-proven cocci or bronchogenic carcinoma seen in our multidisciplinary nodule clinic. Two experienced radiologists who were blinded to the diagnosis read the chest CT scans and identified radiographic characteristics to determine their utility in differentiating lung cancer nodules from those due to cocci. RESULTS: Using univariate analysis, we identified several radiographic findings that differed between lung cancer and cocci infection. We then entered these variables along with age and gender into a multivariate model and found that age, nodule diameter, nodule cavitation, presence of satellite nodules and radiographic presence of chronic lung disease differed significantly between the two diagnoses. Three findings, cavitary nodules, satellite nodules and chronic lung disease, have sufficient discrimination to potentially be useful in clinical decision-making. CONCLUSIONS: Careful evaluation of the three obtained radiographic findings can significantly improve our ability to differentiate benign coccidioidomycosis infection from lung cancer in an endemic region for the fungal disease. Using these data may significantly reduce the cost and risk associated with distinguishing the cause of lung nodules in these patients by preventing unnecessary invasive studies.

Role of endoscopic evaluation prior to diagnostic transesophageal echocardiography: Is it necessary?

Background and Aim: Esophagogastroduodenoscopy (EGD) is often performed prior to transesophageal echocardiogram (TEE) to evaluate for esophageal pathologies. Although TEE is a safe procedure, some contraindications exist, such as esophageal varices. The incidence of bleeding with TEE is <0.01%, which questions the need for this routine invasive procedure prior to TEE. We sought to characterize patients in whom pre-TEE endoscopy was requested to determine its clinical utility and identify those that would most benefit. Methods: We retrospectively studied patients who underwent EGD for TEE clearance between January 2014 and October 2019. We assessed how often EGD changed management and complications after TEE in those with EGD abnormalities. Results: Eighty-three patients were included. Twenty-three percent had prior GI bleed, 63% had cirrhosis, 18% had known varices, and 7% had prior variceal bleed. The most common EGD findings were varices (33%). Eighty-one percent proceeded with TEE. Reasons for TEE deferral included varices (12.5%), high-risk bleeding lesion (12.5%), and mechanical abnormality (12.5%). In the majority (37.5%), TEE was deemed no longer indicated. No patient undergoing TEE had significant hemoglobin drop or overt bleeding. The most common reason for not performing TEE was unrelated to EGD findings: lack of ongoing indication for TEE. Conclusion: Based on our study, EGD is likely not needed for TEE clearance in patients with varices or prior GI bleed. Given that data are limited in patients with abnormalities such as strictures, EGD may still be warranted for these patients. Further studies to identify which patients will benefit from pre-TEE endoscopy are warranted.

COVID-19-Associated Pulmonary Aspergillosis: A Single-Center Experience in Central Valley, California, January 2020-March 2021.

Reports of coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) have been widely published across the world since the onset of the pandemic with varying incidence rates. We retrospectively studied all patients with severe COVID-19 infection who were admitted to our tertiary care center's intensive care units between January 2020 and March 2021, who also had respiratory cultures positive for Aspergillus species. Among a large cohort of 970 patients admitted to the ICU with severe COVID-19 infections during our study period, 48 patients had Aspergillus species growing in respiratory cultures. Based on the 2020 European Confederation of Medical Mycology and the International Society for Human and Animal Mycology (ECMM/ISHAM) consensus criteria, 2 patients in the study had proven CAPA, 9 had probable CAPA, and 37 had possible CAPA. The incidence of CAPA was 5%. The mean duration from a positive COVID-19 test to Aspergillus spp. being recovered from the respiratory cultures was 16 days, and more than half of the patients had preceding fever or worsening respiratory failure despite adequate support and management. Antifungals were given for treatment in 44% of the patients for a mean duration of 13 days. The overall mortality rate in our study population was extremely high with death occurring in 40/48 patients (83%).

Feel It, See It, Get It: Is Internal Medicine Residents' Use of Ultrasound in Lumbar Puncture Associated With Higher Success Rate?

INTRODUCTION:  Multiple emergency medicine and anesthesiology research studies suggest that ultrasound (US) is potentially useful in assisting with needle insertion in a lumbar puncture (LP). However, little is known about its value when utilized by internal medicine (IM) residents. The objective of this study is to examine whether the use of ultrasound in LPs performed by internal medicine residents is associated with a higher success rate than the traditional palpation method. MATERIALS AND METHODS:  We reviewed all LP procedure notes in our hospital's records written by IM residents from June 2017 to December 2018 in a single community teaching hospital. We examined the association between the US use and success using the Chi-squared test and logistic regression model. RESULTS: Among the 152 lumbar punctures documented, 130 specified whether US was used or not. Among these, 39 were ultrasound-assisted and 91 were not. Use of ultrasound was associated with a higher success rate compared to the non-ultrasound-use (87% vs 73%; p=0.1). The association was strengthened using logistic regression but did not reach statistical significance (OR 3.5; CI: 0.9 -13.8; p=0.07). Success was significantly associated with a fewer number of attempts (p<0.001). No statistically significant association was found between success and patients' body mass index (BMI; p=0.57), or level of training (p=0.11). CONCLUSIONS:  Use of ultrasound for needle insertion in lumbar punctures performed by internal medicine residents was associated with a higher success rate compared to the palpation method but without statistical significance. Ultrasound is a non-invasive, quick, and safe tool. Our study favors its use as an aid during lumbar puncture when performed by internal medicine residents. Larger studies are needed to gather more evidence in support of this conclusion.

Combined Endosonographic Mediastinal Lymph Node Staging in Positron Emission Tomography and Computed Tomography Node-Negative Non-Small-Cell Lung Cancer in High-Risk Patients.

Positron emission tomography (PET) with computed tomography (CT) is routinely utilized to investigate lymph node (LN) metastases in non-small-cell lung cancer. However, it is less sensitive in normal-sized LNs. This study was performed in order to define the prevalence of mediastinal LN metastases discovered on combined endosonography by endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) fine needle aspiration in patients with a radiologically normal mediastinum. This study consists of a retrospective, single-institution, tertiary care referral center review of a prospectively maintained database. Patients were identified from a cohort between January 2009 and December 2014. One hundred and sixty-one patients with biopsy-proven, non-small-cell lung cancer were identified in whom both the preendosonography CT and PET-CT were negative for mediastinal LN metastases. Combined endosonography (EBUS + EUS-FNA) was performed in all patients. Z test was used for statistical analysis. A P value of <0.05 was considered statistically significant. A total of 161 consecutive patients were included. Patients were staged if they had central tumor, tumor size >3 cm, N1 lymph node involvement on PET-CT/CT, or if there was low SUV (<2.5) in the primary tumor. A total of 416 lymph nodes were biopsied in the 161 patients using combined endosonography; 147 with EBUS and 269 with EUS. Mean and median number of lymph nodes biopsied per patient using combined EBUS/EUS was 2.5 and 3, respectively (mean and median EBUS: 0.91 and 2.5; mean and median EUS 1.6 and 3). Endosonographic staging upstaged 13% of patients with radiologically normal lymph nodes in the mediastinum, hilum, lobar, and sublobar regions (confidence interval 8.22-19.20). Twenty-one out of 161 patients (13%) with radiologically normal mediastinum were positive on combined EBUS/EUS staging. Out of 21 patients upstaged on endosonography, 15 (71%) had tumor size >3 cm. Six (28%) had occult N1 disease. Thirteen (61%) had occult N2 disease and 2 (9%) had adrenal involvement. None of the upstaged patients had N1 LN involvement on PET-CT or CT scan. Combined endosonographic lymph node staging should be considered in the pretreatment staging of high-risk patients with non-small-cell lung cancer in the presence of radiologically normal mediastinal lymph nodes due to the significant rate of radiologically occult lymph node metastases.

The Epidemiology and Medical Morbidity of Long-Distance Backpackers on the John Muir Trail in the Sierra Nevada.

INTRODUCTION: The baseline characteristics and medical morbidity of hikers on the 354 km (220 mi) John Muir Trail (JMT) have not been previously reported. METHODS: Using online and on-site recruitment, hikers completing the JMT in 2014 were directed to an online 83-question survey. Pearson correlations, regression models, and descriptive statistics were applied to data, reported as mean±SD (range). Statistical significance was set at P<0.05. RESULTS: Of 771 respondents, 57% were men aged 43±14 (13-76) y; they hiked 15.2±7.6 (5-34) days and traveled 272±129 (45-1207) km (169±80 [28-750] mi). Backpackers lost 3.5±2.6 (+3.6 to -18.2) kg (7.7±5.8 [+8 to -40] lbs). Over half (57%) of respondents reported illness or injury, with blisters (57%), sleep problems (57%), and pack strap pain (46%) most prevalent. Altitude illness affected 37%. Thirty hikers left the trail; of these, 4 required emergency medical services evacuations (3 by helicopter). Increasing age, base pack weight, and body mass index (BMI) were all associated with a decrease in the distance hiked per day. Higher base pack weight was associated with illness or injury, whereas older age was slightly protective. Increasing BMI was associated with a slight increase in medical illness or injury and a strong association with evacuation from the trail. CONCLUSIONS: JMT hikers experienced medical issues seen on other national trails. Weight loss was prevalent. Most hikers had medical complaints, with few seeking medical attention. Heavy packs and higher BMIs were associated with undesirable outcomes, while older hikers fared better.

Impact of an integrated disease management program in reducing exacerbations in patients with severe asthma and COPD.

BACKGROUND: Conflicting data exists on the effectiveness of integrated programs in reducing recurrent exacerbations and hospitalizations in patients with Asthma and chronic obstructive lung disease (COPD). We developed a Pulmonologist-led Chronic Lung Disease Program (CLDP) for patients with severe asthma and COPD and analyzed its impact on healthcare utilization and predictors of its effectiveness. METHODS: CLDP elements included clinical evaluation, onsite pulmonary function testing, health education, and self-management action plan along with close scheduled and on-demand follow-up. Patients with ≥2 asthma or COPD exacerbations requiring emergency room visit or hospitalization within the prior year were enrolled, and followed for respiratory related ER visits (RER) and hospitalizations (RHA) over the year (357 ± 43 days) after CLDP interventions. RESULTS: A total of 106 patients were enrolled, and 104 patients were subject to analyses. During the year of follow-up after CLDP enrollment, there was a significant decrease in mean RER (0.56 ± 1.48 versus 2.62 ± 2.81, p < 0.0001), mean RHA (0.39 ± 0.08 versus 1.1 ± 1.62, p < 0.0001), and 30 day rehospitalizations (0.05 ± 0.02 versus 0.28 ± 0.07, p < 0.0001). Reduction of healthcare utilization was strongly associated with GERD and sinusitis therapy, and was independent of pulmonary rehabilitation. Direct variable cost analyses estimated annual savings at $1.17 million. Multivariate logistic regression analysis revealed lack of spirometry utilization as an independent risk factor for severe exacerbations. CONCLUSIONS: A Pulmonologist-led disease management program integrating key elements of care is cost effective and significantly decreases severe exacerbations. Integrated programs should be encouraged for care of frequent exacerbators of asthma and COPD.

Breast cancer survival among South Asian women in California (United States).

BACKGROUND: Very little is known about cancer survival patterns among the growing South Asian community in the United States. METHODS: Breast cancer survival patterns were evaluated among South Asians using California Cancer Registry data from 1988 to 1998, and breast cancer survival among South Asians was compared to non-Hispanic Whites and other Asian subgroups. The analysis included all female, invasive, histologically confirmed breast cancer cases diagnosed from 1988 to 1998. The outcome of interest was death due to breast cancer. The Kaplan-Meier method was used to calculate 5- and 10-year survival probabilities. RESULTS: South Asians were less likely to be diagnosed with early stage carcinomas relative to non-Hispanic Whites, Chinese and Japanese individuals. In unadjusted analyses, South Asians experienced poorer survival than non-Hispanic Whites at later survival times. The 5- and 10-year unadjusted survival probabilities for South Asians were 84% and 76%, respectively, compared to those for non-Hispanic Whites, which were 87% and 80%, respectively. There was no significant difference in survival between South Asians and non-Hispanic Whites after multivariate adjustment. CONCLUSIONS: These data suggest the need for targeted efforts to improve early stage diagnosis among South Asian women. Further research into the factors that influence survival among South Asians is also needed.

Cancer incidence in the south Asian population of California, 1988-2000.

BACKGROUND: Although South Asians (SA) form a large majority of the Asian population of U.S., very little is known about cancer in this immigrant population. SAs comprise people having origins mainly in India, Pakistan, Bangladesh and Sri Lanka. We calculated age-adjusted incidence and time trends of cancer in the SA population of California (state with the largest concentration of SAs) between 1988-2000 and compared these rates to rates in native Asian Indians as well as to those experienced by the Asian/Pacific Islander (API) and White, non-Hispanic population (NHW) population of California. METHODS: Age adjusted incidence rates observed among the SA population of California during the time period 1988-2000 were calculated. To correctly identify the ethnicity of cancer cases, 'Nam Pehchan' (British developed software) was used to identify numerator cases of SA origin from the population-based cancer registry in California (CCR). Denominators were obtained from the U.S. Census Bureau. Incidence rates in SAs were calculated and a time trend analysis was also performed. Comparison data on the API and the NHW population of California were also obtained from CCR and rates from Globocan 2002 were used to determine rates in India. RESULTS: Between 1988-2000, 5192 cancers were diagnosed in SAs of California. Compared to rates in native Asian Indians, rates of cancer in SAs in California were higher for all sites except oropharyngeal, oesophageal and cervical cancers. Compared to APIs of California, SA population experienced more cancers of oesophagus, gall bladder, prostate, breast, ovary and uterus, as well as lymphomas, leukemias and multiple myelomas. Compared to NHW population of California, SAs experienced more cancers of the stomach, liver and bile duct, gall bladder, cervix and multiple myelomas. Significantly increasing time trends were observed in colon and breast cancer incidence. CONCLUSION: SA population of California experiences unique patterns of cancer incidence most likely associated with acculturation, screening and tobacco habits. There is need for early diagnosis of leading cancers in SA. If necessary steps are not taken to curb the growth of breast, colon and lung cancer, rates in SA will soon approximate those of the NHW population of California.