The NAMES assessment: a novel combined-modality screening tool for obstructive sleep apnea

PURPOSE

Obstructive sleep apnea (OSA) remains underdiagnosed, despite our understanding of its impact on general health. Current screening methods utilize either symptoms or physical exam findings suggestive of OSA, but not both. The purpose of this study was to develop a novel screening tool for the detection of OSA, the NAMES assessment (neck circumference, airway classification, comorbidities, Epworth scale, and snoring), combining self-reported historical factors with physical exam findings.

METHODS

Subjects were adults without previously diagnosed OSA, referred to a community sleep center for suspicion of OSA. General health, Epworth Sleepiness Scale (ESS), and Berlin questionnaires were completed, and a physical exam focusing on modified Friedman (MF) grade, body mass index (BMI), and neck circumference (NC) was performed prior to polysomnography. OSA was defined by a respiratory disturbance index ≥15. Each variable was dichotomized, and cutoff values were determined for the NAMES tool in a pilot group of 150 subjects. The NAMES score was calculated from NC, MF, comorbidities, ESS, and loud snoring values. The performances of the NAMES, Berlin questionnaire, and ESS screening tests in predicting OSA were then compared in a validation group of 509 subjects.

RESULTS

In the pilot population, the cutoff value for the composite NAMES tool was calculated at ≥3 points. In the validation group, NAMES demonstrated similar test characteristics to the Berlin questionnaire, and sensitivity was better than that seen with the Epworth scale. The addition of BMI and gender to the tool improved screening characteristics.

CONCLUSIONS

The NAMES assessment is an effective, inexpensive screening strategy for moderate to severe OSA.

Sexual dysfunction in women with obstructive sleep apnea

BACKGROUND

Female sexual dysfunction is vastly under-recognized but has been previously described in chronic disease states. Sexual dysfunction in male patients with obstructive sleep apnea (OSA) is well described, but not in females.

OBJECTIVE

The objective of this study was to assess the prevalence of sexual dysfunction in women with OSA.

METHODS

We studied 21 consecutive pre-menopausal women with OSA, referred to our sleep lab, and who had a positive study for sleep apnea (respiratory disturbance index (RDI) > 5), and 11 healthy pre-menopausal women were included as the control group. Subjects were administered the Female Sexual Function Index (FSFI) questionnaire and a mood scale-Profile of Mood States.

RESULTS

Of the study group, 11 women (52.4%) had FSFI scores in the poor range (<23) as compared to the control group, in which none of the women (0%) had FSFI scores in the poor range (<23). Negative mood domain scores were not different in patients with poor FSFI compared to patients with normal FSFI scores. There was no correlation between obesity, severity of sleep apnea, or mood disorders on overall scores of sexual dysfunction. Among individual domains, there was a correlation between RDI and arousal scores.

CONCLUSION

In our study, we have found that prevalence of sexual dysfunction is high among women with OSA. Physicians should routinely screen and evaluate women with OSA for sexual dysfunction.

Pulmonary complications of hepatic diseases

Severe chronic liver disease (CLD) may result from portal hypertension, hepatocellular failure or the combination of both. Some of these patients may develop pulmonary complications independent from any pulmonary pathology that they may have. Among them the hepatopulmonary syndrome (HPS), portopulmonary hypertension (PPH) and hepatic hydrothorax (HH) are described in detail in this literature review. HPS is encountered in approximately 15% to 30% of the patients and its presence is associated with increase in mortality and also requires liver transplantation in many cases. PPH has been reported among 4%-8% of the patient with CLD who have undergone liver transplantation. The HH is another entity, which has the prevalence rate of 5% to 6% and is associated in the absence of cardiopulmonary disease. These clinical syndromes occur in similar pathophysiologic environments. Most treatment modalities work as temporizing measures. The ultimate treatment of choice is liver transplant. This clinical review provides basic concepts; pathophysiology and clinical presentation that will allow the clinician to better understand these potentially life-threatening complications. This article will review up-to-date information on the pathophysiology, clinical features and the treatment of the pulmonary complications among liver disease patients.

Obesity in the intensive care unit: risks and complications

The steady growing prevalence of critically ill obese patients is posing diagnostic and management challenges across medical and surgical intensive care units. The impact of obesity in the critically ill patients may vary by type of critical illness, obesity severity (obesity distribution) and obesity-associated co-morbidities. Based on pathophysiological changes associated with obesity, predominately in pulmonary reserve and cardiac function, critically ill obese patients may be at higher risk for acute cardiovascular, pulmonary and renal complications in comparison to non-obese patients. Obesity also represents a dilemma in the management of other critical care areas such as invasive mechanical ventilation, mechanical ventilation liberation, hemodynamic monitoring and pharmacokinetics dose adjustments. However, despite higher morbidity associated with obesity in the intensive care unit (ICU), a paradoxical lower ICU mortality ("obesity paradox") is demonstrated in comparison to non-obese ICU patients. This review article will focus on the unique pathophysiology, challenges in management, and outcomes associated with obesity in the ICU.

Evaluation of the efficacy of direct oral anticoagulants (DOACs) in comparison to warfarin in morbidly obese patients

Purpose: There is limited clinical data evaluating anticoagulation with the direct oral anticoagulants (DOACs) in morbidly obese patients. We sought to examine the efficacy in preventing stroke or other systemic embolic events and safety of apixaban, dabigatran, and rivaroxaban, in comparison to warfarin in patients with either a body-mass index (BMI) over 40 kg/m2 and/or a weight over 120 kg.Methods: After approval from IRB, we collected retrospective data from our institution's records on 180 patients. We analyzed the rates of stroke and systemic embolic events as defined as ischemic stroke, pulmonary embolism (PE), deep vein thrombosis (DVT), and myocardial infarction (MI) as well as major bleeding in morbidly obese patients receiving apixaban, dabigatran, or rivaroxaban in comparison to warfarin for anticoagulation due to nonvalvular atrial fibrillation, postoperative thrombus prophylaxis, or DVT/PE treatment and/or reduction in risk for recurrence.Results: The final analysis included 90 patients in both arms. Fifty-two percent (n = 41) of patients in the DOAC group were on apixaban therapy, 12% (n = 11) on dabigatran, and 37% (n = 33) on rivaroxaban. The average BMI and weight in the DOAC group were 46.7 kg/m2 and 139.3 kg, respectively. In the warfarin group, average BMI and weight were 45.8 kg/m2 and 135.9 kg, respectively. There were 11 patients who developed a stroke or thromboembolic event in the DOAC group and 10 in the warfarin group (OR 1.11, 95% confidence interval [CI] 0.45-2.78; p = 0.82). The events in the DOAC group consisted of three patients who developed ischemic stroke, three patients who developed DVTs, one who developed a PE, and four patients who developed MIs. There were two major bleeding events in the DOAC group and three events in the warfarin group (p = 0.65).Conclusions: Anticoagulation therapy with DOACs in morbidly obese patients may be a safe and effective alternative to warfarin for prevention of stroke or systemic embolic events. However, additional studies are necessary to confirm these findings.

Influence of gender on continuous positive airway pressure requirements in patients with obstructive sleep apnea syndrome

INTRODUCTION

Gender differences have been noted in key aspects of upper airway physiology and pathophysiology of obstructive sleep apnea (OSA). We postulate that these will lead to disparities in pharyngeal collapsibility and, consequently, positive airway pressure requirements of patients with OSA.

METHODS

A retrospective review of 95 adult patients (56 women, 39 men) with OSA was done. Patients who underwent continuous positive airway pressure (CPAP) titration were included in the study.

RESULTS

The study groups were similar with regard to the severity of OSA (median apnea-hypopnea index of 34 in men and 24 in women, p = 0.13). The men were older and less obese than the women (mean age of 46 and 41 years, p = 0.03, BMI of 42 and 49 kg/m(2), p < 0.001, in men and women, respectively); Epworth score was similar in the two groups (12 vs.11, p = 0.91). CPAP requirement was higher in men than in women (12.7 vs. 10.2, p < 0.0001). The effect of gender on CPAP requirement was found to be significant even when confounding variables were accounted for using linear regression.

CONCLUSION

Men with OSA are more likely to require higher levels of CPAP support than women. The effect of gender on CPAP requirement persisted even after correcting for the severity of OSA.

Effectiveness of Mechanical Chest Compression Devices over Manual Cardiopulmonary Resuscitation: A Systematic Review with Meta-analysis and Trial Sequential Analysis

INTRODUCTION

Our goal was to systematically review contemporary literature comparing the relative effectiveness of two mechanical compression devices (LUCAS and AutoPulse) to manual compression for achieving return of spontaneous circulation (ROSC) in patients undergoing cardiopulmonary resuscitation (CPR) after an out-of-hospital cardiac arrest (OHCA).

METHODS

We searched medical databases systematically for randomized controlled trials (RCT) and observational studies published between January 1, 2000-October 1, 2020 that compared mechanical chest compression (using any device) with manual chest compression following OHCA. We only included studies in the English language that reported ROSC outcomes in adult patients in non-trauma settings to conduct random-effects metanalysis and trial sequence analysis (TSA). Multivariate meta-regression was performed using preselected covariates to account for heterogeneity. We assessed for risk of biases in randomization, allocation sequence concealment, blinding, incomplete outcome data, and selective outcome reporting.

RESULTS

A total of 15 studies (n = 18474), including six RCTs, two cluster RCTs, five retrospective case-control, and two phased prospective cohort studies, were pooled for analysis. The pooled estimates' summary effect did not indicate a significant difference (Mantel-Haenszel odds ratio = 1.16, 95% confidence interval, 0.97 to 1.39, P = 0.11, I2 = 0.83) between mechanical and manual compressions during CPR for ROSC. The TSA showed firm evidence supporting the lack of improvement in ROSC using mechanical compression devices. The Z-curves successfully crossed the TSA futility boundary for ROSC, indicating sufficient evidence to draw firm conclusions regarding these outcomes. Multivariate meta-regression demonstrated that 100% of the between-study variation could be explained by differences in average age, the proportion of females, cardiac arrests with shockable rhythms, witnessed cardiac arrest, bystander CPR, and the average time for emergency medical services (EMS) arrival in the study samples, with the latter three attaining statistical significance.

CONCLUSION

Mechanical compression devices for resuscitation in cardiac arrests are not associated with improved rates of ROSC. Their use may be more beneficial in non-ideal situations such as lack of bystander CPR, unwitnessed arrest, and delayed EMS response times. Studies done to date have enough power to render further studies on this comparison futile.

Sleep and diabetes

Sleep apnea is clinically recognized as a heterogeneous group of disorders characterized by recurrent apnea and/or hypopnea. Its prevalence ranges from 4% to 24%. It has been implicated as an independent risk factor for several conditions such as hypertension, stroke, arrhythmia, and myocardial infarction. Recently data has been emerging which suggests an independent association of obstructive sleep apnea with several components of the metabolic syndrome, particularly insulin resistance and abnormalities in lipid metabolism. We hereby review the salient features of the association between sleep and diabetes.

Successful urokinase treatment of massive pulmonary embolism in pregnancy

BACKGROUND

Thrombolytic agents have been used successfully to treat patients with massive pulmonary embolism and cardiorespiratory insufficiency, but experience with these drugs in pregnancy is limited.

CASE

A 20-year-old woman at 21 weeks' gestation was admitted with a massive pulmonary embolism. She was initially given intravenous heparin therapy but because of worsening clinical condition, urokinase was used. After two 12-hour periods of therapy, the urokinase was discontinued and the heparin restarted. She remained on subcutaneous heparin therapy for the remainder of her pregnancy, which was otherwise uncomplicated. She delivered a healthy male infant at term without complications and was discharged on warfarin therapy.

CONCLUSION

Thrombolytic therapy can be life-saving and should be considered in the treatment of hemodynamically significant pulmonary embolism in pregnancy.

Sleepy nurses: are we willing to accept the challenge today?

With a shortage of supply of nurses and the increasing demand for nursing care, hospitals require or allow nurses to work extended shifts (in excess of 12 hours) and many shifts per week (up to and in excess of 60 hours per week). The result of these excessive hours of work is that many nurses care for patients while suffering from sleep deprivation. Sleep deprivation has been shown to negatively impact judgment and performance resulting in errors and accidents. Sleep deprivation also negatively affects the health of individuals. Sleep deprivation in nurses is a significant issue that requires more attention.

The relationship between sleep disorders and stroke

Although sleep appears to be a quiescent, passive state externally, there are a multitude of physiological changes occurring during sleep that can affect cerebral homeostasis and predispose individuals to cerebrovascular disorders. Therefore, it is not surprising that sleep-disordered breathing causes significant nocturnal perturbations, such as obstructive sleep apnea (OSA), that can lead to cerebrovascular disorders. There is evidence to suggest that OSA is a risk factor for stroke, although studies have not been able to clearly discern the absence or presence of OSA before the stroke event. Sleep-disordered breathing, such as OSA and central sleep apnea, can occur as a consequence of stroke. Fortunately, treating OSA appears to decrease morbidity and possibly mortality. Unfortunately, continuous positive airway pressure compliance in this population group is low, and significant efforts and resources may be needed to improve compliance and adherence. Various other sleep disorders, such as insomnia, fatigue, hypersomnia, and parasomnia, can occur following a stroke, and physicians treating patients following a stroke need to be aware of these disorders in order to effectively treat such patients.

Adoption and adherence to chronic obstructive pulmonary disease GOLD guidelines in a primary care setting

OBJECTIVES

Over 380 million people in the world live with chronic obstructive pulmonary disease, and it is the third leading cause of death in the United States. Despite updated guidelines, there may be significant variations in diagnosis and management of chronic obstructive pulmonary disease at a primary care level. The aim of the study was to examine primary care physician management of chronic obstructive pulmonary disease in two community clinics.

METHODS

After approval from the Institutional Review Board, a retrospective chart review was done among all patients with the diagnosis of chronic obstructive pulmonary disease in two community clinics. Baseline demographics, utilization of spirometry, exacerbation history and home oxygen use were also obtained.

RESULTS

Chart reviews of 101 patients were completed (52 male and 49 female) in two outpatient primary care provider offices (Office A: 66 patients and Office B: 35 patients). None of the patients had validated measures of dyspnoea such as CAT or mMRC scores. Only 21% (22/101) of the patients had formal pulmonary function test testing done, and of those who had pulmonary function tests, 31.5% of patients were incorrectly diagnosed and mislabelled as chronic obstructive pulmonary disease. Pharmacotherapy for chronic obstructive pulmonary disease was not in alignment with GOLD guidelines, with only 42% of patients on an inhaler regimen that included a long-acting muscarinic antagonist.

CONCLUSION

There is suboptimal use of pulmonary function test in a primary care setting for diagnosis of chronic obstructive pulmonary disease and substantial errors in diagnosis. There is virtually no use routinely of validated symptom scales for diagnosis of chronic obstructive pulmonary disease. There is substantial variance in pharmacotherapy, and regimens routinely do not follow GOLD guidelines.

Novel and Controversial Therapies in COVID-19

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the coronavirus disease (COVID-19) pandemic, which has led scientists all over the world to push for the identification of novel therapies for COVID-19. The lack of a vaccine and specific treatment has led to a surge of novel therapies and their publicity in recent times. Under these unprecedented circumstances, a myriad of drugs used for other diseases is being evaluated and repositioned to treat COVID-19 (example- Remdesivir, Baricitinib). While multiple trials for potential drugs and vaccines are ongoing, and there are many unproven remedies with little or no supporting evidence. Presently, discussions are revolving around the use of multivitamins (Vitamin, C, D, A), minerals (selenium, zinc), probiotics, flavonoids, polyphenols, and herbal remedies (curcumin, artemisinin, herbal drinks). Our review delves further into the details of some of these controversial therapies for COVID-19.

Drug-induced liver injury and prospect of cytokine based therapy; A focus on IL-2 based therapies

Drug-induced liver injury (DILI) is one of the most frequent sources of liver failure and the leading cause of liver transplant. Common non-prescription medications such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and other prescription drugs when taken at more than the recommended doses may lead to DILI. The severity of DILI is affected by factors such as age, ethnicity, race, gender, nutritional status, on-going liver diseases, renal function, pregnancy, alcohol consumption, and drug-drug interactions. Characteristics of DILI-associated inflammation include apoptosis and necrosis of hepatocytes and hepatic infiltration of pro-inflammatory immune cells. If untreated or if the inflammation continues, DILI and associated hepatic inflammation may lead to development of hepatocarcinoma. The therapeutic approach for DILI-associated hepatic inflammation depends on whether the inflammation is acute or chronic. Discontinuing the causative medication, vaccination, and special dietary supplementation are some of the conventional approaches to treat DILI. In this review, we discuss a concise overview of DILI-associated liver complications, and current therapeutic options with special emphasis on biologics including the scope of cytokine therapy in hepatic repair and resolution of inflammation caused by over- the-counter (OTC) or prescription drugs.

Practice patterns of screening for sleep apnea in physicians treating PCOS patients

Women with polycystic ovarian syndrome (PCOS) have been shown to have a very high prevalence of obstructive sleep apnea (OSA). Screening for OSA is recommended for PCOS patients. How far this is carried out in actual practice is unknown. To study practice patterns with regard to screening for OSA in physicians-both obstetrician/gynecologists (ObGyn) and endocrinologist-who manage PCOS. A secondary aim of this study was to identify practice differences, if any. Two hundred ObGyn and 140 endocrine academic institutions were contacted and mailed with questionnaires, if willing to participate. Responses were obtained from 50 (29.4%) ObGyn physicians and 29 (26.4%) endocrine physicians. The questionnaire was closed-ended. Physicians reported a high occurrence of obesity-36.7% of the physicians reported that 75-100% of their patients had morbid obesity. However, reported prevalence of symptoms was low-86.1% of the physicians felt their patients snored infrequently (<25% of the time) and 74.7% felt that their patients had excess daytime sleepiness (EDS) infrequently. Of the physicians, 92.4% ordered a sleep study <25% of the time. No significant difference in practice between the specialties was identified. Physicians who manage PCOS patients do not believe that these patients have significant symptoms nor warrant frequent testing for OSA. This may reflect lack of knowledge about the link or may imply that PCOS patients remain largely asymptomatic. Educating specialist physicians managing PCOS about OSA and improved tools for OSA screening may improve detection.

Spontaneous extraperitoneal lumbar artery hemorrhage

BACKGROUND

Spontaneous extraperitoneal hemorrhage (SEH) is an uncommon complication of anticoagulation therapy. Cases of SEH that are unresponsive to management through correction of coagulopathy, fluid resuscitation, blood transfusion, and other supportive measures are typically treated with surgery. Nevertheless, treatment of SEH with the use of angiography and arterial embolization may provide a safe, efficacious alternative to surgery.

OBJECTIVES

This case is presented to increase awareness among Emergency Physicians of the management options for patients with SEH.

CASE REPORT

A 67-year-old man presented to the Emergency Department with hemodynamic collapse due to retroperitoneal bleeding secondary to spontaneous rupture of a lumbar artery. An emergency abdominal angiogram revealed an actively bleeding left lumbar vessel. The localized bleeding was treated with catheter embolization and detachable microcoil embolization. This resulted in stabilization of the patient's condition without surgical intervention.

CONCLUSION

Overall, the improvement in hemodynamic stability and the decreased percentage of transfusion requirements can be achieved safely without surgical intervention through the prompt use of coil or catheter embolization.

Spotlight on solithromycin in the treatment of community-acquired bacterial pneumonia: design, development, and potential place in therapy

Community-acquired bacterial pneumonia (CABP) is a leading cause of death worldwide. However, antibacterial agents used to treat common pathogens in CABP are marked by adverse drug events and increasing antimicrobial resistance. Solithromycin is a new ketolide antibiotic, based on the macrolide antibiotic structure, being studied for use in CABP. It has efficacy in vitro against the common causative pathogens in CABP including Streptococcus pneumoniae, Haemophilus influenzae, and atypical pathogens. In Phase II and Phase III clinical trials, it has been demonstrated efficacious as a single agent for treatment of CABP with an apparently milder adverse event profile than alternative agents.

Sleepiness in medical residents: impact of mandated reduction in work hours

OBJECTIVES

To assess the sleepiness among Family Practice residents using subjective data, the Epworth sleepiness scale (ESS), as well as objective assessment, the multiple sleep latency test (MSLT).

METHOD

We conducted the study on Family Practice residents at Texas A&M University, Corpus Christi. Sixteen residents, aged 21-40 yrs, were recruited and divided into two groups. The study group was comprised of residents who were on night-float rotation for at least three days and underwent MSLT post-call, and the control group was comprised of residents who were not on night-float and were not post-call. Daytime sleepiness was evaluated using both the ESS and MSLT. Respondents also completed a questionnaire assessing their beliefs regarding effects of sleep loss.

RESULTS

Sleep latencies <10 min were observed in 6 out of the 8 day shift-work interns, while only 1 out of 8 night-float residents had an average sleep latency <10 min (p=0.0195). Following night-float, despite less sleep, residents had sleep latencies which were higher [14.2 (+/-5.0) min] than those in the control group [8.4 (+/-5.4) min, (p=0.043)]. Despite the difference in objective sleepiness, subjective sleepiness (Epworth scores) did not differ. Over 80% of interns reported having driven while sleepy.

CONCLUSION

Sleepiness continues to be a significant issue among medical residents despite recently mandated reductions in resident work hours. MSLT values in the pathologic range are seen in the majority of residents studied, but in those who were post-night call there seemed to be a paradoxical improvement.

Acute Fibrinous and Organizing Pneumonia: A Case Report and Review of the Literature

BACKGROUND Acute fibrinous organizing pneumonia (AFOP) is a rare condition of the lung that is associated with acute lung injury, and has a poor prognosis. AFOP is characterized histologically by intra-alveolar fibrin. AFOP has been described to be associated with lung infections, connective tissue disorders, drugs, toxic environmental exposure, and in lung transplantation. However, most cases of AFOP remain idiopathic, and because the condition can present with a wide variety of clinical manifestations, open lung biopsy or video-assisted thoracoscopic (VAT) lung biopsy is necessary for the diagnosis. Currently, treatments for AFOP remain under investigation. CASE REPORT A 35-year-old woman presented with a cough and dyspnea, and was initially diagnosed to have pneumonia.  Due to the progression of her symptoms and increasing respiratory failure she underwent video-assisted thoracoscopic (VAT) biopsy and was diagnosed with AFOP, 19 days following hospital admission. She was treated with mechanical ventilation, intravenous steroids, and cyclophosphamide. She required tracheostomy after 14 days of mechanical ventilation and died two weeks later. CONCLUSIONS AFOP is an uncommon clinical condition, with a poor prognosis, which often has a delay in diagnosis. Some patients benefit from steroids and immunosuppressive therapy. Currently, new treatments for AFOP are under investigation.

ViSHWaS: Violence Study of Healthcare Workers and Systems-a global survey

OBJECTIVE

To provide insights into the nature, risk factors, impact and existing measures for reporting and preventing violence in the healthcare system. The under-reporting of violence against healthcare workers (HCWs) globally highlights the need for increased public awareness and education.

METHODS

The Violence Study of Healthcare Workers and Systems study used a survey questionnaire created using Research Electronic Data Capture (REDCap) forms and distributed from 6 June to 9 August 2022. Logistic regression analysis evaluated violence predictors, including gender, age, years of experience, institution type, respondent profession and night shift frequency. A χ2 test was performed to determine the association between gender and different violence forms.

RESULTS

A total of 5405 responses from 79 countries were analysed. India, the USA and Venezuela were the top three contributors. Female respondents comprised 53%. The majority (45%) fell within the 26-35 age group. Medical students (21%), consultants (20%), residents/fellows (15%) and nurses (10%) constituted highest responders. Nearly 55% HCWs reported firsthand violence experience, and 16% reported violence against their colleagues. Perpetrators were identified as patients or family members in over 50% of cases, while supervisor-incited violence accounted for 16%. Around 80% stated that violence incidence either remained constant or increased during the COVID-19 pandemic. Among HCWs who experienced violence, 55% felt less motivated or more dissatisfied with their jobs afterward, and 25% expressed willingness to quit. Univariate analysis revealed that HCWs aged 26-65 years, nurses, physicians, ancillary staff, those working in public settings, with >1 year of experience, and frequent night shift workers were at significantly higher risk of experiencing violence. These results remained significant in multivariate analysis, except for the 55-65 age group, which lost statistical significance.

CONCLUSION

This global cross-sectional study highlights that a majority of HCWs have experienced violence, and the incidence either increased or remained the same during the COVID-19 pandemic. This has resulted in decreased job satisfaction.

Artificial Intelligence and Lung Cancer: Impact on Improving Patient Outcomes

Lung cancer remains one of the leading causes of cancer-related deaths worldwide, emphasizing the need for improved diagnostic and treatment approaches. In recent years, the emergence of artificial intelligence (AI) has sparked considerable interest in its potential role in lung cancer. This review aims to provide an overview of the current state of AI applications in lung cancer screening, diagnosis, and treatment. AI algorithms like machine learning, deep learning, and radiomics have shown remarkable capabilities in the detection and characterization of lung nodules, thereby aiding in accurate lung cancer screening and diagnosis. These systems can analyze various imaging modalities, such as low-dose CT scans, PET-CT imaging, and even chest radiographs, accurately identifying suspicious nodules and facilitating timely intervention. AI models have exhibited promise in utilizing biomarkers and tumor markers as supplementary screening tools, effectively enhancing the specificity and accuracy of early detection. These models can accurately distinguish between benign and malignant lung nodules, assisting radiologists in making more accurate and informed diagnostic decisions. Additionally, AI algorithms hold the potential to integrate multiple imaging modalities and clinical data, providing a more comprehensive diagnostic assessment. By utilizing high-quality data, including patient demographics, clinical history, and genetic profiles, AI models can predict treatment responses and guide the selection of optimal therapies. Notably, these models have shown considerable success in predicting the likelihood of response and recurrence following targeted therapies and optimizing radiation therapy for lung cancer patients. Implementing these AI tools in clinical practice can aid in the early diagnosis and timely management of lung cancer and potentially improve outcomes, including the mortality and morbidity of the patients.

Gastrointestinal Histoplasmosis Presenting as an Acute Abdomen with Jejunal Perforation

INTRODUCTION

Gastrointestinal histoplasmosis (GH) is a well-described albeit uncommon disease. It is found almost exclusively in the immunocompromised host, especially those with untreated HIV and low CD4 counts. Presentation with intestinal perforation is seen mostly commonly in the colon. We present a patient with jejunal perforation, and there have been only 3 previous cases reported in the literature.

CASE

A 39-year-old male with known, untreated HIV presented to the ED with an acute abdomen after experiencing worsening intermittent abdominal pain for 2 months before that was associated with nausea, vomiting, diarrhea, and weight loss. CT of the abdomen and pelvis revealed evidence of gas in the mesentery, small bowel thickening, edema, and free fluid in the abdomen. Emergency exploratory laparotomy was conducted. Intraoperative findings included a perforated jejunum that was studded with nodular lesions as well as mesenteric masses. Histopathologic exam of these mesenteric masses and jejunal lesions were positive for histoplasmosis.

CONCLUSION

Disseminated histoplasmosis is a life-threatening disease that occurs nearly exclusively in immunocompromised hosts. Untreated, mortality is as high as 80%. This rare presentation with jejunal perforation highlights the need for awareness of histoplasmosis involvement throughout the entirety of the GI tract.

Sleepiness in medical ICU residents

BACKGROUND AND METHODS

Sleepiness in medical residents has crucial implications for the safety of both patients and residents. Measures to improve this have primarily included an Accreditation Council for Graduate Medical Education-mandated reduction in work hours in residency programs. The impact of these work-hour limitations has not been consistent. The purpose of this study was to provide an objective assessment of daytime sleepiness in medical residents working in the medical ICU. Sleep times for 2 days/nights prior to on call and on the day/night of being on call were assessed by actigraphy and sleep diaries. On-call and post-call measurements of residents' sleepiness were measured both objectively, by means of a modified multiple sleep latency test (MSLT) [two nap sessions], as well as subjectively, by the Stanford Sleepiness Scale.

RESULTS

Our data showed that despite an average sleep time of 7.15 h on nights leading to being on call, the mean sleep latency (MSL) on the on-call day was (+/- SD) 9 +/- 4.4 min, and 4.8 +/- 4.1 min (p < 0.001) on the post-call day. On the post-call day, 14 residents (70%) had an MSL of < 5 min, suggesting severe sleepiness, compared to 6 residents (30%) on the on-call day.

CONCLUSION

Our results demonstrate that residents working in the ICU despite reductions in work hours demonstrate severe degree of sleepiness post-call.

Effect of the COVID-19 pandemic on surgery for indeterminate thyroid nodules (THYCOVID): a retrospective, international, multicentre, cross-sectional study

BACKGROUND

Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours.

METHODS

In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186.

FINDINGS

Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78·6%] female patients and 4922 [21·4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1·4 [IQR 0·6-3·4]) compared with the prepandemic phase (2·0 [0·9-3·7]; p<0·0001) and pandemic decrease phase (2·3 [1·0-5·0]; p<0·0001). Compared with the prepandemic phase, in the pandemic decrease phase we observed an increased occurrence of thyroid tumours larger than 10 mm (2554 [69·0%] of 3704 vs 1515 [71·5%] of 2119; OR 1·1 [95% CI 1·0-1·3]; p=0·042), lymph node metastases (343 [9·3%] vs 264 [12·5%]; OR 1·4 [1·2-1·7]; p=0·0001), and tumours at high risk of structural disease recurrence (203 [5·7%] of 3584 vs 155 [7·7%] of 2006; OR 1·4 [1·1-1·7]; p=0·0039).

INTERPRETATION

Our study suggests that the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic period could have led to an increased occurrence of aggressive thyroid tumours. However, other compelling hypotheses, including increased selection of patients with aggressive malignancies during this period, should be considered. We suggest that surgery for indeterminate thyroid nodules should no longer be postponed even in future instances of pandemic escalation.

FUNDING

None.