Current practice patterns, challenges, and educational needs of asthma care providers in the United States

OBJECTIVE

For severe, uncontrolled asthma (SUA), a gap exists between recent scientific advances and their incorporation into clinical practice. Using a Knowledge-to-Action Framework, new knowledge can be translated into evidence-based interventions to improve outcomes. The AstraZeneca U.S. PRECISION initiative aims to apply this Framework to improve recognition and management of SUA. The study objective was to identify factors contributing to gaps in care for patients with SUA. Results from a needs assessment survey of U.S. pulmonologists and allergists/immunologists were assessed within the Knowledge-to-Action Framework to advance bench-to-bedside care.

METHODS

Pulmonologists and allergists/immunologists from across the United States were invited to complete a customized, quantitative severe asthma survey in person at the 2017 American Thoracic Society annual meeting or via the Internet. Responses were summarized descriptively, and chi-squared tests evaluated associations between variables of interest.

RESULTS

Overall, 140 U.S. providers responded, most of whom were pulmonologists (84%). Most (60%) practiced in a community-based setting; 40% practiced at an academic medical center. Key challenges to providing care for patients with severe asthma included insurance company requirements and identification of the pathophysiology of an individual patient's severe asthma. Traditional measures of asthma-related morbidity were ranked as highly important by significantly more respondents compared with assessment of biomarkers (p < 0.0001). Respondents generally valued online virtual self-education.

CONCLUSIONS

Survey results identified unmet needs for the identification and management of patients with SUA and opportunities to improve patient outcomes through evidence-based management of SUA, including testing for biologic eligibility and subsequent use of biologic therapies.

Development of the Asthma Impairment and Risk Questionnaire (AIRQ): A Composite Control Measure

BACKGROUND

Asthma exacerbation risk increases with worsening asthma control. Prevailing numerical control tools evaluate only current symptom impairment despite the importance of also assessing risk based on exacerbation history. An easy-to-use questionnaire addressing impairment and risk domains of control is needed.

OBJECTIVE

To validate a composite asthma control tool that includes impairment and risk assessments (Asthma Impairment and Risk Questionnaire [AIRQ]).

METHODS

Four-hundred forty-two patients aged ≥12 years with physician-diagnosed asthma who were followed in specialty practices completed 15 impairment and risk questions with dichotomized yes/no responses. Patients spanned all Global Initiative for Asthma severities and were classified as well-controlled, not well-controlled, or very poorly controlled according to a standard of Asthma Control Test (ACT) score plus prior-year exacerbations. Logistic regression analyses identified questions with the greatest predictive validity to discriminate among patients and determine cut points for these 3 classifications.

RESULTS

The final AIRQ comprises 10 equally weighted yes/no impairment and risk questions. The final 10-item models yielded receiver operating characteristic curves of 0.94 to identify well-controlled versus not well-/very poorly controlled and 0.93 to identify well-/not well-controlled versus very poorly controlled asthma, as reflected by the ACT plus prior-year exacerbations standard. Cut points of 0-1, 2-4, and 5-10 best represented well-, not well-, and very poorly controlled asthma.

CONCLUSIONS

AIRQ is a rigorously validated composite measure designed to identify adults and adolescents with varying degrees of asthma control. Ongoing investigations will determine test-retest reliability, responsiveness to change, and predictive ability for future exacerbations.

Cardiopulmonary resuscitation in television medical dramas: Results of the TVMD2 study

INTRODUCTION

Television medical dramas (TVMDs) use cardiopulmonary resuscitation (CPR) as a mean of achieving higher viewing rates. TVMDs portrayal of CPR can be used to teach laypersons attempting to perform CPR and to form a shared professional and layperson mental model for CPR decisions. We studied the portrayal of CPR across a wide range of TVMDs to see whether newer series fulfill this promise.

MATERIALS AND METHODS

Advanced cardiac life support (ACLS) certified healthcare providers underwent training in the use of a unique instrument based on the AHA (American Heart Association) guidelines to assess TVMD CPR scenarios. Components of the assessment included the adequacy of CPR techniques, gender distribution in CPR scenes, performance quality by different healthcare providers, and CPR outcomes. Thirty-one TVMDs created between 2010 and 2018 underwent review.

RESULTS

Among 836 TVMD episodes reviewed, we identified 216 CPR attempts. CPR techniques were mostly portrayed inaccurately. The recommended compressions depth was shown in only 32.0% of the attempts (n = 62). The recommended rate was shown in only 44.3% of the attempts (n = 86). Survival to hospital discharge was portrayed as twice higher in male patients (67.6%, n = 71) than in female patients (32.4%, n = 29) (p < 0.05). Paramedics were portrayed as having better performance than physicians or nurses; compression rates were shown to be within the recommendations in only 42% (n = 73) of the CPR attempts performed by physicians, 44% (n = 8) of those performed by nurses, and 64% (n = 9) of those performed by paramedics. Complete chest recoil after compression was shown in only 34% (n = 58) of the CPR attempts performed by physicians, 38% (n = 7) of those performed by nurses, and 64% (n = 9) of those performed by paramedics. Outcomes were better on the screen than in real life; among the episodes showing outcome (n = 202), the overall rate of survival from CPR was 61.9% (n = 125).

CONCLUSION

Portrayal of CPR in TVMDs remains a missed opportunity for improving performance and communication on CPR.

A Case Series of Vaping-Induced Lung Injury in a Community Hospital Setting

Acute and subacute injury to the lung parenchyma can be caused by multiple products. Over the past few years, vaping (also known as E-cigarettes) has become a popular trend and has been considered "safer" alternative to smoking cigarettes, especially among young adults. The use of E-cigarettes has rapidly increased, and according to the most recent report by CDC released at the end of December 2019, 2,506 cases and more than 54 associated deaths due to vaping/E-cigarette-associated lung injury were reported. Though vitamin E acetate and tetrahydrocannabinol (THC) have been found in most of the bronchoalveolar lavage samples, there are still small numbers of cases that have not reported to using THC-containing compounds. Research looking into other possible constituents in E-cigarettes that can account for the etiology of disease and effects of vaping as it relates to pulmonary physiology still remains limited and uncertain. We hereby present a case series of 5 patients who were admitted primarily for respiratory symptoms of cough, dyspnea, and fevers and were diagnosed with vaping-induced pulmonary injury.

Abdominal compartment syndrome: Often overlooked conditions in medical intensive care units

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome are well recognized entities among surgical patients. Nevertheless, a number of prospective and retrospective observational studies have shown that IAH is prevalent in about half of the critically ill patients in the medical intensive care units (ICU) and has been widely recognized as an independent risk factor for mortality. It is alarming to note that many members of the critical care team in medical ICU are not aware of the consequences of untreated IAH and the delay in making the diagnosis leads to increased morbidity and mortality. Frequently it is underdiagnosed and undertreated in this patient population. Elevated intra-abdominal pressure decreases the blood flow to the kidneys and other abdominal viscera and also results in reduced cardiac output and difficulties in ventilating the patient because of increased intrathoracic pressure. When intraabdominal hypertension is not promptly recognized and treated, it leads to abdominal compartment syndrome, multiorgan dysfunction syndrome and death. Large volume fluid resuscitation is very common in medical ICU patients presenting with sepsis, shock and other inflammatory conditions like pancreatitis and it is one of the major risk factors for the development of intra-abdominal hypertension. This article presents an overview of the epidemiology, definitions, risk factors, pathophysiology and management of IAH and abdominal compartment syndrome in critically ill medical ICU patients.

Hepatic hemangioma: What internists need to know

Hepatic hemangioma (HH) is the most common benign liver tumor and it is usually found incidentally during radiological studies. This tumor arises from a vascular malformation; however, the pathophysiology has not been clearly elucidated. Symptoms usually correlate with the size and location of the tumor. Less commonly the presence of a large HH may cause life-threatening conditions. The diagnosis can be established by the identification of HH hallmarks in several imaging studies. In patients that present with abdominal symptoms other etiologies should be excluded first before attributing HH as the cause. In asymptomatic patient’s treatment is not required and follow up is usually reserved for HH of more than 5 cm. Symptomatic patients can be managed surgically or with other non-surgical modalities such as transcatheter arterial embolization or radiofrequency ablation. Enucleation surgery has shown to have fewer complications as compared to hepatectomy or other surgical techniques. Progression of the tumor is seen in less than 40%. Hormone stimulation may play a role in HH growth; however, there are no contraindications for hormonal therapy in patients with HH due to the lack of concrete evidence. When clinicians encounter this condition, they should discern between observation and surgical or non-surgical management based on the clinical presentation.

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.

Hemothorax induced by severe cough: An unusual presentation

Massive hemothorax resulting from cough-induced rib fracture is a condition in which blood accumulates in the chest, compromising the lungs and mediastinal structures. The most common cause of massive hemothorax is acute pro-traumatic injury. We present a case of a 47-year-old gentleman with morbid obesity and psoriasis, who was admitted to the emergency department due to shortness of breath that has been increased progressively after coughing for a period of 2 weeks. Chest radiograph demonstrated a large density in the left hemithorax, collapsing the left lung. Chest computerized tomography showed a left seventh rib fracture and massive pleural effusion. A closed chest tube thoracostomy was performed draining 3 L of hemorrhagic effusion, likely due to bleeding from the intercostal artery tear due to severe and prolonged cough. Cough-induced hemothorax due to spontaneous rib fractures are rare and clinicians should be well aware of this entity to prevent hemorrhagic shock and organ damage.

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.

Sarcoidosis and Its Splenic Wonder: A Rare Case of Isolated Splenic Sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown etiology characterized by presence of noncaseating granulomas in the involved organs. The pulmonary interstitium is most commonly affected but extrapulmonary involvement can occur in almost any other organ system. Such an involvement can occur with or without the presence of pulmonary involvement, but isolated extrapulmonary involvement has been noted only in around 10% of cases. Isolated splenomegaly is very rare and an uncommon presentation of sarcoidosis. It is clinically challenging because of the extensive differential diagnosis. Among the many considerations are hematologic malignancies, primary splenic or metastatic tumors, infiltrative disorders, inflammatory disorders, and infections. We hereby discuss an interesting case of a 40-year-old female with isolated splenic sarcoidosis.

The SCARE 2018 statement: Updating consensus Surgical CAse REport (SCARE) guidelines

INTRODUCTION

The SCARE Guidelines were published in 2016 to provide a structure for reporting surgical case reports. Since their publication, SCARE guidelines have been widely endorsed by authors, journal editors, and reviewers, and have helped to improve reporting transparency of case reports across a range of surgical specialties. In order to encourage further progress in reporting quality, the SCARE guidelines must themselves be kept up to date. We completed a Delphi consensus exercise to update the SCARE guidelines.

METHODS

A Delphi consensus exercise was undertaken. All members of the previous Delphi group were invited to participate, in addition to researchers who have previously studied case reports, and editors from the International Journal of Surgery Case Reports. The expert group was sent an online questionnaire where they were asked to rate their agreement with proposed changes to each of the 24 items.

RESULTS

56 people agreed to participate and 45 (80%) invitees completed the survey which put forward modifications to the original guideline. The collated responses resulted in modifications. There was high agreement amongst the expert group.

CONCLUSION

A modified and improved SCARE checklist is presented, after a Delphi consensus exercise was completed. The SCARE 2018 Statement: Updating Consensus Surgical CAse REport (SCARE) Guidelines.

Pseudomyxoma pleurii and peritonei secondary to sigmoid colon adenocarcinoma: a rare clinico-pathologico-radiological presentation

Pseudomyxoma peritonei (PMP) is a rare condition resulting from mucin-producing tumors that have disseminated into intraperitoneal implants and mucinous ascites. The extra-abdominal spread of PMP is exceptionally rare, with few reported cases in the medical literature. Pseudomyxoma pleurii is an infrequently encountered clinical syndrome characterized by transdiaphragmatic pleural extension and spread of PMP. The disease is highly fatal. We hereby report a case of 58 years old woman who presented with an abdominal distension and shortness of breath of 2 months duration. Histopathology confirmed the diagnosis of large mucin-producing rectosigmoid adenomatous polypoid lesion with malignant transformation and PMP that had spread to the right pleural space. PMP from colon tumor is uncommon and its transdiaphragmatic pleural extension is very unusual complicated by management challenge and high mortality rate.

Capnocytophaga Induced Acute Necrotizing and Exudative Pericarditis with Abscess Formation

We present the case of a 55-year-old gentleman, with bilateral pulmonary embolism and a large pericardial effusion that lead to a pericardial window with evacuation of creamy pus. Gram stains were negative, with culture growing Capnocytophaga. Pathology revealed acute necrotizing and exudative changes, including frank abscess formation. In developed countries, pericardial abscess and acute pericarditis are uncommon due to availability of broad-spectrum antibiotics. Pericardial abscess due to Capnocytophaga is even more uncommon.

Nontyphi Salmonella Empyema with Bronchopleural Fistula in a Patient with Human Immunodeficiency Virus

Patients with human immunodeficiency virus (HIV) have an increased risk of inoculation with nontyphoid Salmonella compared to the general population. While nontyphoid Salmonella commonly manifests as gastroenteritis, Salmonella bacteremia can be seen in patients with HIV. We present a case of disseminated Salmonellosis in a patient with HIV complicated by bronchopleural fistula and secondary empyema. Case Presentation. A 40-year-old African American male with HIV noncompliant with HAART therapy presented with complaints of generalized weakness, weight loss, cough, night sweats, and nonbloody, watery diarrhea of four weeks' duration. A computed tomography (CT) scan demonstrated a bilobed large, thick-walled cavitary lesion in the right upper lobe communicating with the pleural space to form a bronchopleural fistula. Thoracentesis yielded growth of nontyphi Salmonella species consistent with empyema; he was treated with intravenous Ceftriaxone and underwent placement of chest tube for drainage of empyema with instillation of alteplase/dornase twice daily for three days. Repeat CT chest showed a hydropneumothorax. The patient subsequently underwent video-assisted thoracoscopy with decortication. The patient continued to improve and follow-up CT chest demonstrated improved loculated right pneumothorax with resolution of the right bronchopleural fistula and resolution of the cavitary lesions. Discussion. We describe one of the few cases of development of bronchopulmonary fistula and the formation of empyema in the setting of disseminated Salmonella. Empyema complicated by bronchopulmonary fistula likely led to failure of intrapleural fibrinolytic therapy and the patient ultimately required decortication in addition to antibiotics. While Salmonella bacteremia can be seen in immunocompromised patients, extraintestinal manifestations of Salmonella infection such as empyema and bronchopleural fistulas are uncommon. Bronchopleural fistulas most commonly occur as a postoperative complication of pulmonary resection. Conclusions. This case highlights the unusual pulmonary manifestations that can occur due to disseminated Salmonella in an immunocompromised patient as well as complex management decisions related to these complications.

Development and validation of a tool to assess knowledge of healthy lifestyles in early grade school children

Objective

Healthy habits during childhood has been of prime importance. We aimed to gather baseline information about health habits from children in kindergarten and first grade (typically ages 5–7). Our objectives were to validate the questionnaire in assessing health habits, as well as the electronic audience response system, iClicker (MPS, Gordonsville, VA), in this age group.

Results

The questionnaire completed by 75 kindergarteners and 66 first graders. For the first graders, questions involving healthy choices were answered correctly 78% of the time (range 8–94%) and had 84% agreement on repeat testing (range 64–93%). Questions on diabetes were answered correctly 79% of the time (range 65–94%) and had 85% agreement on repeat testing. Crohnbach’s alpha was calculated to determine the reliability of the questionnaire: on the revised kindergarten questionnaire, this ranged from 0.79 to 0.81 on Day 1 and 0.84–0.97 on Day 5; for the first graders, this ranged 0.79–0.81 on Day 1 and 0.84–0.97 on Day 5. Both kindergarteners and first graders answered the simplest of the basic knowledge questions correctly > 80% of the time, with acceptable test–retest agreement. Additionally, these children demonstrated acceptable understanding of the use of the iClicker classroom response system.

Endovascular Repair of Aortobronchial Fistula after Bentall Procedure

Aortobronchial fistula (ABF) is a rare complication of aortic repair seen with both surgical and endovascular manipulation. The available literature largely refers to the need for surgical repair. We are not aware of any reports of endovascular repair after the Bentall procedure. This report describes a patient who after the Bentall procedure presented with massive hemoptysis from ABF, a multidisciplinary team decided on endovascular repair due to patient frailty to avoid redo sternotomy. We believe this is the first case report of endovascular repair and represents the success of multidisciplinary collaboration.

Thoracic herniation secondary to pleural effusion

We present the case of a 61-year-old gentleman with history of stage IV esophageal cancer presented to the emergency department with the complaints of dyspnea on exertion and cough of 1-month duration. Patient had undergone resection of distal esophagus 4 years' prior this admission. Chest radiograph revealed a large right pleural effusion and, a computed tomography scan of the chest revealed a portion of the effusion herniating between the ribs in the right hemithorax. Thoracentesis was performed with improvement in patient's dyspnea and overall condition. Patient was doing better and asymptomatic on his 3-month follow-up. Inadequate closure after surgical procedure can lead to presentation of a lung herniation. This can appear immediately after or many years later. Video-assisted thoracoscopy has been attributed to post-operative presentation of thoracic hernias when compared to more extensive operative procedures.

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.

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.

Social media usage among health care providers

Objective

The objective of this study was to evaluate the use of social media among healthcare workers in an attempt to identify how it affects the quality of patient care.

Results

An anonymous survey of 35 questions was conducted in South Texas, on 366 healthcare workers. Of the 97% of people who reported owning electronic devices, 87.9% indicated that they used social media. These healthcare workers indicated that they spent approximately 1 h on social media every day. The healthcare workers below the age of 40 were more involved in social media compared to those above 40 (p < 0.05). The use of social media among physicians and nurses was noted to be identical (88% for each group), and both groups encouraged their patients to research their clinical conditions on social media (p < 0.05). A higher number of physicians reported awareness of a social media policy in their hospital compared to nurses (p < 0.05). However, a large proportion of healthcare workers (40%) were unaware of their workplace policy, which could potentially cause a privacy breach of confidential medical information. Further studies are required to evaluate specific effects of these findings on the quality of patient care.

Plexiform Fibromyxoma: A Rare Gastric Tumor

Plexiform fibromyxoma is a rare and distinctive benign mesenchymal neoplasm that occurs in the gastric antrum. This tumor has a potential for misdiagnosis as gastrointestinal stromal tumor (GIST). It causes mucosa and vascular ulcerations without advancement of the tumor. Cytological bland spindle cells within a variably myxoid stroma characterize the histology of the tumor. We report the case of a 41-year-old African Tanzanian lady who presented with melena and recurrent anemia. Endoscopy and imaging studies revealed antral mass with initial suspicion of a GIST. However, immunohistochemically it turned to be a plexiform fibromyxoma. Follow-up evaluation 12 months after surgery revealed no evidence of recurrence or metastasis. This is a very uncommon tumor, which, to our knowledge, has been reported only once in Africa. The clinicians need to be aware of this rare occurrence to avoid misdiagnosis as GIST tumor.

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.

Role of long-term acute care in reducing hospital readmission

Long-term acute care hospitals (LTACs) are health care facilities capable of admitting complex patients with high acuity that are unable to return home after hospitalization in acute care. Its defining characteristic is to accommodate patients for a length of stay greater than 25 days, however, little is known about its role of preventing hospital readmissions. Created in the 1980s, these facilities were designed to help acute care facilities improve their resource management, expenditures, and quality of care. Although these units were initially created for chronic ventilator weaning, their scope of practice has broadened. This article analyzes studies and suggests role of LTACs in reducing hospital readmissions.

An Unusual Presentation of Congenital Lobar Emphysema

Congenital lobar emphysema is an uncommon bronchopulmonary malformation characterized by lobar overinflation and accompanying alveolar septum damage that leads to compression atelectasis of the lung parenchyma and displacement of mediastinal structures, with the resultant ventilation-perfusion mismatch. We present a case of a 33-year-old lady with progressive exertional dyspnea. Chest radiograph findings lead to the suspicion of congenital lobar emphysema, which was then confirmed by a computed tomography (CT) scan. This condition is most commonly identified in newborns, with very few cases being reported in adults. Lobectomy remains the treatment of choice and in general has good outcome.

Endotoxin, Toll-like Receptor-4, and Atherosclerotic Heart Disease

Background:

Endotoxin is a lipopolysaccharide (LPS) constituent of the outer membrane of most gram negative bacteria. Ubiquitous in the environment, it has been implicated as a cause or con-tributing factor in several disparate disorders from sepsis to heatstroke and Type II diabetes mellitus. Starting at birth, the innate immune system develops cellular defense mechanisms against environmen-tal microbes that are in part modulated through a series of receptors known as toll-like receptors. Endo-toxin, often referred to as LPS, binds to toll-like receptor 4 (TLR4)/ myeloid differentiation protein 2 (MD2) complexes on various tissues including cells of the innate immune system, smooth muscle and endothelial cells of blood vessels including coronary arteries, and adipose tissue. Entry of LPS into the systemic circulation ultimately leads to intracellular transcription of several inflammatory mediators. The subsequent inflammation has been implicated in the development and progression atherosclerosis and subsequent coronary artery disease and heart failure.

Objective:

The potential roles of endotoxin and TLR4 are reviewed regarding their role in the pathogen-esis of atherosclerotic heart disease.

Conclusion:

Atherosclerosis is initiated by inflammation in arterial endothelial and subendothelial cells, and inflammatory processes are implicated in its progression to clinical heart disease. Endotoxin and TLR4 play a central role in the inflammatory process, and represent potential targets for therapeutic intervention. Therapy with HMG-CoA inhibitors may reduce the expression of TLR4 on monocytes. Other therapeutic interventions targeting TLR4 expression or function may prove beneficial in athero-sclerotic disease prevention and treatment.

Airway Complications from an Esophageal Foreign Body

Introduction. Foreign body impaction (FBI) in the esophagus can be a serious condition, which can have a high mortality among children and adults, if appropriate diagnosis and treatment are not instituted urgently. 80–90% of all foreign bodies trapped in the esophagus usually pass spontaneously through the digestive tract, without any medical or surgical intervention. 10–20% of them will need an endoscopic intervention. Case Report. We hereby present a case of a large chicken piece foreign body impaction in the esophagus in a 25-year-old male with mental retardation. Patient developed hypoxemic respiratory failure requiring intubation. The removal required endoscopic intervention. Conclusions. Foreign bodies trapped in the upper gastrointestinal tract are a serious condition that can be fatal if they are not managed correctly. A correct diagnosis and treatment decrease the chances of complications. Endoscopic treatment remains the gold standard for extracting foreign body impaction.

Pneumothorax Causing Pneumoperitoneum: Role of Surgical Intervention

The most common cause of a pneumoperitoneum is a perforation of a hollow viscus and the treatment is an exploratory laparotomy; nevertheless, not all pneumoperitoneums are due to a perforation and not all of them need surgical intervention. We hereby present a case of pneumoperitoneum due to a diaphragmatic defect, which allowed air from a pneumothorax to escape through the diaphragmatic hernia into the abdominal cavity.

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.

Sleep Quality and Vigilance Differ Among Inpatient Nurses Based on the Unit Setting and Shift Worked

OBJECTIVES

Sleepiness in nurses has been shown to impact patient care and safety. The objectives of this study are to measure sleep quality, sleepiness, fatigue, and vigilance in inpatient nurses and to assess how setting (intensive care unit versus the general floor) and shift worked (day versus night) affect these measures.

METHODS

Nurses from both the ICU and floor were included in the study. Participants completed questionnaires assessing self-reported sleep quality (Pittsburgh Sleep Quality Index, PSQI), sleepiness (Stanford Sleepiness Scale and Epworth Sleepiness Scale, ESS), and fatigue (Fatigue Severity Scale, FSS). Vigilance was measured by means of the psychomotor vigilance test (PVT), before and after a 12-hour duty shift.

RESULTS

The ESS was abnormal in 22% of all nurses, the FSS was abnormal in 33%, and the global PSQI was abnormal in 63%. More ICU nurses than floor nurses reported abnormal sleep quality (component 5) on the PSQI. Sleep medication use (PSQI component 6) was higher in night shift nurses. The FSS was greater in night shift nurses. On preshift PVT testing, day-shift nurses overall provided faster mean reaction time (RT) than night-shift nurses. ICU nurses working the day shift made more than twice as many total errors and false starts than day shift floor nurses. Floor nurses demonstrated a significant decrease from preshift to postshift in the mean of the fastest 10% RT.

CONCLUSIONS

Our data indicate that a significant number of inpatient nurses have impaired sleep quality, excessive sleepiness, and abnormal fatigue, which may place them at a greater risk of making medical errors and harming patients; these problems are especially pronounced in night shift workers. PVT results were inconsistent, but floor and day shift nurses performed better on some tasks than ICU and night shift nurses.

When a liver transplant recipient goes back to alcohol abuse: Should we be more selective?

Alcoholic liver disease (ALD) is one of the most common indications for liver transplantation (LT). However, it has always remained as a complicated topic from both medical and ethical grounds, as it is seen for many a “self-inflicted disease”. Over the years, the survival rate of transplanted patients has significantly improved. The allocation system and the inclusion criteria for LT has also undergone some modifications. Early LT for acute alcoholic hepatitis has been subject to recent clinical studies with encouraging results in highly selected patients. We have learned from studies the importance of a multidisciplinary evaluation of candidates for LT. Complete abstinence should be attempted to overcome addiction issues and to allow spontaneous liver recovery. Risk factors for relapse include the presence of anxiety or depressive disorder, short duration of sobriety pre-LT and lack of social support. The identification of risk factors and the strengthen of social support system may decrease relapse among these patients. Family counseling of candidates is highly encouraged to prevent relapse to alcohol. Relapse has been associated with different histopathological changes, graft damage, graft loss and even decrease in survival among some studies. Therefore, each patient should be carefully selected and priority is to continue to lean on patients with high probability of success. The ethical issue remains as to the patient returning to drinking after the LT, hindering the way for other patients who could have received the same organ.

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.

To round or not to round: that is the question!

Bedside rounding and clinical examination has been an integral part of medical education and patient care for centuries. With the advent of computers and regulatory requirements for documentation by insurance carriers and third party providers, bedside rounding time has consistently decreased over the past several decades. Several studies have attempted to address the most effective way of bedside rounding, but no definite conclusion has been reached. We suggest multi-center broad base studies of key stakeholders to address this challenging issue.

Multifaceted interventions to decrease mortality in patients with severe sepsis/septic shock-a quality improvement project

Despite knowledge that EGDT improves outcomes in septic patients, staff education on EGDT and compliance with the CPOE order set has been variable. Based on results of a resident survey to identify barriers to decrease severe sepsis/septic shock mortality in the medical intensive care unit (MICU), multifaceted interventions such as educational interventions to improve awareness to the importance of early goal-directed therapy (EGDT), and the use of the Computerized Physician Order Entry (CPOE) order set, were implemented in July 2013. CPOE order set was established to improve compliance with the EGDT resuscitation bundle elements. Orders were reviewed and compared for patients admitted to the MICU with severe sepsis/septic shock in July and August 2013 (controls) and 2014 (following the intervention). Similarly, educational slide sets were used as interventions for residents before the start of their ICU rotations in July and August 2013. While CPOE order set compliance did not significantly improve (78% vs. 76%, p = 0.74), overall EGDT adherence improved from 43% to 68% (p = 0.0295). Although there was a trend toward improved mortality, this did not reach statistical significance. This study shows that education interventions can be used to increase awareness of severe sepsis/septic shock and improve overall EGDT adherence.

Pattern of external injuries sustained during bomb blast attacks in Karachi, Pakistan from 2000 to 2007

OBJECTIVE

To evaluate patterns of external injury resulting from bomb blasts in Karachi, and compare the injury profile resulting from explosions in open versus semi-confined blast environments.

METHODS

The retrospective, cross-sectional study was conducted in Karachi and comprised relevant data from January 2000 to October 2007. Casualty medical records and medico-legal certificates of the victims presented to three large public-sector hospitals were evaluated using a self-designed proforma. SPSS 17 was used for statistical analysis.

RESULTS

Of the 1146 victims, data of 481(42%) represented the final study sample. Of these, 306(63.6%) were injured in open spaces and 175(36.4%) in semi-confined spaces. Of the 896 recorded injuries, lacerations were encountered as external injury in 427(47.7%) cases, followed by penetrating wounds in 137(15.3%). Lower and upper extremities were injured in 348(38.8%) and 170(19%) victims respectively. Open and semi-confined blast environments produced specific injury pattern and profile (p<0.001).

CONCLUSIONS

External injuries sustained during bomb blast attacks in Karachi demonstrated specific injury patterns and profiles. Further studies are required to account for internal injuries and classification of injuries based on standardised scoring systems.