An Unusual Etiology of Fluorodeoxyglucose Avid Intrathoracic Lymph Nodes

A middle-aged man in his 50s, active smoker, presented to the pulmonary office for lung cancer evaluation. On a low-dose computed tomography for lung cancer screening, he was found to have an 8 mm endobronchial lesion in the right main stem bronchus. A PET-CT revealed no endobronchial lesion, but incidentally, fluorodeoxyglucose (FDG) avidity was present in the right hilar (SUV 13.2) and paratracheal lymph nodes (LNs). He underwent bronchoscopy and EBUS-TBNA of station 7 and 10 R LNs. The fine needle aspiration (FNA) revealed necrotizing epithelioid granuloma. The acid-fast bacilli (AFB) and Grocott methenamine silver (GMS) stains were negative. He had suffered from pneumonic tularemia 13 months ago and immunohistochemical staining for Francisella tularensis on FNA samples at Center for Disease Control and Prevention was negative. The intense positron emission tomography (PET) avidity was attributed to prior tularemic intrathoracic lymphadenitis without active tularemia, a rare occurrence. To the best of our knowledge, PET-positive intrathoracic lymph node beyond one year without evidence of active tularemia has not been previously reported.

Evaluating newly approved drugs in combination regimens for multidrug-resistant tuberculosis with fluoroquinolone resistance (endTB-Q): study protocol for a multi-country randomized controlled trial

BACKGROUND

Treatment for fluoroquinolone-resistant multidrug-resistant/rifampicin-resistant tuberculosis (pre-XDR TB) often lasts longer than treatment for less resistant strains, yields worse efficacy results, and causes substantial toxicity. The newer anti-tuberculosis drugs, bedaquiline and delamanid, and repurposed drugs clofazimine and linezolid, show great promise for combination in shorter, less-toxic, and effective regimens. To date, there has been no randomized, internally and concurrently controlled trial of a shorter, all-oral regimen comprising these newer and repurposed drugs sufficiently powered to produce results for pre-XDR TB patients.

METHODS

endTB-Q is a phase III, multi-country, randomized, controlled, parallel, open-label clinical trial evaluating the efficacy and safety of a treatment strategy for patients with pre-XDR TB. Study participants are randomized 2:1 to experimental or control arms, respectively. The experimental arm contains bedaquiline, linezolid, clofazimine, and delamanid. The control comprises the contemporaneous WHO standard of care for pre-XDR TB. Experimental arm duration is determined by a composite of smear microscopy and chest radiographic imaging at baseline and re-evaluated at 6 months using sputum culture results: participants with less extensive disease receive 6 months and participants with more extensive disease receive 9 months of treatment. Randomization is stratified by country and by participant extent-of-TB-disease phenotype defined according to screening/baseline characteristics. Study participation lasts up to 104 weeks post randomization. The primary objective is to assess whether the efficacy of experimental regimens at 73 weeks is non-inferior to that of the control. A sample size of 324 participants across 2 arms affords at least 80% power to show the non-inferiority, with a one-sided alpha of 0.025 and a non-inferiority margin of 12%, against the control in both modified intention-to-treat and per-protocol populations.

DISCUSSION

This internally controlled study of shortened treatment for pre-XDR TB will provide urgently needed data and evidence for clinical and policy decision-making around the treatment of pre-XDR TB with a four-drug, all-oral, shortened regimen.

TRIAL REGISTRATION

ClinicalTrials.Gov NCT03896685. Registered on 1 April 2018; the record was last updated for study protocol version 4.3 on 17 March 2023.

Tension hydrothorax in a patient with a history of pulmonary tuberculosis

A tension hydrothorax is a massive pleural effusion that leads to hemodynamic instability. Here we present a case of tension hydrothorax secondary to poorly differentiated carcinoma. A 74-year-old male smoker presented after a one-week history of dyspnea and unintentional weight loss. Physical exam demonstrated tachycardia, tachypnea, and decreased breath sounds diffusely over the right lung. Imaging revealed a massive pleural effusion causing mass effect on the mediastinum with tension physiology. Chest tube placement revealed an exudative effusion with negative cultures and cytology. Pleural biopsy revealed atypical epithelioid cells consistent with poorly differentiated carcinoma.

The Role of Surgery in Stage I Small Cell Lung Cancer: A National VA Database Analysis

BACKGROUND

Historically, limited stage Small Cell Lung Cancer (SCLC) has been treated with concurrent chemoradiation (CRT). While current NCCN guidelines recommend consideration of lobectomy in node-negative cT1-T2 SCLC, data regarding the role of surgery in very limited SCLC is lacking.

METHODS

Data from the National VA Cancer Cube were compiled. A total of 1,028 patients with pathologically confirmed stage I SCLC were studied. Only 661 patients that either received surgery or CRT were included. Interval-censored Weibull and Cox proportional hazard regression models were used to estimate median overall survival (OS) and hazard ratio (HR), respectively. Two survival curves were compared by a Wald test. Subset analysis was performed based on the location of the tumor in the upper vs. lower lobe as delineated by ICD-10 codes C34.1 and C34.3.

RESULTS

Four-hundred and forty-six patients received concurrent CRT; while 223 underwent treatment that contained surgery (93 surgery only, 87 surgery/chemo, 39 surgery/chemo/radiation and 4 surgery/radiation). The median OS for the surgery-inclusive treatment was 3.87 years (95% CI 3.21-4.48) while median OS for the CRT cohort was 2.45 years (95% CI 2.17-2.74). HR of death for surgery-inclusive treatment when compared to CRT is 0.67 (95% CI 0.55-0.81; P < .001). Subset analysis based on the location of the tumor in both the upper or lower lobes showed improved survival with surgery as compared to CRT regardless of the location. HR for the upper lobe was 0.63 (95% CI 0.50-0.80; P < .001) and lower lobe 0.61 (95% CI 0.42-0.87; P = .006). Multivariable regression analysis accounting for age and ECOG-PS shows a HR 0.60 (95% CI 0.43-0.83; P = .002) favoring surgery.

CONCLUSIONS

Surgery was used in less than a third of patients with stage I SCLC who received treatment. Surgery-inclusive multimodality treatment was associated with a longer overall survival as compared to chemoradiation, independent of age, performance status or tumor location. Our study suggests a more expansive role for surgery in stage I SCLC.

Progression of ECG in hydroxychloroquine overdose

Hydroxychloroquine overdose is associated with myocardial toxicity and conduction disorders. We report a case of hydroxychloroquine overdose that demonstrated a rapid progressive intraventricular conduction delay and QT prolongation resulting in significant bradycardia and shock despite aggressive treatment. We describe the rare capture of abrupt abnormalities of this overdose in sequential electrocardiograms in the immediate hours post-ingestion.

A Woman With Progressive Dyspnea and Seronegative Rheumatoid Arthritis

CASE PRESENTATION

A 66-year-old woman with a medical history of seronegative rheumatoid arthritis on long-standing methotrexate and adalimumab therapy was referred to the pulmonary clinic for abnormal chest imaging. The patient was also under evaluation by rheumatology physicians for increased fatigue, nonproductive cough, and recurrent sinus infections. At the time of the initial pulmonary visit, the patient complained of acute onset of bilateral blurry vision and subsequently was diagnosed with anterior uveitis and received ophthalmic steroids with significant improvement. The patient's biologic therapy was discontinued because of a concern for possible drug toxicity. Over the course of 4 months, the patient experienced worsening dyspnea with exertion. She was a lifelong nonsmoker and had no history of recent travel. However, on review of possible environmental exposures, patient stated using feather pillows and bedding for several decades.

Fixed right ventricular collapse: A loculated pericardial effusion due to metastatic pulmonary adenocarcinoma

Pericardial effusions can occur as either circumferential or loculated when referencing their anatomic distribution in the pericardium. These effusions can result from multiple different etiologies, including malignancy, infection, trauma, connective tissue disease, acute pericarditis drug induced, or idiopathic. Loculated pericardial effusions can be difficult to manage. Even small loculated effusions can result in hemodynamic compromise. Oftentimes in the acute setting, point of care ultrasound can be used to evaluate pericardial effusions directly at the bedside. We present a case of a malignant loculated pericardial effusion and offer insight into management and clinical evaluation using point of care ultrasound.

Malpositioned nephrostomy tube with associated hemorrhagic pleural effusion

Pleural effusion of extra-vascular origin has a large differential diagnosis. Ultrasonography can be utilized alongside pleural fluid analysis to determine a pleural effusion's complexity and size, thus helping aid in both diagnostic and therapeutic management. We describe the case of a 38-year-old male with a prior medical history of neurogenic bladder and nephrolithiasis with percutaneous nephrostomy tube placed one week prior to presentation. Using ultrasonography, the nephrostomy tube was determined to be positioned within the pleural cavity with a resultant hemorrhagic pleural effusion.

Comparison of Carboplatin With Cisplatin in Small Cell Lung Cancer in US Veterans

IMPORTANCE

The current standard of care for the treatment of small cell lung cancer (SCLC) is concurrent chemoradiation for patients with limited-stage SCLC (LS-SCLC) and chemoimmunotherapy for extensive-stage SCLC (ES-SCLC). The backbone of chemotherapy regimens in both is a platinum-etoposide doublet: cisplatin is traditionally the preferred platinum agent in the curative intent setting, whereas carboplatin is preferred in ES-SCLC because of its favorable toxicity profile.

OBJECTIVE

To determine whether cisplatin is associated with better survival outcomes than carboplatin in treating LS-SCLC and ES-SCLC.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, data were compiled from the National Veterans Affairs Central Cancer Registry for patients with SCLC who received platinum-based multiagent chemotherapy between 2000 and 2020 for ES-SCLC and 2000 and 2021 for LS-SCLC. Only patients with pathologically confirmed cases of LS-SCLC who received concurrent chemoradiation and ES-SCLC who received chemotherapy were included.

MAIN OUTCOMES AND MEASURES

The primary end point was overall survival (OS). The secondary end points included OS by Eastern Cooperative Oncology Group performance status, age, and laterality. Interval-censored Weibull and Cox proportional hazard regression models were used to estimate median OS and hazard ratios (HRs), respectively. Survival curves were compared by a Wald test.

RESULTS

A total of 4408 SCLC cases were studied. Most patients were White (3589 patients [81.4%]), male (4252 [96.5%]), and non-Hispanic (4142 [94.0%]); 2262 patients (51.3%) were 60 to 69 years old, followed by 1476 patients (33.5%) aged 70 years or older, 631 patients (14.3%) aged 50 to 59 years, and 39 patients (0.9%) aged 30 to 49 years. Among 2652 patients with ES-SCLC, 2032 were treated with carboplatin-based therapy and 660 received cisplatin; the median OS was 8.45 months (95% CI, 7.75-9.20 months) for cisplatin and 8.51 months (95% CI, 8.07-8.97 months) for carboplatin (HR, 1.01; 95% CI, 0.91-1.12; P = .90). Subset analysis showed no survival difference between the 2 agents in different age or performance status groups except for patients aged 70 years and older, for whom the median OS was 6.36 months (95% CI, 5.31-7.56 months) for cisplatin and 8.47 months (95% CI, 7.79-9.19 months) for carboplatin (HR, 0.77; 95% CI, 0.61-0.96; P = .02). Multivariable analysis of performance status and age did not show a significant difference in survival between the 2 groups (HR, 0.96; 95% CI, 0.83-1.10; P = .54). Of 1756 patients with LS-SCLC, 801 received carboplatin, and 1018 received cisplatin. The median OS was 26.92 months (95% CI, 25.03-28.81 months) for cisplatin and 25.58 months (95% CI, 23.64-27.72 months) for carboplatin (HR, 1.04; 95% CI, 0.94-1.16; P = .46). The median OS was not significantly different between 2 agents according to cancer stage (I-III), performance status, and age groups. A multivariable analysis of factors associated with OS accounting for stage (I-III), performance status, and age did not demonstrate a significant difference in survival between carboplatin and cisplatin in patients with LS-SCLC (HR, 0.995; 95% CI, 0.86-1.15; P = .95).

CONCLUSIONS AND RELEVANCE

Cisplatin is not associated with a survival advantage over carboplatin among patients with either ES-SCLC or LS-SCLC, irrespective of performance status and age. The favorable toxicity profile of carboplatin and comparable OS support its use in both LS-SCLC and ES-SCLC in clinical practice and may allow more room for combination with novel treatment strategies in clinical trials.

355 Comparison of Outcomes in Surgical and Endoscopic Transgastric Cystgastrostomy for Severe Acute Pancreatitis

Aim

The heterogeneous nature of severe acute pancreatitis (SAP) renders decisions related to complications challenging. A select group of patients may be suitable for surgical (S-CG), which can be performed open or laparoscopic, or endoscopic (E-CG) transgastric cystgastrostomy (TCG) of symptomatic or infected retrogastric pancreatic collections (walled-off pancreatic necrosis (WOPN) or pseudocyst). There is limited data comparing outcomes between these approaches.

Method

Retrospective analysis of all patients that underwent S-CG or E-CG was performed from a single, high-volume benign pancreatic centre between 2012 – 2021 inclusive. Patient demographics, clinical characteristics, and outcomes of these 3 groups was compared. One-way analysis of variance tests was used to compare categorical data.

Results

47 patients underwent TCG: 20 S-CG (12 open and 8 laparoscopic), and 27 E-CG. There was no statistical difference between S-CG and E-CG for age, body mass index (BMI), aetiology, organ failure and type or position of collection. S-CG patients had less burden of pre-existing co-morbidities (APACHE-II and Charlson-Co-morbidity-Index (CCI)) (p&lt;0.05). S-CG patients had shorter length of stay, emergency readmission and reintervention (p&lt;0.05). Those who underwent E-CG had higher burden of intervention due to persistent/recurrent pancreatic collections, with 33% mortality rate (p &lt;0.05).

Conclusions

S-CG, in a select group of patients, provides a single-staged intervention for drainage of transgastric pancreatic collections, especially when they predominantly contain solid necrosis and patient is suitable for general anaesthetic. Outcomes are favourable for S-CG, but multidisciplinary approach is critical to delineate the most appropriate approach for each individual patient.

Clinical Characteristics and Outcomes of COVID-19 Acute Respiratory Distress Syndrome (ARDS) Survivors in Early Pandemic: A Single Healthcare System Retrospective Study

Introduction: Acute respiratory distress syndrome (ARDS) management in the intensive care unit (ICU) has attracted strong interest since the start of the COVID-19 pandemic. Our retrospective study aims to describe the outcomes and predictors of mortality of ARDS associated with COVID-19 within one university-based healthcare system.

Methods: We identified 165 patients within our healthcare system during the months of April 2020 through July 2020, who were admitted to our medical ICUs and eligible for our study. Baseline patient characteristics, ICU and hospital course information, ICU interventions, ventilator settings, and hospital complications were collected and analyzed using descriptive statistical techniques.

Results: Our cohort had an average age of 64. No significant difference in mortality was identified with male vs. female gender or BMI. Most of the patient cohort was identified as black (68.2%). The overall mortality of our cohort was 38.2%. Hyperlipidemia, coronary artery disease, and chronic obstructive pulmonary disease were all associated with higher mortality. There was a significant difference in mortality between those with higher observed ventilator plateau pressures at 24 hours and higher driving pressures at 24 hours.

Conclusion: COVID-19-associated ARDS is associated with significant mortality. Physicians should be aware of pre-existing conditions potentially related to worse outcomes so that they receive an appropriate level of care in a timely manner. Ventilator management should focus on maintaining low intra-thoracic pressure changes. Prospective studies are needed to guide COVID-19-associated ARDS management.

Actual and projected gaps in the provision of residential aged care in New South Wales, Australia

ObjectiveThe need for residential care services will grow significantly over the coming years as the general population in Australia continues to age. The aim of this study was to assess the adequacy of residential care services across New South Wales (NSW), Australia, in relation to the current and predicted future aging population.MethodThis study was a secondary data analysis. Existing datasets were compiled for analysis by creation of a temporal geodatabase, with predicted population data from 2019 to 2029 linked to corresponding geographic zones.ResultsDemand for operational places was over capacity in 2019, at 101.5%. From 2019 to 2029, this will grow to 120.2% of 2019 capacity by 2024 and to 135.6% by 2029. An additional 25 800 operational places will be required by 2029 to meet targets. During the previous decade of 2008-18, operational places grew by only 11 502 places.ConclusionsNSW was not providing an adequate level of residential aged care and, under current allocations, this problem will worsen substantially over time, with flow-on impacts for the health sector. With aged care reform a current federal government focus, the results of this study may guide decisions that better support the provision of residential aged care.What is known about this topic?The recently completed Australian Royal Commission into aged care noted widespread system failure and highlighted the gaps in medical services that older Australians were experiencing.What does this paper add?This paper reports that demand for residential aged care places in NSW was already over capacity in 2019 and that the availability of places varies considerably across the state. Further, an additional 25 800 operational places are required by 2029 to meet government targets. If the growth rate from the past decade is maintained, this will result in a shortfall of 14 298 aged care places in NSW alone.What are the implications?Without significant increases in the current rate of growth for aged care places, the mainstream medical and health sectors will face significant additional pressures arising from unmet need in both older patients and their informal carers.

Early weight gain trajectories in first episode anorexia: predictors of outcome for emerging adults in outpatient treatment

BACKGROUND

Early response to treatment has been shown to be a predictor of later clinical outcomes in eating disorders (EDs). Specifically, early weight gain trajectories in anorexia nervosa (AN) have been shown to predict higher rates of later remission in inpatient treatment. However, no study has, as of yet, examined this phenomenon within outpatient treatment of first episode cases of AN or in emerging adults.

METHODS

One hundred seven patients with AN, all between the ages of 16 and 25 and with an illness duration of < 3 years, received treatment via the first episode rapid early intervention in eating disorders (FREED) service pathway. Weight was recorded routinely across early treatment sessions and recovery outcomes (BMI > 18.5 kg/m2 and eating psychopathology) were assessed up to 1 year later. Early weight gain across the first 12 treatment sessions was investigated using latent growth mixture modelling to determine distinct classes of change. Follow-up clinical outcomes and remission rates were compared between classes, and individual and clinical characteristics at baseline (treatment start) were tested as potential predictors.

RESULTS

Four classes of early treatment trajectory were identified. Three of these classes (n = 95), though differing in their early change trajectories, showed substantial improvement in clinical outcomes at final follow-up. One smaller class (n = 12), characterised by a 'higher' start BMI (> 17) and no early weight gain, showed negligible improvement 1 year later. Of the three treatment responding groups, levels of purging, depression, and patient reported carer expressed emotion (in the form of high expectations and low tolerance of the patient) determined class membership, although these findings were not significant after correcting for multiple testing. A higher BMI at treatment start was not sufficient to predict optimal clinical outcomes.

CONCLUSION

First episode cases of AN treated via FREED fit into four distinct early response trajectory classes. These may represent subtypes of first episode AN patients. Three of these four trajectories included patients with substantial improvements 1 year later. For those in the non-response trajectory class, treatment adjustments or augmentations could be considered earlier, i.e., at treatment session 12.

Pleural abnormalities in COVID-19: a narrative review

Objective

This narrative review aims to provide a detailed overview of pleural abnormalities in patients with coronavirus disease 19 or COVID-19.

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) is a novel beta coronavirus responsible for COVID-19. Although pulmonary parenchymal and vascular changes associated with COVID-19 are well established, pleural space abnormalities have not been the primary focus of investigations.

Methods

Narrative overview of the medical literature regarding pleural space abnormalities in COVID-19. The appropriate manuscripts were identified by searching electronic medical databases and by hand searching the bibliography of the identified papers. Pleural abnormalities on transverse and ultrasound imaging are discussed. The incidence, clinical features, pathophysiology, and fluid characteristics of pleural effusion are reviewed. Studies reporting pneumothorax and pneumomediastinum are examined to evaluate for pathogenesis and prognosis. A brief comparative analysis of pleural abnormalities among patients with COVID-19, severe acute respiratory syndrome (SARS), and Middle Eastern respiratory syndrome (MERS) has been provided.

Conclusions

Radiologic pleural abnormalities are common in COVID-19, but the incidence of pleural effusion appears to be low. Pneumothorax is rare and does not independently predispose the patient to worse outcomes. SARS-CoV-2 infects the pleural space; however, whether the pleural fluid can propagate the infection is unclear.

Cisplatin versus carboplatin for the treatment of limited-stage small cell lung cancer (LS-SCLC)

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Background: Standard of care therapy for LS- SCLC is concurrent chemo-radiation (CRT) with a platinum-etoposide backbone. Cisplatin is traditionally the preferred platinum agent in the curative intent setting. Data comparing the efficacy of the less toxic carboplatin to cisplatin in LS-SCLC are lacking. Methods: Data from the National VA Cancer Cube were collected. Pathologically confirmed cases of LS-SCLC that received concurrent CRT with platinum-based multiagent chemotherapy were included. Interval-censored Weibull and Cox proportional hazard regression models were used to estimate median overall survival (OS) and hazard ratio (HR), respectively. Survival curves were compared by a Wald test. Results: 801 LS-SCLC patients who received carboplatin-based therapy (Carbo-SCLC) and 1018 who cisplatin-based therapy (Cis-SCLC) were included in the analysis. Median OS with Carbo-SCLC and Cis-SCLC were 2.13 years (95% CI 1.97-2.31) and 2.24 years (95% CI 2.09-2.4), respectively (HR=1.04;95% CI, 0.94-1.16; p=0.46). Subset analysis showed similar median OS for Carbo-SCLC and Cis-SCLC in patients with ECOG-PS of 0, 1 and 2, as well as patients in their 50s, 60s and >70. Multivariable regression analysis accounting for age and ECOG-PS shows a HR of 0.99 (95% CI 0.86-1.14; p=0.91). Conclusions: Concurrent CRT with carboplatin-etoposide was associated with similar OS compared to cisplatin-etoposide in LS-SCLC, irrespective of PS and age. Carboplatin’s advantageous toxicity profile and comparable OS indicate that it is an acceptable choice of platinum for LS- SCLC.[Table: see text]

699 Pre-Operative Screening and Investigation of Patients with Suspected Non-Alcoholic Fatty Liver Disease Among Bariatric Surgery Patients

Introduction

Non-alcoholic fatty liver disease (NAFLD) is becoming more prevalent. The investigations used to diagnose NAFLD include FIB-4 score, NAFLD score and AST/ALT ratio (AAR). Gold-standard for diagnosis is liver biopsy. Bariatric surgery reduces steatosis and fibrosis in NAFLD patients. However, in undiagnosed NAFLD, it can lead to worsening fibrosis and decompensation of cirrhosis, causing complications.

The aim is to identify how well bariatric patients are being screened for NAFLD pre-operatively.

Method

Database analysis was conducted in the bariatric clinics at Royal Derby Hospital and analysed using SPSS.

Results

392 patients’ data (Overall group) were analysed and compared with those who had an AAR&gt;1 (Abnormal group). Abnormal group had a higher mean AAR, NAFLD and FIB-4 scores. Surprisingly, ALT and AST levels were higher in Overall group compared to Abnormal. Generally, patients were not pre-operatively checked sufficiently (81.9% LFTs, 62.2% ASTs).

Conclusions

A large number of patients could have undiagnosed NAFLD due to the lack of LFT/AST checks as ALT scores alone would miss fibrosis. Using AAR&gt;1 and FIB-4 would allow clinicians to detect fibrosis earlier to carry out non-invasive diagnostic measures, avoiding unnecessary biopsies. Early diagnosis means patients undergoing bariatric surgery with possible cirrhosis will not experience decompensation and associated complications.

Blastomycosis in the Capital District of New York State: A Newly Identified Emerging Endemic Area

BACKGROUND

The Centers for Disease Control and Prevention and New York State Department of Health recently identified the Capital District of New York (CDNY) as an emerging endemic area for blastomycosis. However, no clinical or epidemiological description of blastomycosis in the CDNY has been published.

METHODS

We performed a retrospective analysis of blastomycosis cases at Albany Medical Center (AMC) and Albany Stratton Veterans Affairs Medical Center (VAMC) from January 1, 2000, through June 1, 2019. Patients were identified via an institution-approved informatics system at the hospital's microbiology laboratory.

RESULTS

We identified 20 patients diagnosed with blastomycosis over the past 2 decades. There was a nearly 9-fold increase in the annual number of cases in 2016-2019 compared with 2000-2015. The majority of patients resided in the CDNY (90%), and 65% lived within the Mohawk River valley. Most cases (85%) were assumed to be malignancies or non-mycotic infections prior to diagnosis, with median time between presentation and diagnosis of 53 days.

CONCLUSIONS

Our data support recent reports that blastomycosis is an emerging disease in the CDNY. Most patients were misdiagnosed as malignancy or non-mycotic infection, which led to treatment delays.

The Significance of Subpleural Sparing in CT Chest: A State-of-the-Art Review

The subpleural sparing pattern is a common finding on computed tomography (CT) of the lungs. It comprises of pulmonary opacities sparing the lung peripheries, typically 1cm and less from the pleural surface. This finding has a variety of causes, including idiopathic, inflammatory, infectious, inhalational, cardiac, traumatic, and bleeding disorders. Specific disorders that can cause subpleural sparing patterns include nonspecific interstitial pneumonia (NSIP), organizing pneumonia (OP), pulmonary alveolar proteinosis (PAP), diffuse alveolar hemorrhage (DAH), vaping-associated lung injury (VALI), cracked lung, pulmonary edema, pneumocystis jirovecii pneumonia (PJP), pulmonary contusion, and more recently, Coronavirus disease 2019 (COVID-19) pneumonia. Knowledge of the many etiologies of this pattern can be useful in preventing diagnostic errors. In addition, although the etiology of subpleural sparing pattern is frequently indistinguishable during an initial radiologic evaluation, the differences in location of opacities in the lungs, as well as the presence of additional radiologic findings, patient history, and clinical presentation, can often be useful to suggest the appropriate diagnosis. We did a comprehensive search on Pubmed and Google Scholar database using keywords of "subpleural sparing," "peripheral sparing," "sparing of peripheries," "CT chest," "chest imaging," and "pulmonary disease." This review aims to describe the primary differential diagnosis of subpleural sparing pattern seen on chest imaging with a strong emphasis on clinical and radiographic findings. We also discuss the pathogenesis and essential clues that are crucial to narrow the differential diagnosis.

Comparing trends of perinatal mortality in two rural areas of Matlab, Bangladesh

The study conducted in a rural sub-district, Matlab, Bangladesh among adolescent motherhood (10-19 years) in the International Centre for Diarrhoeal Disease Research, Bangladesh included total of 4,996 adolescent mothers in the analysis. Chi-square tests and binary logistic regression were used to document adolescent pregnancy trends and the differences in and causes of perinatal death. The fertility rate was 27 per 1000 adolescent mothers in ISA and 20 per 1000 adolescent mothers in GSA, during the 9 year of study period. The adjusted odds of an adolescent mother having a perinatal death in ISA, relative to GSA was 0.69 (95% CI: 0.52 - 0.91, p-value&lt;0.05). Significant determinants of perinatal death among adolescent mothers were: maternal education, paternal education, mothers' age at first birth, asset score and distance from nearest facility. Dr. Rahman will raise the importance of addressing these determinants in designing health policy interventions targeting this specifically vulnerable group.

Carboplatin versus cisplatin for the treatment of extensive-stage small cell lung cancer (SCLC): A National VA Database analysis

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Background: Current standard of care first line treatment for extensive stage SCLC includes combination of platinum-etoposide doublet with an immune checkpoint inhibitor. Carboplatin is preferred over cisplatin in the extensive stage disease because of its favorable toxicity profile. Data comparing the efficacy of carboplatin with cisplatin in the metastatic setting are limited. Methods: Data from the National VA Cancer Cube database were compiled. Only pathologically confirmed cases of extensive stage SCLC that received platinum-based multiagent chemotherapy were included. Interval-censored Weibull and Cox proportional hazard regression models were used to estimate median overall survival (OS) and hazard ratio (HR), respectively. Two survival curves were compared by a Wald test. Results: Overall, 2600 SCLC cases were studied: 1968 received carboplatin-based therapy (Carbo-SCLC) while 632 received cisplatin-based therapy (Cis-SCLC). Median OS of Carbo-SCLC and Cis-SCLC was 0.71 years (95% CI 0.68-0.75) versus 0.70 years (95% CI 0.64-0.76), respectively (HR = 0.99; 95% CI 0.90-1.10; p = 0.90). Median OS of patients with ECOG-PS of 0, 1, 2 and 3 was similar for Carbo-SCLC and Cis-SCLC. HR of death for Carbo-SCLC compared to Cis-SCLC stratified by performance status were: ECOG-PS 0: 1.04 (95% CI 0.78-1.38; p = 0.80); ECOG-PS 1: 0.87 (95% CI 0.71-1.06; p = 0.17); ECOG-PS 2: 0.92 (95% CI 0.69-1.24; p = 0.6); ECOG- PS 3: 1.13 (95% CI 0.66-1.92; p = 0.66). Multivariable regression analysis accounting for age and ECOG-PS shows a HR of 0.92 (95% CI 0.80-1.05; p = 0.24). Conclusions: Cisplatin-based chemotherapy was not associated with a survival advantage over carboplatin-based chemotherapy in extensive-stage SCLC., including in patients with robust performance status and young patients. The findings from this large dataset along with the favorable toxicity profile of carboplatin support its use as the platinum agent of choice in extensive stage SCLC.

The role of surgery in stage I small-cell lung cancer: A national VA database analysis

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Background: Historically, limited stage Small Cell Lung Cancer (SCLC) has been treated with concurrent chemoradiation (CRT). While current NCCN guidelines recommend consideration of lobectomy in node-negative cT1-T2 SCLC, real world data regarding the role of surgery in very limited SCLC is lacking. To our knowledge, only one retrospective study has evaluated the role of surgery in stage I SCLC. Methods: Data from the National VA Cancer Cube were compiled. A total of 1,028 patients with pathologically confirmed Stage I SCLC were studied. Only 661 patients that either received surgery or CRT were included. Interval-censored Weibull and Cox proportional hazard regression models were used to estimate median overall survival (OS) and hazard ratio (HR), respectively. Two survival curves were compared by a Wald test. Subset analysis was performed based on the location of the tumor in the upper vs lower lobe as delineated by ICD-10 codes C34.1 and C34.3. Results: Four-hundred and forty-two patients received concurrent CRT; while 219 underwent treatment that contained surgery (92 surgery only, 84 surgery/chemo, 39 surgery/chemo/radiation and 4 surgery/radiation). The median OS for the surgery-inclusive treatment was 3.87 years (95% CI 3.25-4.60) while median OS for the CRT cohort was 2.43 years (95% CI 2.15-2.72). HR of death for surgery-inclusive treatment when compared to CRT was 0.65 (95% CI 0.54-0.79; p < 0.001). Subset analysis based on the location of the tumor in upper lobe and lower lobe showed improved survival with surgery as compared to CRT regardless of the location. HR for upper lobe was 0.61 (95% CI 0.48-0.78; p < 0.001) and lower lobe 0.60 (95% CI 0.41-0.87; p = 0.007). Multivariable regression analysis accounting for age and ECOG-PS shows a HR 0.60 (95% CI 0.42-0.85; p = 0.004) favoring surgery. Conclusions: Surgery was used in less than a third of patients with stage I SCLC who received treatment. Surgery-inclusive multimodality treatment was associated with a longer overall survival as compared to chemoradiation, independent of age, performance status or tumor location. Our study supports a more expansive role for surgery in stage I SCLC.

Rapid reversal of diffuse cerebral edema with correction of serum sodium in acute water intoxication

Acute water intoxication (AWI) is a disorder of excess water intake that can manifest in neurological injury and death. We describe a case of a 54-year-old man that presents to the emergency department with a generalized toxic-clonic seizure due to AWI. Initial computed tomography of the brain demonstrated diffuse cerebral edema. However, with correction of serum sodium over the one hospital day, the patient's neurological symptoms and imaging completely resolved. Clinicians should recognize of reversibility of this entity with management of hyponatremia.

Diagnostic Accuracy of Thoracic Ultrasonography to Differentiate Transudative From Exudative Pleural Effusion

BACKGROUND

There are limited data examining the diagnostic accuracy of thoracic ultrasonography (TUS) in distinguishing transudative from exudative pleural effusions.

RESEARCH QUESTION

What is the diagnostic accuracy of TUS in distinguishing transudative from exudative effusions in consecutive patients with pleural effusion?

STUDY DESIGN AND METHODS

Consecutive patients who underwent TUS and subsequently a diagnostic thoracentesis with a pleural fluid analysis were identified. TUS images of the pleural effusions were interpreted by previously published criteria. We evaluated the diagnostic performance of TUS findings in predicting a transudative vs exudative pleural effusions and specific pleural diagnoses.

RESULTS

We evaluated 300 consecutive pleural effusions in 285 patients. The pleural effusions were classified as exudative in 229 of 300 cases (76%). TUS showed anechoic effusions in 122 of 300 cases (40%) and complex effusions in 178 of 300 cases (60%). An anechoic appearance on TUS was associated with exudative effusions (68/122; 56%) as compared with transudative effusions (54/122; 44%). The presence of a complex-appearing effusion on TUS was highly predictive of an exudative effusion (positive predictive value of 90%). However, none of the four TUS characteristics were highly specific of a pleural diagnosis.

INTERPRETATION

Thoracic ultrasonography is inadequate to diagnose a transudative pleural effusion reliably. Although the TUS findings of a complex effusion may suggest an exudative pleural effusion, specific pleural diagnoses cannot be predicted confidently.

Ankylosis of a knee joint from Medieval London: Trauma, congenital anomaly or osteoarthritis?

OBJECTIVE

To explore the differential diagnoses of a fused left knee joint and the subsequent impairment.

MATERIALS

An adult female skeleton from the Medieval cemetery of St Mary Spital (London, England).

METHODS

We employed digital radiography and macroscopic observation to record the changes observed throughout the skeleton. We also used the Index of Care to explore the subsequent impairment.

RESULTS

A range of congenital and developmental conditions were identified throughout the axial skeleton, with changes to the spine, pelvis, arms and leg bones reflecting adaptation to the mobility impairment.

CONCLUSIONS

In all probability, the left knee reflects a case of congenital ankylosis with a differential diagnosis of subadult trauma. The female's skeleton had adapted to the impairment. Their risk is likely to have been elevated because of climatic and pandemic events during this period.

SIGNIFICANCE

First reported case of congenital knee ankylosis.

LIMITATIONS

The left knee joint was damaged during excavation.

SUGGESTIONS FOR FURTHER RESEARCH

Additional imaging is advised.

A transudative chylothorax associated with superior vena cava syndrome

The chylothorax is a lymphocyte predominant protein-discordant exudative pleural effusions with low lactate dehydrogenase and elevated triglyceride levels. Transudative chylothoraces associated with Superior Cava syndrome (SVC) are an extremely rare clinical entity. In this manuscript, we describe a case of transudative chylothorax due to SVC obstruction secondary to thrombosis of a peripheral inserted central venous catheter, which ultimately resolved after endovascular intervention. In our review of the literature, only five cases of transudative chylothorax associated with SVC syndrome were identified with 60% of cases associated with thrombosis and complications due to catheters in the central venous circulation. Treatment of the underlying cause is key to resolution of the chylothorax. Thoracentesis is an initial intervention for diagnostic and therapeutic purposes. Endovascular intervention is the primary mode of treatment for SVC thrombosis and stenting is preferred for malignant causes, however anticoagulation alone has been reported in the resolution of chylothorax. In patients with recurrent chylothorax despite of relief of SVC obstruction, a medium-chain triglyceride diet and octreotide can be prescribed in order to decrease the chyle flow in the thoracic duct. Surgical ligation of the thoracic duct can be considered if medical management and endovascular treatment fails.

ANCA associated vasculitis: experience of a tertiary care referral center

Background and objectives:

Anti-neutrophil cytoplasmic autoantibodies (ANCA) associated vasculitis is a small vessel vasculitis with insufficient epidemiologic estimates in the United States. We aimed to determine demographic and clinical features of ANCA associated vasculitis patients presenting to a large tertiary care referral center in Upstate New York. Design, setting, participants, and measurements: A retrospective analysis of cases with pauci-immune GN on renal biopsy and clinical diagnosis of ANCA vasculitis presenting over 11 years was conducted. Outcomes of interest were: demographics, ANCA antibody positivity, patient and renal survival, and regional trends.

Results:

986 biopsies were reviewed, 41 cases met the criteria for inclusion: 18 GPA, 19 MPA, and 4 double positive (anti-GBM disease plus ANCA vasculitis). Mean age at presentation was 52.4 years (SD 23.7), 23 (56%) were male and median creatinine was 2.6 mg/dL. The median patient follow up was 77 weeks (IQR 10 - 263 weeks), with a 3-month mortality rate of 5.7% and a 1-year estimated mortality rate of 12%. Thirteen patients required hemodialysis at the time of diagnosis; 7 patients came off dialysis, with median time to renal recovery of 4.86 weeks (IQR 1.57 - 23.85 weeks). C-ANCA positivity (p < 0.001) and C-ANCA plus PR3 antibody pairing (p = 0.005) was statistically significant in GPA versus MPA. P-ANCA positivity was observed in MPA versus GPA (p = 0.02) and double positive versus GPA (p = 0.002), with P-ANCA and MPO antibody pairing in MPA versus GPA (p = 0.044). Thirty-seven of the 41 cases were referred locally, 16 cases were from within a 15-mile radius of Albany, Schenectady, and Saratoga counties.

Conclusions:

ANCA vasculitis is associated with end stage renal disease and increased mortality. Our study suggests the possibility of higher regional incidence of pauci-immune GN in Upstate New York. Further studies should investigate the causes of clustering of cases to specific regions.

Novel use of Cytosorb™ haemadsorption to provide biochemical control in liver impairment

We describe the use of Cytosorb™, a synthetic extracorporeal haemoperfusion adsorption column, in the management of two patients with drug induced cholestasis and a third with alcoholic hepatitis and subsequent acute on chronic liver failure. Cytosorb was used in these patients to remove bilirubin and bile acids by supporting impaired excretory hepatic function, alleviating symptoms with the intention of serving as a bridge to endogenous recovery. The first two cases demonstrate favourable biochemical and symptomatic responses; the third case demonstrated a good biochemical response but subsequently died from the complications of multiple organ failure. These cases suggest Cytosorb™ be evaluated as an adjunct to support liver excretory functions in other arenas, such as acute liver failure or overdose. It remains unclear whether extracorporeal therapies removing liver toxins allow faster or more complete spontaneous recovery of endogenous function.

The Assessment of Cough in a Sarcoidosis Clinic Using a Validated instrument and a Visual Analog Scale

PURPOSE

Cough is a common symptom of pulmonary sarcoidosis. We analyzed the severity of cough and factors associated with cough in a university sarcoidosis clinic cohort.

METHODS

Consecutive patients completed the Leicester Cough Questionnaire (LCQ) and a cough visual analog scale (VAS). Clinical and demographic data were collected. Means of the LCQ were analyzed in patients who had multiple visits in terms of constant variables (e.g., race, sex).

RESULTS

355 patients completed the LCQ and VAS at 874 visits. Cough was significantly worse in blacks than whites as determined by the LCQ-mean (16.5 ± 2.6 vs. 17.8 ± 3.0, p < 0.001) and VAS-mean (3.8 ± 3.0 vs. 2.0 ± 2.6, p < 0.0001). Cough was worse in women than men as measured by the VAS-mean (2.7 ± 2.9 vs. 2.2 ± 2.7, p = 0.002), one of the LCQ-mean domains (LCQ-Social-mean 5.4 ± 0.9 vs. 5.2 ± 1.0, p = 0.03), but not the total LCQ-mean score. Cough was not significantly different by either measure in terms of smoking status, age, or spirometric parameter (FVC % predicted, FEV1 % predicted, FEV1/FVC). In a multivariable linear regression analysis, cough was significantly worse in blacks than whites and in pulmonary sarcoidosis than non-pulmonary sarcoidosis with both cough measures, in women than men for the VAS only, and not for spirometric parameters, Scadding stage, or age. The LCQ and VAS were strongly correlated.

CONCLUSIONS

In a large university outpatient sarcoidosis cohort, cough was worse in blacks than whites. Cough was not statistically significantly different in terms of age, spirometric measures, Scadding stage, or smoking status. The LCQ correlated strongly with a visual analog scale for cough.

The Urinothorax: A Comprehensive Review With Case Series

Urinothorax is an uncommon thoracic complication of genitourinary (GU) tract disease, which is most frequently caused by obstructive uropathy, but may also occur as a result of iatrogenic or traumatic GU injury. It is underrecognized because of a perceived notion as to the rarity of the diagnosis and the absence of established diagnostic criteria. Urinothorax is typically described as a paucicellular, transudative pleural effusion with a pleural fluid/serum creatinine ratio >1.0. It is the only transudate associated with pleural fluid acidosis (pH < 7.40). When the pleural fluid analysis demonstrates features of a transudate, pH <7.40 and a pleural fluid/serum creatinine ratio >1.0, a confident clinical diagnosis of urinothorax can be established. A technetium 99m renal scan can be considered a confirmatory test in patients who lack the typical pleural fluid analysis features or fail to demonstrate evidence of obstructive uropathy that can be identified via conventional radiographic modalities. Management of a urinothorax requires a multidisciplinary approach with an emphasis on the correction of the underlying GU tract pathology, and once corrected, this often leads to a rapid resolution of the pleural effusion.

Sevoflurane Induced Diffuse Alveolar Hemorrhage in a young patient

We report a very rare case of Sevoflurane Induced Diffuse Alveolar Hemorrhage in a previously healthy young adult in the post-operative period following general anesthesia. Diffuse alveolar hemorrhage (DAH) associated with inhalation injury from halogenated gases is a unique entity in the literature that practicing clinicians should be cognizant of and considered in post-operative cases of acute respiratory distress whereby other etiologies have been excluded.

Review article: 2014 UK consensus guidelines - hepatitis C management and direct-acting anti-viral therapy

BACKGROUND

Therapeutic options for the management of hepatitis C virus (HCV) infection have evolved rapidly over the past two decades, with a consequent improvement in cure rates. Novel therapeutic agents are an area of great interest in the research community, with a number of these agents showing promise in the clinical setting.

AIMS

To assess and present the available evidence for the use of novel therapeutic agents for the treatment of HCV, updating previous guidelines.

METHODS

All Phase 2 and 3 studies, as well as abstract presentations from international Hepatology meetings were identified and reviewed for suitable inclusion, based on studies of new therapies in HCV. Treatment-naïve and experienced individuals, as well as cirrhotic and co-infected individuals were included.

RESULTS

Sofosbuvir, simeprevir and faldaprevir, along with pegylated interferon and ribavirin, have a role in the treatment of chronic HCV infection. The precise regimens are largely dependent on the patient characteristics, patient and physician preferences, and cost implication.

CONCLUSIONS

Therapies for chronic HCV have evolved dramatically in recent years. Interferon-free regimens are now possible without compromise in the rate of sustained viral response. The decision as to which regimen is most appropriate is multifactorial, and based on efficacy, safety and cost.