A comparison of the effect of weather and climate on emergency department visitation in Roanoke and Charlottesville, Virginia

Compared with mortality, the impact of weather and climate on human morbidity is less well understood, especially in the cold season. We examined the relationships between weather and emergency department (ED) visitation at hospitals in Roanoke and Charlottesville, Virginia, two locations with similar climates and population demographic profiles. Using patient-level data obtained from electronic medical records, each patient who visited the ED was linked to that day's weather from one of 8 weather stations in the region based on each patient's ZIP code of residence. The resulting 2010-2017 daily ED visit time series were examined using a distributed lag non-linear model to account for the concurrent and lagged effects of weather. Total ED visits were modeled separately for each location along with subsets based on gender, race, and age. The relationship between the relative risk of ED visitation and temperature or apparent temperature over lags of one week was positive and approximately linear at both locations. The relative risk increased about 5% on warm, humid days in both cities (lag 0 or lag 1). Cold conditions had a protective effect, with up to a 15% decline on cold days, but ED visits increased by 4% from 2 to 5 days after the cold event. The effect of thermal extremes tended to be larger for non-whites and the elderly, and there was some evidence of a greater lagged response for non-whites in Roanoke. Females in Roanoke were more impacted by winter cold conditions than males, who were more likely to show a lagged response at high temperatures. In Charlottesville, males sought ED attention at lower temperatures than did females. The similarities in the ED response patterns between these two hospitals suggest that certain aspects of the response may be generalizable to other locations that have similar climates and demographic profiles.

Initiation and characterization of small cell lung cancer patient-derived xenografts from ultrasound-guided transbronchial needle aspirates

Small cell lung cancer (SCLC) is a devastating disease with limited treatment options. Due to its early metastatic nature and rapid growth, surgical resection is rare. Standard of care treatment regimens remain largely unchanged since the 1980’s, and five-year survival lingers near 5%. Patient-derived xenograft (PDX) models have been established for other tumor types, amplifying material for research and serving as models for preclinical experimentation; however, limited availability of primary tissue has curtailed development of these models for SCLC. The objective of this study was to establish PDX models from commonly collected fine needle aspirate biopsies of primary SCLC tumors, and to assess their utility as research models of primary SCLC tumors. These transbronchial needle aspirates efficiently engrafted as xenografts, and tumor histomorphology was similar to primary tumors. Resulting tumors were further characterized by H&E and immunohistochemistry, cryopreserved, and used to propagate tumor-bearing mice for the evaluation of standard of care chemotherapy regimens, to assess their utility as models for tumors in SCLC patients. When treated with Cisplatin and Etoposide, tumor-bearing mice responded similarly to patients from whom the tumors originated. Here, we demonstrate that PDX tumor models can be efficiently established from primary SCLC transbronchial needle aspirates, even after overnight shipping, and that resulting xenograft tumors are similar to matched primary tumors in cancer patients by both histology and chemo-sensitivity. This method enables physicians at non-research institutions to collaboratively contribute to the rapid establishment of extensive PDX collections of SCLC, enabling experimentation with clinically relevant tissues and development of improved therapies for SCLC patients.

A randomised trial of lung sealant versus medical therapy for advanced emphysema

Uncontrolled pilot studies demonstrated promising results of endoscopic lung volume reduction using emphysematous lung sealant (ELS) in patients with advanced, upper lobe predominant emphysema. We aimed to evaluate the safety and efficacy of ELS in a randomised controlled setting.Patients were randomised to ELS plus medical treatment or medical treatment alone. Despite early termination for business reasons and inability to assess the primary 12-month end-point, 95 out of 300 patients were successfully randomised, providing sufficient data for 3- and 6-month analysis.57 patients (34 treatment and 23 control) had efficacy results at 3 months; 34 (21 treatment and 13 control) at 6 months. In the treatment group, 3-month lung function, dyspnoea, and quality of life improved significantly from baseline when compared to control. Improvements persisted at 6 months with >50% of treated patients experiencing clinically important improvements, including some whose lung function improved by >100%. 44% of treated patients experienced adverse events requiring hospitalisation (2.5-fold more than control, p=0.01), with two deaths in the treated cohort. Treatment responders tended to be those experiencing respiratory adverse events.Despite early termination, results show that minimally invasive ELS may be efficacious, yet significant risks (probably inflammatory) limit its current utility.

Treatment of toxic epidermal necrolysis with intravenous immunoglobulin

Toxic epidermal necrolysis is a severe adverse drug reaction that produces extensive mucocutaneous damage, with full-thickness epidermal detachment, and has many clinical similarities to severe burn injuries. The treatment is mainly supportive and aimed at preventing complications while the disease takes its natural course, and the skin reepithelializes. Much interest exists in the development of a specific therapy targeted at the disease process itself. Because the diagnosis has an incidence of only 0.5-1 case/million/year, large controlled studies are lacking, but a recent, better understanding of this disease has provided the rationale for the use of intravenous immunoglobulin. We present a case of toxic epidermal necrolysis that showed a good response to intravenous immunoglobulin G and review the recent literature condition and its management.

Thoracoscopic management of pleural effusions in Kaposi's sarcoma: a rapid and effective alternative for diagnosis and treatment

Kaposi's sarcoma (KS) is one of the most common causes of pleural effusion in patients with acquired immunodeficiency syndrome (AIDS). Pleural effusions due to KS carry a high morbidity and mortality. Their treatment is difficult, and they respond poorly to chemical pleurodesis. Even systemic chemotherapy against KS has little effect on the pleural effusions. Commonly, repeated therapeutic thoracentesis or chest tube drainage is required. We present a case of advanced KS with bilateral pleural effusions. We believe this is the first reported case in which medical thoracoscopy with talc pleurodesis has been shown to achieve adequate control of the effusions.

Endoscopic management of obstruction due to an acquired bronchial web

Bronchial webs are thin, membrane-like diaphragms that may obstruct the airway. Several congenital cases have been reported. Though rare, the true incidence of these lesions is probably underestimated because many of them are unrecognized. The case of a 71-year-old woman with an acquired bronchial web causing right main stem bronchus obstruction that went unrecognized for 47 years post-trauma is reported. The lesion was successfully treated using rigid bronchoscopy with laser therapy, balloon dilation and stent placement. This is the first reported case of an acquired bronchial web formation. It is also the first reported case that was successfully treated with this technique.

Lymphangioleiomyomatosis: an unusual cause of dyspnea in young women

Lymphangioleiomyomatosis is a rare and complicated disorder that affects the young, almost exclusively women. It may be associated with the tuberous sclerosis complex, which includes renal angiolipoma, chylothorax and lymph node myomatosis. Its clinical pulmonary manifestations vary from simple cough to the development of recurrent pneumothoraces, hemoptysis, and even complicated pleural effusions. Progressive dyspnea develops as the disease evolves. Eventually most patients require lung transplantation. This wide array of symptoms and signs makes the differential diagnosis extensive, and the clinician must be familiar with this disorder to arrive promptly to the correct diagnosis. We report a case of a 36-year-old woman with a long history of recurrent pleuritic chest pain with associated dyspnea before being diagnosed with lymphangioleiomyomatosis. A review of the literature pertinent to this case is provided.

Airway obstruction due to bilateral giant pulmonary artery aneurysms

Large pulmonary artery aneurysms are rare, but they are associated with significant morbidity and mortality. Significant airway obstruction due to extrinsic compression solely by a pulmonary artery aneurym is an extremely rare occurrence. We present a case of large bilateral pulmonary artery aneurysms causing extrinsic airway compression with collapse of the left primary bronchus in a 51-year-old woman. This is the first report in an adult in which airway compression due solely to the pulmonary artery aneurysm resulted in airway collapse. Furthermore, we describe the use of interventional bronchoscopy with stent placement as a minimally invasive alternative to surgery for treatment of these patients.

Respiratory complications of pregnancy

The pregnant woman is susceptible to a variety of respiratory complications. When a pregnant patient presents with an abnormal chest x-ray or a pulmonary complaint, an understanding of the pathophysiology of pregnancy will guide the clinician in establishing a diagnosis. Pregnancy brings about many changes to a woman's body. One of the more intriguing is a decrease in the T helper cells, resulting in a state of relative immunosuppression. Despite this, the prevalence of infectious pneumonia is not increased in pregnancy. Complications from pneumonia, however, are increased in the pregnant host. Most notably are increases in both mortality related to influenza infection and the risk for dissemination of coccidioidomycosis. Other physiologic changes predispose the pregnant woman to certain disease processes. Hypercoagulability associated with pregnancy results in a marked increase in the incidence of thromboembolic disease. Although rare, pregnancy is also associated with other embolic phenomena including amniotic fluid embolism, air embolism, and trophoblastic embolism. Because of the increases in intravascular volume and cardiac output that occur in pregnancy, women with underlying structural heart disease will frequently present for the first time or have an exacerbation of their disease. This is especially true of mitral stenosis. Peripartum cardiomyopathy also can occur, and for the majority of patients, the heart remains damaged for life. Finally, although uncommon, lymphangioleiomyomatosis will often present or become exacerbated during pregnancy. Patients with this disorder need to be counseled concerning the increased risk associated with pregnancy. This paper reviews the various respiratory complications associated with pregnancy.

Complicated persistent patent ductus arteriosus with acute pneumonia in an adult

Patent ductus arteriosus (PDA) is a malady usually identified during childhood. Prompt surgical correction provides definitive therapy with long-term survival. When not corrected, PDA leads to significant morbidity and mortality, making it a rare condition in the adult population. We report the case of a 44-year-old man with a history of persistent PDA admitted for worsening dyspnea and fever. Radiographic studies are illustrative of this complex syndrome. We review the complications and treatment alternatives in these patients.

Persistent paralysis after prolonged use of atracurium in the absence of corticosteroids

Neuromuscular blocking agents (NMBAs) are often used for patients requiring prolonged mechanical ventilation. Reports of persistent paralysis after the discontinuance of these drugs have most often involved aminosteroid-based NMBAs such as vecuronium bromide, especially when used in conjunction with corticosteroids. Atracurium besylate, a short-acting benzylisoquinolinium NMBA that is eliminated independently of renal or hepatic function, has also been associated with persistent paralysis, but only when used with corticosteroids. We report a case of atracurium-related paralysis persisting for approximately 50 hours in a patient who was not treated with corticosteroids.