Jeffrey R. Hammersley

The c-myc x E2F-1/p21 interactive gene expression index augments cytomorphologic diagnosis of lung cancer in fine-needle aspirate specimens

Morphological analysis of cytologic samples obtained by fine-needle aspirate (FNA) or bronchoscopy is an important method for diagnosing bronchogenic carcinoma. However, this approach has only about 65 to 80% diagnostic sensitivity. Based on previous studies, the c-myc x E2F-1/p21WAF1/CIP1 (p21 hereafter) gene expression index is highly sensitive and specific for distinguishing normal from malignant bronchial epithelial tissues. In an effort to improve sensitivity of diagnosing lung cancer in cytologic specimens, we used Standardized Reverse Transcriptase Polymerase Chain Reaction (StaRT-PCR) to measure the c-myc x E2F-1/p21 index in cDNA samples from 14 normal lung samples (6 normal lung parenchyma and 8 normal bronchial epithelial cell [NBEC] biopsies), and 16 FNA biopsies from 14 suspected tumors. Based on cytomorphologic criteria, 11 of the 14 suspected tumors were diagnosed as bronchogenic carcinoma and three specimens were non-diagnostic. Subsequent biopsy samples confirmed that the three non-diagnostic samples were derived from lung carcinomas. The index value for each bronchogenic carcinoma was above a cut-off value of 7000 and the index value of all but one normal sample was below 7000. Thus the c-myc x E2F-1/p21 index may augment cytomorphologic diagnosis of bronchogenic carcinoma biopsy samples, particularly those considered non-diagnostic by cytomorphologic criteria.

Fecal Transplant for Treatment of Toxic Megacolon Associated With Clostridium Difficile Colitis in a Patient With Duchenne Muscular Dystrophy.

Clostridium difficile (C diff) colitis infection is the most common cause of nosocomial infectious diarrhea and the prevalence is increasing worldwide. Toxic megacolon is a severe complication of C diff colitis associated with high mortality. Gastrointestinal (GI) comorbidity and impaired smooth muscle contraction are risk factors for the development of C diff-associated toxic megacolon. We present a case of fulminant C diff colitis with toxic megacolon in a patient with Duchenne muscular dystrophy (DMD) in the intensive care unit. C diff colitis was diagnosed by clinical presentation and positive C diff DNA amplification test (polymerase chain reaction). The impairment of GI tract due to DMD predisposes these patients to severe C diff infection and toxic megacolon, as observed in this case report. For the same reason, the recovery of GI function in these patients can be prolonged. While surgery was conducted for relieving the pressure from toxic megacolon, fecal microbiota transplantation through colonoscopy resulted in successful resolution of the C diff symptoms, although the recovery is prolonged due to DMD.

New-onset acute interstitial lung disease after treatment with erlotinib in a patient with metastatic squamous cell carcinoma of the lung.

Erlotinib is a Human Epidermal Growth Factor Receptor Type 1/tyrosine kinase (EGFR) inhibitor, which is used for non-small-cell lung cancer treatment. Erlotinib usually has a favorable safety profile however; adverse events such as interstitial lung disease (ILD) have been reported in pivotal studies. ILD usually occurs weeks to months after initiating therapy with Erlotinib. We report a case of Erlotinib induced ILD presenting within 5 days of initiating treatment with Erlotinib.

Flow simulation in a 3D model of pig airways and connection to lung sounds

Fundamental to the understanding of the various transport processes within the respiratory system, airway fluid dynamics plays an important role in biomedical research. When air flows through the respiratory tract, it is constantly changing direction through a complex system of curved and bifurcating tubes. As a result, numerical simulations of the airflow through this tracheobronchial system must be capable of resolving such fluid dynamic phenomena as flow separation, recirculation, secondary flows due to centrifugal instabilities, and shear stress variation along the airway surface. Anatomic complexities within the tracheobronchial tree, such as sharp carinal regions at asymmetric bifurcations, have motivated the application of the incompressible Computational Fluid Dynamics code PHI3D to the modeling of airflow. Developed at ORNL, PHI3D implements the new Continuity Constraint Method. Using a finite-element methodology, complex geometries can be easily simulated with PHI3D using unstructured grids. A time- accurate integration scheme allows the simulation of both transient and steady-state flows. A realistic geometry model of the central airways for the fluid flow studies was obtained from pig lungs using a new high resolution x-ray computed tomography system developed at ORNL for generating 3D images of the internal structure of laboratory animals.

Pyocholethorax secondary to biliopleural fistula: a rare complication of percutaneous transhepatic biliary drainage

A 62-year-old woman presented to the hospital with the complaints of right upper abdominal pain and dyspnea for the past 3 days. She described the pain as dull, constant, and radiating to her back and right side of the chest. She also complained of progressive dyspnea, both on rest and on exertion. She has been feeling nauseated, but denied any vomiting. She had a past medical history of stage-IV adenocarcinoma of the pancreas diagnosed 3 years prior, and had received palliative chemoradiation treatment. She also had recurrent episodes of biliary obstruction with jaundice with the evidence of common bile duct (CBD) obstruction by the mass on previous imaging. One week prior, she underwent percutaneous transhepatic biliary drain (PTBD) catheter and endoscopic retrograde cholangiography (ERCP) guided self-expandable metallic stent (SEMS) placement in the common bile duct (CBD) to relieve biliary obstruction. The PTBD catheter was removed following the stent placement. Vital signs at the time of presentation were temperature 37 °C, heart rate 76 beats/min, blood pressure of 135/99 mmHg, respiratory rate 22 breaths/min, and oxygen saturation 98% on 3 l of oxygen by nasal cannula. Physical examination showed a thin, cachectic female in moderate distress. Precordial examination showed normal S1 and S2 without any murmurs. Pulmonary examination showed dullness to percussion on the right side along with decreased breath sounds in the right-middle and -lower quadrant on auscultation. Abdominal examination showed a soft, nondistended abdomen with a gastrostomy tube, and tenderness to palpation in the right upper quadrant. A chest radiograph showed opacification of the right-mid and -lower lung zone consistent with a moderate-to-large right-sided pleural effusion (Fig. 1a). A CT scan of the chest confirmed the presence of a large right-sided pleural effusion (Fig. 1b). A thoracentesis was performed, and the drained fluid appeared grossly bilious (Fig. 1c). The metallic biliary stent is not visible in the images. Fluid analysis showed total bilirubin to be 16 mg/dl in the pleural fluid with a serum total bilirubin of 0.9 mg/dl. The fluid was an exudate by Light’s criteria with an LDH of 4446 U/l, glucose of 10 mg/dl, and pH of 6.92. A video-assisted thoracotomy was done with the drainage of pleural fluid and decortication of the adjacent right lung. Gram’s stain and cultures from the pleural fluid and lung tissue showed polymicrobial infection with Klebsiella and Streptococcus. A diagnosis of pyocholethorax was established resulting from the penetration and injury of the pleura by the PTBD catheter with the formation of a biliary pleural fistula and superimposed infection. The patient was started on i.v. ceftriaxone and metronidazole. Repeat chest radiographs showed improvement in the pleural effusion with re-expansion of the right lung. She recovered well, and was discharged home.

Organizing pneumonia related to electronic cigarette use: A case report and review of literature

Electronic cigarettes (e cigarettes) are battery operated devices that produce aerosol by heating a solution typically made up of nicotine, propylene glycol, glycerin and flavouring agents. The use of e cigarettes has risen dramatically in recent years especially among adolescents and young adults. These devices have been marketed as safer alternatives to tobacco smoking by their manufactures despite lack of adequate safety data.

Pyridostigmine Induced Prolonged Asystole in a Patient with Myasthenia Gravis Successfully Treated with Hyoscyamine

Reversible acetylcholinesterase inhibitors are used as first-line treatment for myasthenia gravis. They improve symptoms by increasing concentration of acetylcholine at the neuromuscular junction and stimulating nicotinic receptors. Serious bradyarrhythmias can occur from muscarinic stimulation in heart, which in rare cases may progress to asystole. These patients can initially be managed with hyoscyamine, a muscarinic antagonist. Persistence of bradyarrhythmias even after hyoscyamine treatment may warrant pacemaker placement. We present a case of 65-year-old female patient who presented with diplopia, dysphagia, and muscle weakness who was diagnosed with myasthenia gravis. She developed significant sinoatrial node block with prolonged asystole after starting treatment with pyridostigmine which was successfully treated with hyoscyamine, thus avoiding pacemaker placement.