Kassem Harris

Cement pulmonary embolism after percutaneous vertebroplasty and kyphoplasty: An overview

BACKGROUNDnBecause of the aging of the American population, osteoporotic vertebral fractures are becoming a common problem in the elderly. Minimally invasive percutaneous vertebral augmentation techniques have gained a great deal of importance in relieving the pain associated with these fractures, and are becoming the standard of care.nnnMETHODSnThese procedures involve the injection of polymethylmethacrylate (PMMA) into the vertebral body. However, these techniques have their complications, and among these, pulmonary embolism is one of the most feared. It is attributable to the passage of cement into the pulmonary vasculature. After encountering a case of PMMA embolism in our practice, we decided to highlight this topic and discuss the incidence, clinical presentation, diagnosis, and treatment of cement pulmonary embolisms.

The use of the PleurX catheter in the management of non-malignant pleural effusions:

Purpose: To evaluate the effectiveness of the PleurX catheter in the management of recurrent non-malignant pleural effusions. Methods: All subjects who underwent a PleurX catheter placement between 2003 and 2009 were evaluated. General demographic data, time to pleurodesis, complications, and a satisfaction questionnaire were collected. The subjects were divided into two groups. Group I included patients with non-malignant effusions and group II included patients with malignant effusions. Results: A total of 64 subjects were included in the final data analysis. A total of 23 subjects were included in group I and 41 subjects were included in group II. The diagnoses in group I included congestive heart failure (CHF; 13), hepatic hydrothorax (8), traumatic bloody (1), and idiopathic exudative (1). The diagnoses in group II included lung cancer (20), breast cancer (11), colon cancer (5), prostate cancer (2), B-cell lymphoma (2), and mesothelioma (1). The time to pleurodesis was 36 ± 12 days for group II compared to 110.8 ± 41 days for group I (p < 0.0001). The mean satisfaction score was similar in both groups (3.8 ± 0.4). Time to pleurodesis was significantly shorter in hepatic hydrothorax compared to CHF (73.6 ± 9 days vs. 113 ± 36 days, p = 0.006). There was one case of exit site infection in a patient with hepatic hydrothorax. Among subjects who were alive at 3 months after the catheter removal, none had recurrence of their pleural effusion. Conclusion: The Denver catheter was effective in achieving pleurodesis in non-malignant pleural effusions. The complication rate was low and patient satisfaction was high.

Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review

Gastroduodenal artery (GDA) aneurysms are rare but a potentially fatal condition if rupture occurs. They represent about 1.5% of all visceral artery (VAA) aneurysms and are divided into true and pseudoaneurysms depending on the etiologic factors underlying their development. Atherosclerosis and pancreatitis are the two most common risk factors. Making the diagnosis can be complex and often requires the use of Computed Tomography and angiography. The later adds the advantage of being a therapeutic option to prevent or stop bleeding. If this fails, surgery is still regarded as the standard for accomplishing a definite treatment.

Primary neuroendocrine breast cancer, how much do we know so far?

Primary neuroendocrine cancer of the breast (NECB) is an extremely rare tumor. In 2003, the World Health Organization (WHO) recognized this category with three well-described subtypes: small cell, large cell, and carcinoid-like carcinoma; very few peer-review publications based on the WHO definition were encountered in the literature, and we conducted a literature search to investigate the reported incidence, diagnosis, prognosis, hormone receptor status, and treatment options for this rare tumor. Confirming the breast as an origin of neuroendocrine tumor represents a challenge. The diagnosis is mainly dependent on the exclusion of other extra-mammary organs based on clinical, radiological, and pathological data. Except for the very rare type small cell carcinoma, estrogen and progesterone receptors were reported to be expressed in 90 and 83xa0% of NECB, respectively. It is hypothesized that primary breast neuroendocrine carcinoma differentiates from the epithelial cells during the carcinogenesis process; the prognosis of non-small cell primary NECB seems to improve as the amount of mucinous component increases in the tumor specimen. Management similar to interventions utilized to manage the usual ductal-type carcinoma has been attempted in the past, such as chemotherapy and hormonal therapy; however, due to the rarity of the tumor, none of the published studies are randomized nor do they have a large number of patients. Additionally, none of reports analyzed NECB based on its distinct subtypes. These limitations make recommendations largely based on anecdotal and small observatory studies and call for the need for further research in this extremely rare tumor.

Lipoid pneumonia: a challenging diagnosis.

Lipoid pneumonia is a rare medical condition, and is usually classified into two groups, ie, exogenous or endogenous, depending on the source of lipids found in the lungs. Exogenous lipoid pneumonia may result from the aspiration of food and lipids. Although most cases are asymptomatic, common symptoms include cough, dyspnea, chest pain, pleural effusions, fever, and hemoptysis. Radiologically, lipoid pneumonia can manifest as consolidations, pulmonary nodules, or soft-tissue densities. These presentations involve a wide differential diagnosis, including lung cancer. Other rare causes of fatty pulmonary lesions include hamartomas, lipomas, and liposarcomas. The avoidance of further exposures and the use of corticosteroids, antibiotics, and lavage comprise the mainstays of treatment. The exclusion of mycobacterial infections is important during diagnosis, in view of their known association. Generally, acute presentations run a benign course, if promptly treated. Chronic cases are more persistent and difficult to treat. Although the radiologic and pathologic diagnosis is fairly reliable, more research is needed to clarify the optimal treatment and expected outcomes. We report on a 54-year-old man presenting with progressively worsening cough, hemoptysis, and dyspnea over a few weeks. The patient underwent multiple computed tomographies of the chest and bronchoscopies. All failed to diagnose lipoid pneumonia. The diagnosis was finally established using video-assisted thoracoscopic surgery. Most of the paraffinoma was resected during this surgery. He was treated with antibiotics and steroids, and discharged from the hospital in stable condition.

The Use of a PleurX Catheter in the Management of Recurrent Benign Pleural Effusion: A Concise Review

Recurrent pleural effusion (RPE) can be encountered in various benign conditions such as inflammatory, infectious, or other systemic diseases (e.g., congestive heart failure (CHF), hepatic hydrothorax, post lung transplants, post coronary artery bypass graft (CABG) surgery, and chronic exudative pleurisy). Each condition is treated based on its unique pathophysiologic characteristics, and medical management is successful in the majority of patients. In rare circumstances, pleural effusions are rapidly recurring despite optimal medical therapy and patients have frequent hospitalisations that require repeated thoracenteses. Other than medical therapy and repeat thoracentesis, treatment options are limited to chest tube placement and chemical pleurodesis or, rarely, surgical pleurodesis. We conducted a literature review using PubMed and Google Scholar, finding 33 articles that were relevant to our topic over the last 30 years. In patients with recurrent benign pleural effusion that is refractory to medical management, the PleurX catheter seems to be a useful tool in relieving respiratory symptoms, decreasing the rate of hospitalisation and achieving pleurodesis.

Tracheal papillomatosis: what do we know so far?

Tracheal papillomatosis (TP) is a benign condition characterized by papillomatous growth of the bronchial epithelium that involves the trachea. This abnormal growth is a result of infection with human papilloma virus (HPV). Two subtypes of HPV were found in most cases of TP, HPV-6 and HPV-11. TP, presents in two forms, the juvenile onset (JO) or adult onset (AO). The clinical presentation is typically nonspecific and it ranges from mild symptoms like cough to life-threatening conditions like upper airway obstruction. Treatment depends on the location of the papillomas and age of the patient and the plan of therapy is usually made on an individual basis. Treatment can range from observation with symptomatic control to specific medical therapy and multiple surgeries in case of recurrence or progressively worsening disease. The recent invention of HPV vaccine is expected to be the first step in eradicating respiratory papillomatosis.

The Use of Endobronchial Ultrasonography With Transbronchial Needle Aspiration To Sample a Solitary Substernal Thyroid Nodule

Solitary thyroid nodules (STNs) are frequently encountered in clinical practice. When sampling of an STN is deemed necessary, ultrasound-guided fine needle aspiration biopsy (US-FNAB) is the procedure of choice. In substernal STNs, US-FNAB is not feasible, and the patients are usually offered either more invasive diagnostic testing (mediastinoscopy or surgical excision) or follow-up imaging studies based on the clinical suspicion of malignancy. We report a case in which a substernal STN was sampled using endobronchial ultrasonography with transbronchial fine needle aspiration (EBUS-TBNA). Our patient is a 74-year-old woman who was admitted with an asthma exacerbation. She underwent a chest CT scan with intravenous contrast (CTA) to rule out pulmonary embolism (PE). The CTA was negative for PE but showed a substernal STN that was successfully sampled by EBUS-TBNA without complications. The cytology was consistent with a colloid adenoma. EBUS-TBNA can sample substernal STNs that are not amenable to US-FNAB.

Value of albumin-globulin ratio as a predictor of all-cause mortality after non-ST elevation myocardial infarction.

Low albumin and the albumin–globulin ratio (AGR) were associated with vascular adverse events. Our study explores the AGR as a predictor of mortality after non-ST-segment elevation myocardial infarction (NSTEMI). In an observational study of 570 NSTEMI patients admitted to a tertiary center between 2004 and 2006, patients were stratified into equal tertiles according to AGR. The primary outcome was 4-year all-cause mortality. The 4-year mortality rates in the first, second, and third AGR tertiles were 88 (47%) of 189, 48 (25%)of 190 , and 19 (10%) of 191, respectively (P < .0001). After adjusting for 20 confounding variables, AGR first tertile (AGR <1.12) had a higher mortality versus second tertile (hazard ratio [HR] 2.6, P < .001). Likewise, the AGR second tertile had higher mortality versus the third tertile (AGR ≥1.34; HR 2.3, P = .004). The albumin–globulin ratio is a significant independent predictor of long-term mortality after NSTEMI in patients with normal serum albumin levels. Further studies are needed to explain the underlying mechanisms.

Gastroduodenal artery aneurysm rupture in hospitalized patients: An overlooked diagnosis

Gastroduodenal artery (GDA) aneurysm rupture is a rare serious condition. The diagnosis requires a high level of suspicion with specific attention to warning signs. Early diagnosis can prevent fatal outcomes. In this report, we describe a case of GDA aneurysm rupture presenting as recurrent syncope and atypical back and abdominal discomfort. The rupture manifested as hemorrhagic shock. The diagnosis was made by computed tomography of the abdomen which showed acute peritoneal and retroperitoneal bleeding. Angiographic intervention failed to coil the GDA and surgery with arterial ligation was the definitive treatment.