Setu Patolia

Obstructive fibrinous tracheal pseudomembrane.

Obstructive fibrinous tracheal pseudomembrane (OFTP) is a relatively rare cause of failed extubation. OFTP may be more common than described in the literature. OFTP results from ischemic injury to tracheal mucosa and may be the initial stage of the development of tracheal stenosis. Early diagnosis and treatment can prevent re intubation and mortality. We present a rare case of OFTP. The patient was intubated for 3 days for asthma exacerbation and was appropriately discharged. The patient was seen the second time in the emergency room and was treated for asthma exacerbation on the same day. Because of persistent symptoms after 3 days, CT scan of the chest was performed, which indicated necrotizing tracheitis with gas formation within the tracheal wall. Bronchoscopy showed no evidence of necrosis, but there was a thick white plaque toughly adherent to the tracheal wall.

EBUS-TBNA and EUS-FNA: Risk Assessment for Patients Receiving Clopidogrel.

Background:Clopidogrel is widely used for the prevention of thrombotic vascular complications. Its primary potential toxicity is bleeding. Management of clopidogrel therapy for patients undergoing invasive procedures is an area of ongoing study. We sought to evaluate the bleeding risk for patients undergoing needle aspiration biopsy by endobronchial ultrasound (EBUS) or esophageal ultrasound (EUS) while taking clopidogrel. Methods:Retrospective review of sequential cases of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and esophageal ultrasound fine needle aspiration (EUS-FNA). Results:Three hundred ninety-five consecutive procedures were reviewed. Thirty-seven patients were taking clopidogrel at time of biopsy. The patients taking clopidogrel were significantly older than those in the control group. Two patients (1%) in the control group were admitted for observation, but neither was found to have a significant bleed. There were no clinically significant bleeding complications in either of the study groups. Conclusions:It is reasonable to proceed with EBUS-TBNA or EUS-FNA when both, (1) clopidogrel cannot be stopped and, (2) an important diagnostic question is at stake.

Bilateral pneumothorax after bronchoscopy without biopsy--a rare complication: case presentation and literature review.

Bronchoscopy and bronchoalveolar lavage (BAL) are widely accepted diagnostic procedures in various pulmonary etiologies. Complications of bronchoscopy are relatively infrequent and most often minor, namely, bleeding and infection. Pneumothorax is a rare complication of bronchoscopy with transbronchial biopsy. Bilateral pneumothorax developing after BAL without biopsy has been rarely described in the literature. A 51-year-old woman presented with symptoms suggestive of reactive airway syndrome and underwent bronchoscopy with BAL to rule out vocal cord paralysis and to investigate other potential causes of her symptoms. Immediately after BAL, she developed bilateral pneumothorax requiring chest tube placement. The pneumothorax was resolved with the chest tube and the patient recovered. However, the etiology of the pneumothorax remained unclear. We presume that cough-related increase in intrathoracic pressure might have led to interstitial air dissection and bilateral pneumothorax.

Risk factors and outcomes for multidrug-resistant Gram-negative bacilli bacteremia:

Background: The incidence of multidrug-resistant (MDR) organisms is increasing along with mortality. Identifying risk factors for the development of MDR Gram-negative bacilli (GNB) bacteremia could greatly impact patient care and management. Methods: Data from the electronic health record of patients with GNB over 13-month period were collected at a single university medical center. Baseline demographic data, risk factor, microbiological data, recurrence of bacteremia, and mortality were recorded. Results: A total of 177 patients were included in the analysis. MDR GNB occurred in 46 patients (26%). The mortality rate in the MDR group was 34.8% compared to 13.7% in non-MDR group (p = 0.002). In multivariate analysis, diabetes mellitus [DM; odds ratio (OR): 2.8, 95% confidence interval (CI): 1–4.88], previous antibiotic use (OR: 2.93, 95% CI: 1.25–6.87), and urinary catheter as a source of infection (OR 5.96, 95% CI: 1.78–19.94) were significant risk factors for the development of MDR GNB. In addition, end-stage liver disease (OR: 3.64, 95% CI: 1.07–12.3), solid organ malignancy (OR: 3.64, 95% CI: 1.25–10.56), intra-abdominal source of infection (OR: 3.66, 95% CI: 1.14–11.73), inappropriate empiric antibiotics (OR 7.59, 95% CI: 1.68–34.34) and urinary catheter as a source of infection (OR 5.68, 95% CI: 1.37–23.5) were significant factors for mortality in patients with MDR GNB. Conclusion: Our study provides important information about the risk factors for the development of MDR GNB bacteremia and helps prognosticate patient with MDR GNB.

Exploration under the dome: Esophageal ultrasound with the ultrasound bronchoscope is indispensible

Background: Effective use of the convex curvilinear ultrasound bronchoscope in the esophagus (EUS-B) for fine needle aspiration biopsy of mediastinal structures is now well described. In contrast, there is little to no reporting, depending on the site of EUS-B for access to sub-diaphragmatic structures. Our practice has been accessing sub-diaphragmatic sites for years. This review documents our experience with EUS-B to biopsy liver, left adrenal glands, and coeliac lymph nodes. Methods: After Institutional Review Board′s approval, all endosonographic procedures performed by interventional pulmonary between July 2013 and June 2015 were reviewed. Those including biopsy of sub-diaphragmatic sites were then selected for analysis. Results: Over the study interval, 45 sub-diaphragmatic biopsy procedures (25 left adrenal glands, 7 liver, and 13 celiac node) were performed with EUS-B. In all cases, cellular adequacy was present, and samples were large enough for immunohistochemistry and any relevant ancillary studies. Metastatic malignancy was documented in 58% of cases, 16% of cases contained benign diagnostic findings, and in 27% of cases, normal organ tissue was documented. There were no complications. Conclusions:  Operators comfortable with the endobronchial ultrasound scope in both the airway and the esophagus can actively seek and successfully perform biopsy of sub-diaphragmatic abnormalities when present and can thereby add to the diagnostic value of the procedure.

Ectopic Thymoma- Presenting as a Large Pleural Mass

Thymoma is the most common neoplasm of the anterior mediastinum. Patients may be asymptomatic or present with symptoms of local compression, myasthenia gravis or other paraneoplastic syndrome. We present case of a middle aged woman with a large pleural based mass who was relatively asymptomatic Biopsy of the mass revealed thymoma type AB.Work up showed that she has multiple abdominal masses etiology of which is not known. Whenever feasible, surgery is the treatment of choice for thymoma.Our patient is undergoing chemotherapy with the goal that once the tumor size is reduced she will be able to undergo surgery.

The knowledge, concerns and healthcare practices among physicians regarding electronic cigarettes

ABSTRACT Background: Electronic cigarettes (e-cigarettes) are battery-powered devices that deliver aerosolized nicotine. With easy access and over-the-counter availability, many patients consider using electronic cigarettes for smoking cessation. Few studies have looked at long-term safety/efficacy and physician knowledge/attitudes toward e-cigarettes. Physicians have insufficient guidelines for advising their patients about e-cigarettes. Objective: 1) To identify knowledge and attitude of health care practitioners toward electronic cigarettes. 2) To identify the effect of level of training, experience and speciality on knowledge and practice of electronic cigarettes. 3) To identify factors influencing electronic cigarettes advise/prescribing practice. Methods: An anonymous online questionnaire was sent to residents, fellows, and faculty in pre-selected specialties at Saint Louis University (SLU) Hospital. Results: We received 115 responses. Nine percent reported being ‘very familiar’ with e-cigarettes, while 25% reported no familiarity; 18% of physicians would advise e-cigarettes as nicotine-replacement therapy if asked by patients; 91% were aware of the nicotine content of e-cigarettes, but only 20% and 39%, respectively, were aware of the presence of carcinogens and polyethylene glycol. Only 63% of respondents knew what ‘vape’ meant. Lack of evidence regarding long-term safety (76%), e-cigarettes as starter products for nonsmokers (50%), absence of Food and Drug Administration (FDA) regulations (51%) and marketing to youth (42%) were major concerns. Stricter regulations (54%), warning labels similar to tobacco products (53%), restricting advertising (36%), banning sales to minors (34%), and banning use in public spaces (25%) were favored as regulatory measures. More than 50% of physicians see a role for e-cigarettes as part of ‘harm-reduction strategy’. Conclusions: Further research is needed to assess whether e- cigarettes could be an effective smoking-cessation tool. There is an apparent knowledge deficit among physicians and an urgent need for evidence-based guidelines to aid with advising patients enquiring about e-cigarettes.

Antisynthetase syndrome (ASS) presenting as acute respiratory distress syndrome (ARDS) in a patient without myositis features

A woman aged 61 years presented to the emergency room with a 1-week history of dyspnoea on exertion and dry cough. X-ray of the chest showed diffuse interstitial opacities and was started on antibiotics and furosemide, and despite these measures, patients respiratory status worsened, prompting endotracheal intubation. CT of the chest showed diffuse bilateral ground glass opacities and underwent bronchoscope with trans-bronchial biopsy that showed chronic bronchitis. Pt was empirically started on intravenous steroids due to concerns for interstitial lung disease (ILD). Autoimmune work up was sent and underwent video-assisted thoracoscopic surgery-guided biopsy of the lung that showed non-specific interstitial pattern with fibrosis. The patient was diagnosed as having antisynthetase syndrome with pulmonary involvement (ILD) as the cause of her acute respiratory failure. Azathioprine was started as steroid-sparing agent and was weaned off the ventilator to a tracheostomy collar and discharged to long-term rehabilitation centre.

Intrapleural cisplatin for management of malignant pleural effusion in a patient with plasma cell leucaemia

Plasma cell leucaemia (PCL) is a rare aggressive form of multiple myeloma. It occasionally involves the pleura, causing malignant pleural effusion (MPE). MPE presents a management dilemma for physicians, given the different treatment options available with varying efficacy and side effects. We report a case of a 64-year-old man with MPE due to PCL, successfully managed with intrapleural cisplatin and a tunnelled pleural catheter. We believe this to be the first report of management of PCL-associated MPE with intrapleural cisplatin.