Vandana Seeram

Characteristics and Outcomes of Cocaine-Related Spontaneous Intracerebral Hemorrhages

To date there is only one single-center study that has exclusively reported characteristics, location, and outcomes of spontaneous intracerebral hemorrhages (ICH) among cocaine users. We aimed to describe the radiological location and characteristics along with clinical outcomes of spontaneous ICH in a similar population. We conducted a retrospective chart review of consecutive patients admitted to a tertiary care hospital, with a spontaneous ICH, who had a urine drug screen performed within 48 hours of admission. Exposure to cocaine was defined by a positive urine drug screen within 48 hours of hospital admission. Demographics, radiographic features of ICH, and short-term clinical outcomes of patients with a positive urine drug screen were analyzed and compared with the cocaine negative group. Among the 102 patients analyzed, 20 (19.6%) had documented exposure to cocaine. There was a predominance of males in both groups with significantly more Blacks in the cocaine positive group (P = 0.0246). A statistically significant number of patients with cocaine use had ICH in a subcortical location (P = 0.0224) when compared to cocaine negative patients. There was no difference in GCS, ICH volume, intraventricular extension, ICU days, hospital days, hospital cost, mortality, and ICH score. ICH in cocaine use is more frequently seen in the subcortical location.

Predicting the Need for Upfront Combination Therapy in Pulmonary Arterial Hypertension

Background: Combination therapy is commonly used for pulmonary arterial hypertension (PAH) treatment. We aimed to identify factors that may predict the need for future combination therapy. Methods: We conducted a retrospective chart review of consecutive patients with PAH in an aim to describe baseline clinical, echocardiogram, and hemodynamic characteristics of patients who eventually required combination therapy during the course of their disease and compared them to the ones who were maintained on monotherapy. Results: The monotherapy group was followed for an average of 31.8 ± 18.8 months and the combination therapy group was followed for an average of 28.7 ± 13.6 months. Among the 71 patients analyzed, a significantly higher number of patients who eventually required combination therapy belonged to World Health Organization functional class 3 (45% vs 37%) and 4 (23% vs 0) at baseline, compared with those on monotherapy (P < .05). Combination group also had a higher Registry to Evaluate Early And Long-term PAH Disease Management (REVEAL) PAH risk score at presentation. End of 6-minute walk test (6MWT), oxygen saturation (Spo 2) was also lower in the combination therapy group, 86% ± 8% versus 91% ± 7% (P < .05). Patients who eventually required combination therapy were more frequently noticed to have right ventricular enlargement, right atrial enlargement, and had a higher resting estimated right ventricular systolic pressure (RVSP). Right heart catheterization-derived hemodynamics data at baseline showed that the combination therapy group had a higher mean pulmonary artery (PA) pressure, lower pulmonary capillary wedge pressure, lower cardiac output, and higher pulmonary vascular resistance (PVR). On univariate analysis, only PVR ≥300 dyne·s/cm5, mean PA pressure of ≥40 mm Hg, estimated RVSP ≥ 60 mm Hg, PAH risk score ≥ 10, and end of 6MWT saturation of ≤ 90% were of significance. Conclusion: Patients with PAH who require combination therapy in the course of their disease have worse hemodynamics, PAH risk score, functional class, and end of 6MWT oxygen saturation at the time of presentation compared to patients maintained on monotherapy.

Is There Any Association between PEEP and Upper Extremity DVT

Background. We hypothesized that positive end-exploratory pressure (PEEP) may promote venous stasis in the upper extremities and predispose to upper extremity deep vein thrombosis (UEDVT). Methods. We performed a retrospective case control study of medical intensive care unit patients who required mechanical ventilation (MV) for >72 hours and underwent duplex ultrasound of their upper veins for suspected DVT between January 2011 and December 2013. Results. UEDVT was found in 32 (28.5%) of 112 patients. Nineteen (67.8%) had a central venous catheter on the same side. The mean ± SD duration of MV was 13.2 ± 9.5 days. Average PEEP was 7.13 ± 2.97 cm H2O. Average PEEP was ≥10 cm H2O in 23 (20.5%) patients. Congestive heart failure (CHF) significantly increased the odds of UEDVT (OR 4.53, 95% CI 1.13–18.11; P = 0.03) whereas longer duration of MV (≥13 vs. <13 days) significantly reduced it (OR 0.29, 95% CI 0.11–0.8; P = 0.02). Morbid obesity showed a trend towards significance (OR 3.82, 95% CI 0.95–15.4; P = 0.06). Neither PEEP nor any of the other analyzed predictors was associated with UEDVT. Conclusions. There is no association between PEEP and UEDVT. CHF may predispose to UEDVT whereas the risk of UEDVT declines with longer duration of MV.

A Large Pleural Effusion following Abdominal Aortic Surgery

Chylous ascites and coexistent chylothorax is a rare but important complication following retroperitoneal abdominal surgery. We report a 70-year-old male who developed gradual abdominal distension, chest tightness, and dyspnea five months after having an uncomplicated aortobifemoral bypass performed. Physical examination was consistent with a large right sided effusion and ascites which were confirmed by computed tomography. Thoracentesis yielded an opaque milky fluid with analysis consistent with a chylothorax with a paracentesis revealing fluid that was similar in both appearance and biochemistry. The patient failed initial conservative management so a chest tube was placed followed by chemical pleurodesis. We review the literature of the pathophysiology and treatment approach to such a pleural effusion.

Postgraduate Education CornerChest Imaging and Pathology for CliniciansAn 82-Year-Old Woman With Left Upper Lobe Atelectasis

An 82-year-old woman was seen in the pulmonary clinic for complaints of shortness of breath and intermittent wheeze associated with cough productive of scanty white phlegm. This persisted despite treatment with an inhaled bronchodilator and two courses of antibiotics and prednisone that were prescribed by her primary care physician prior to evaluation in the pulmonary clinic. She was a lifelong nonsmoker with a medical history signifi cant only for a partial colectomy, secondary to two reportedly malignant polyps in her colon, 5 years previously. She did not require any additional treatment after the colectomy and was told that she did not require any follow-up. Physical examination was unremarkable at the time of initial evaluation in the pulmonary clinic. CBC count with differential, basic metabolic panel and hepatic panel was unremarkable. A chest radiograph showed atelectasis of the left upper lobe ( Figs 1A , 1B ), which was confi rmed on CT scan ( Figs 1C , 1D ). Flexible bronchoscopy performed the subsequent week revealed an endobronchial lesion in the left main-stem bronchus partially occluding the left upper lobe bronchus ( Fig. 2 ). Endobronchial biopsy specimens using forceps were sent for pathology, and bronchial brushings and washings were sent for cytology. The initial pathology revealed infi ltrative atypical lymphoid tissue that was highly suspicious for lymphoma, but more tissue was requested for a defi nitive diagnosis. The neoplastic cells stained positive for LCA and CD20 and negative for CD3, cytokeratins (AE 1:3, MAK-6), S-100 protein, and thyroid transcription factor-1 . The bronchial brushings also revealed atypical cells that were suspicious for malignancy ( Fig 3 ). In the interim, the patient’s lactate dehydrogenase level and a fl ow cytometric analysis of her peripheral blood revealed no evidence of an overt B-cell lymphop roliferative disorder or an acute myeloproliferative disorder. A PET-CT scan showed increased fl uorodeoxyglucose (FDG ) uptake in the area of the left main-stem bronchus, with increased soft tissue density tracking along this structure. Maximal standardized uptake value (SUV) was 17.1. There was also left hilar lymphadenopathy with hypermetabolic activity and SUV measuring 22.89, as well as bilateral subcentimeter pulmonary nodules that did not demonstrate increased FDG activity ( Fig 4 ). Flexible bronchoscopy was repeated to obtain more tissue, as well as to perform endobronchial ultrasoundguided transbronchial needle aspiration of the left hilar lymph node. Specimens were sent for fl ow cytometric analysis and pathology. Enough tissue was obtained for the pathologist to make a defi nitive diagnosis on this occasion, and additional fresh tissue was sent for fl ow cytometric analysis.

An 82-Year-Old Woman With Left Upper Lobe Atelectasis

An 82-year-old woman was seen in the pulmonary clinic for complaints of shortness of breath and intermittent wheeze associated with cough productive of scanty white phlegm. This persisted despite treatment with an inhaled bronchodilator and two courses of antibiotics and prednisone that were prescribed by her primary care physician prior to evaluation in the pulmonary clinic. She was a lifelong nonsmoker with a medical history signifi cant only for a partial colectomy, secondary to two reportedly malignant polyps in her colon, 5 years previously. She did not require any additional treatment after the colectomy and was told that she did not require any follow-up. Physical examination was unremarkable at the time of initial evaluation in the pulmonary clinic. CBC count with differential, basic metabolic panel and hepatic panel was unremarkable. A chest radiograph showed atelectasis of the left upper lobe ( Figs 1A , 1B ), which was confi rmed on CT scan ( Figs 1C , 1D ). Flexible bronchoscopy performed the subsequent week revealed an endobronchial lesion in the left main-stem bronchus partially occluding the left upper lobe bronchus ( Fig. 2 ). Endobronchial biopsy specimens using forceps were sent for pathology, and bronchial brushings and washings were sent for cytology. The initial pathology revealed infi ltrative atypical lymphoid tissue that was highly suspicious for lymphoma, but more tissue was requested for a defi nitive diagnosis. The neoplastic cells stained positive for LCA and CD20 and negative for CD3, cytokeratins (AE 1:3, MAK-6), S-100 protein, and thyroid transcription factor-1 . The bronchial brushings also revealed atypical cells that were suspicious for malignancy ( Fig 3 ). In the interim, the patient’s lactate dehydrogenase level and a fl ow cytometric analysis of her peripheral blood revealed no evidence of an overt B-cell lymphop roliferative disorder or an acute myeloproliferative disorder. A PET-CT scan showed increased fl uorodeoxyglucose (FDG ) uptake in the area of the left main-stem bronchus, with increased soft tissue density tracking along this structure. Maximal standardized uptake value (SUV) was 17.1. There was also left hilar lymphadenopathy with hypermetabolic activity and SUV measuring 22.89, as well as bilateral subcentimeter pulmonary nodules that did not demonstrate increased FDG activity ( Fig 4 ). Flexible bronchoscopy was repeated to obtain more tissue, as well as to perform endobronchial ultrasoundguided transbronchial needle aspiration of the left hilar lymph node. Specimens were sent for fl ow cytometric analysis and pathology. Enough tissue was obtained for the pathologist to make a defi nitive diagnosis on this occasion, and additional fresh tissue was sent for fl ow cytometric analysis.

A case of worsening pulmonary arterial hypertension and pleural effusions by bosutinib after prior treatment with dasatinib

A 52-year-old man with a past medical history of chronic myeloid leukemia (CML) in remission developed progressive shortness of breath over a two-month period. He was initially treated with dasatinib for four years, until developing pulmonary arterial hypertension (PAH) with pleural effusions. His symptoms improved after stopping dasatinib. He was then switched to bosutinib for approximately one year, which was then stopped before admission due to worsening shortness of breath. His initial workup showed bilateral pleural effusions with severe PAH and cor pulmonale. He had symptomatic improvement with PAH-specific therapy following discontinuation of the bosutinib. The life expectancy of CML patients has increased in the era of the tyrosine kinase inhibitors (TKIs), and managing adverse events (AEs) of the TKIs and improving quality of life are becoming more important. Pulmonary hypertension (PH) and pleural effusions are rarely reported AEs of bosutinib. More reports with PH and pleural effusions arising after bosutinib use in patients previously treated with dasatinib is furthermore concerning. In this era with novel chemotherapeutic agents, physicians ought to be weary of the significant morbidity implicated by these agents in the lives of patients.

Operator dependent factors implicated in failure of non-invasive positive pressure ventilation (NIPPV) for respiratory failure

Non‐invasive Positive Pressure Ventilation (NIPPV) is employed for the management of acute respiratory failure and studies have shown that it can prevent the need for endotracheal intubation, mechanical ventilation and associated complications. Given limited studies evaluating the factors, other than those related patient or underlying disease severity, that may lead to NIPPV failure, we performed this study to gain insight into current practices in terms of utilization of NIPPV and operator dependent factors that may possibly contribute to failure of NIPPV.

An unusual case of iatrogenic haemoptysis

Summary Transbronchial needle aspiration (TBNA) of the hilar and mediastinal lymph nodes and lung masses is a powerful tool in the diagnostic evaluation of mediastinal adenopathies including malignancies. As its use becomes more widespread, few cases have been reported with complications. We present a case of a 57-year-old man who was transferred to our institution for uncontrolled haemoptysis following endobronchial ultrasound-guided TBNA. At our institution, emergent bronchoscopy revealed a large clot distal to the right upper lobe bronchus without a visible fistula tract. A CT pulmonary angiogram and a subsequent pulmonary angiogram showed an aneurysm originating from the right superior pulmonary vein. Management was conservative with strict blood pressure control and lowering the left atrial pressure allowed spontaneous resolution of the bleed.