Search

Lung Cancer is the primary cause of cancer-related death in the United States. We have recognized a need for novel methods of identification and consideration of enrollment into a lung cancer screening program for those at the highest risk of lung cancer. Our primary goal was to determine if pulmonary function test (PFT) demographic data would be useful in identifying patients for lung cancer screening. We retrospectively reviewed PFTs performed at Lahey Hospital & Medical Center (LHMC) January 2012 through January 2013 and found that of patients identified as high risk of lung cancer, 89% had passed through our PFT lab but had not yet been screened. Investigation into the barriers of lung cancer screening to better understand how to increase appropriate enrollment then followed. A total of 3098 PFTs were reviewed from January 2012 through January 2013 and 634 patients (20%) were identified as high risk for lung cancer. Of 634 patients, 70 (11%) were already in the LHMC lung cancer screening program. The remaining 564 patients (89%) were not enrolled, and of these, it was found that 292 patients identified as high risk for lung cancer represented missed opportunities for screening. The remaining 272 patients were appropriately not screened with the three most common reasons being prior imaging with positive finding, lung cancer within five years, and provider discussed but scan not yet performed. Appropriate enrollment in a lung cancer screening program may be increased with the careful use of demographic data obtained from a PFT lab.Â

Background Cardiac sarcoidosis (CS) is associated with significant morbidity and mortality including progressive heart failure and sudden cardiac death. High-dose steroid immunosuppression remains standard of care for CS but there is a lack of randomized clinical trial data. As a result, there remains significant treatment variability among specialized centers. TNF alpha inhibitors are widely used for other inflammatory diseases and are generally well tolerated. However, little data, if any, exists regarding their utility in CS. TNF alpha inhibitors are particularly attractive given the potential adverse effects of chronic glucocorticoid based immunosuppression. The purpose of this study was to explore the effectiveness of TNF alpha inhibitors in active CS. Methods We performed a retrospective analysis of patients with metabolically active CS (defined by increased FDG avidity by cardiac PET imaging) who were treated with TNF alpha inhibitors. All patients underwent follow up PET imaging. Disease activity was quantified by the number of left ventricular (LV) myocardial segments with FDG avidity (based on a 17 segment model of the LV). Adverse events related to therapy was also recorded. Results Nine patients treated with TNF alpha inhibitors were included in this analysis. Eight Patients received the TNF alpha inhibitor, infliximab, one patient received adalimumab. Eight of the nine patients had previously received prednisone for CS; four transitioned from prednisone to infliximab due to adverse effects of steroid use; three transitioned because of continued active CS despite steroid therapy; one patient exhibited recurrent cardiac FDG avidity after prednisone discontinuation and another declined steroid treatment. The number of LV myocardial segments with active CS decreased from 8.6 +/- 3.6 to 1.9 +/- 3.5 (p=0.001) after a mean treatment duration of 7 months of infliximab that represents a decline of FDG avid LV segments by 72%. There was no significant change in LV ejection fraction (45 +/- 15% to 50 +/- 11% after therapy, p=NS). Six of the nine patients had complete resolution of active CS, and two had partial improvement. One patient experienced pancytopenia felt possibly related to infliximab; no other obvious adverse events were observed. Conclusions In this retrospective cohort, TNF alpha inhibition lead to significant improvement in disease activity based on FDG PET imaging. Most patients demonstrated complete resolution of active CS with minimal adverse effects. Further investigation into the use of TNF alpha inhibitors for treating active CS is warranted.

While patients have been known to aspirate pills, they virtually never persist long enough to lead to complications. A spectrum of events, however, may arise especially from iron pill aspiration. If not identified and removed early, cytotoxic damage from local free-radical generation may result in airway damage. We report a case of an aspirated iron pill, which did not disintegrate and presented with chronic cough. Imaging revealed a foreign body in the right bronchus, and bronchoscopic removal allowed resolution of an associated pneumonia, without any further symptoms on subsequent surveillance.

A 70-year-old man with history of stage IV renal cell carcinoma, chronic atrial fibrillation on warfarin, coronary artery disease status post-percutaneous coronary intervention resulting in an ischaemic cardiomyopathy with left ventricular ejection fraction of 40%–45%, presented with shortness of breath 10 days after starting pazopanib. Within the first week of starting pazopanib, the patient developed fatigue and progressive dyspnoea on exertion. His symptoms quickly worsened and he had compromised mental status. He was transferred to the intensive care unit (ICU) and intubated due to continued respiratory distress. He was found to be in cardiogenic shock and was started on inotropic support with dobutamine and norepinephrine. With maximum support, the patient was slowly weaned off vasopressors and was successfully extubated on ICU day 9. His hospital stay lasted 29 days with management of multiple medical complications, and he was eventually discharged to a rehabilitation facility.

Objective To assess the degree of agreement between propensity score studies and randomized clinical trials in critical care research. Data sources Propensity score studies published in highly cited critical care or general medicine journals or included in a previous systematic review; corresponding randomized clinical trials included in Cochrane Systematic Reviews or published in PubMed. Study selection We identified propensity score studies of the effects of therapeutic interventions on short- or long-term mortality. We systematically matched propensity score studies to randomized clinical trials based on patient selection criteria, interventions, and outcomes. Data extraction We appraised the methods of included studies and extracted treatment effect estimates to compare the results of propensity score studies and randomized clinical trials. When multiple studies were identified for the same topic, we performed meta-analyses to obtain summary treatment effect estimates. Data synthesis We matched 21 propensity score studies with 58 randomized clinical trials in 18 distinct comparisons (median, one propensity score study and two randomized clinical trials per comparison), for short- and long-term mortality. We found one statistically significant difference between designs (hyperoncotic albumin vs crystalloid fluids) among these 18 comparisons. Propensity score studies did not produce systematically higher (or lower) treatment effect estimates compared with randomized clinical trials, but estimates from the two designs differed by more than 30% in one third of the comparisons examined. Observational studies in critical care met widely accepted methodological standards for propensity score analyses. Conclusions Across diverse critical care topics, propensity score studies published in high-impact journals produced results that were generally consistent with the findings of randomized clinical trials. However, caution is needed when interpreting propensity score studies because occasionally their results contradict those of randomized clinical trials and there is no reliable way to predict disagreements.

Background:Infliximab is a chimeric monoclonal antibody against tumor necrosis factor (TNF)-alpha, used for the treatment of Crohn's disease and rheumatoid arthritis. Recently, an increased risk of infection due toMycobacterium tuberculosisand rare cases of invasive fungal disease have been reported following infliximab therapy.Case Report:A 73-year-old woman with chronic rheumatoid arthritis who had been treated with methotrexate, leflunomide, and prednisone was given the first of three doses of infliximab in June 2001. In July 2001, she presented with cough, and in August, she had a right upper lobe infiltrate that was treated with levofloxacin without improvement. In October, the patient had right upper and middle lobe infiltrates on a chest x-ray and computed tomography scan. At bronchoscopy, an endobronchial mass was biopsied, which demonstratedAspergillus fumigatus. Our patient had frequently accompanied her daughter on visits to another medical center following a stem cell transplant, where her daughter was instructed to wear a mask during all visits because of extensive building construction. We postulate that our patient may have acquired pulmonary aspergillosis during this period. Literature reviews on granulomatous diseases following infliximab therapy and hospital-acquired aspergillosis are presented.Conclusion:The temporal relationship between the administration of infliximab andA. fumigatusinfection in this patient suggests a causal relationship and possible healthcare-associated acquisition. These data underscore the importance of both patient and family education on prevention strategies when potent immune-modulating medications such as infliximab have been prescribed (Infect Control Hosp Epidemiol2003;24:477-482)

A 42-year-old woman was hospitalized with fever and hypoxemia. The workup for fever was unrevealing. A computed tomographic scan of the chest showed centrilobular, small, nodular opacities throughout both the lung fields. A flexible bronchoscopy with transbronchial biopsy was performed. Pathology specimens consisted of intravascular foreign material with birefringent properties suggestive of microcrystalline cellulose. It was later determined that the patient was self-injecting herself with crushed pill fragments through a tunneled central venous catheter. The central venous catheter was removed and fever resolved.

Study objective To compare the diagnostic sensitivity of a modified Abrams needle pleural biopsy technique (Al) with the standard Abrams (A2) and Cope needle biopsy methods. The modified Abrams pleural biopsy technique consisted of suctioning each tissue sample into a syringe without removing the needle completely from the chest until the completion of the entire procedure. Both the standard Abrams and Cope needle techniques required needle removal from the chest after each pleural biopsy. Design Retrospective chart analysis. Setting Community teaching hospital affiliated with Stanford University. Patients Forty-seven patients (30 men and 17 women) with a mean age of 44.5 years (range, 19 to 81 years) who were referred to a pulmonary consultation service for pleural biopsy. Interventions Two of us (C.M.K. and F.T.K.) used the modified Abrams technique and two of us (W.A.J. and A.C.C.) used the standard Abrams technique. The Cope needle was used as originally described. Measurements We recorded the type of pleural biopsy needle and technique used in each patient. Biopsy specimen diameter and number of tissue samples obtained, final diagnoses, and complications were recorded. Results The diagnostic sensitivity for tuberculous pleurisy was 82% for the modified Abrams method, 71% for the standard Abrams method, and 88% for the standard Cope technique (p≥0.3). There was no difference in size of tissue sample obtained (Al vs A2), number of biopsies, or complications among the three methods of pleural biopsy. Conclusions The modified method of Abrams needle biopsy demonstrates a diagnostic sensitivity for pleural tuberculosis (82%) that is equivalent to that for the standard Abrams or Cope methods.

A 56-year-old diabetic man presented with left upper lobe collapse and postobstructive pneumonitis. Fiberoptic bronchoscopy revealed an endobronchial mass obstructing the left mainstem bronchus. The lesion resembled a bronchial adenoma; however, cytologic and histologic examination revealed invasive mucormycosis. The patient was treated with intravenous amphotericin B followed by endoscopic laser surgery that relieved the obstruction.

Study objective To evaluate the prevalence and response to therapy of Strongyloides stercoralis infection in immigrant patients with asthma from areas endemic for Strongyloides. Design and interventions In all patients, we performed a complete history and physical examination, complete blood cell counts (CBC), S stercoralis serologic tests, spirometry, and evaluated three stool samples for ova and parasites. Patients treated for S stercoralis infection had follow-up CBC, spirometry, serologic tests, and at least three additional stool examinations to confirm eradication of the parasite. Setting Ambulatory and hospitalized patients who were referred to the respiratory medicine clinic of a general hospital for the evaluation and treatment of asthma. Patients Forty-five asthmatic adults, representing 12 endemic countries, ranging in age from 20 to 76 years, were prospectively evaluated. Results Six of 45 patients were infected with S stercoralis , which yielded a prevalence of 13 percent. The patients with asthma and S stercoralis infection had higher blood eosinophil counts (p=0.006) and were younger (p=0.006) compared with patients with only asthma. There was no difference in the duration of asthma, spirometry, or steroid use between the two groups. Patients with S stercoralis and asthma tended to be more recent immigrants (p=0.05). Five of the six patients with S stercoralis agreed to be treated with thiabendazole but only four returned for follow-up evaluation. All four patients had eradication of S stercoralis infection confirmed by negative stool examinations and a decline in S stercoralis serology (160 ± 25 percent vs 13 ± 13 percent, p=0.03). All four patients had a decline in total blood eosinophil counts (2,476 ±832 cells per cubic millimeter vs 551 ± 138 cells per cubic millimeter, p=0.03) without a clinical improvement in asthma. Conclusions Our data suggest that patients with asthma from areas endemic for S stercoralis , who have elevated peripheral blood eosinophil counts, should be screened for S stercoralis infection. Successful eradication of S stercoralis , however, may not result in a clinical improvement of asthma.

We investigated the outcome and potential cost savings of a system designed to limit physician access to induced sputum analysis (ISA) for the diagnosis of Pneumocystis carinii pneumonia (PCP). Four respiratory medicine physicians screened all requests for ISA to determine the pretest likelihood of PCP. Twenty-two of 102 requests for ISA over a 1-year period were denied due to a low clinical suspicion for PCP. Seven individuals had a definitive alternative diagnosis confirmed and the remaining 15 were empirically treated for a presumptive diagnosis. All individuals were followed for at least 60 days or until death. None of the 22 individuals developed PCP during the follow-up period. We estimate that this approach saved $27,474, avoided exposure of health care workers to Mycobacterium tuberculosis, and was educational for the referring physicians.

Pulmonary manifestations are not infrequent in the L-tryptophan-induced eosinophilia-myalgia syndrome (EMS). However, previous reports have not described the results of longitudinal pulmonary function, exercise testing, high-resolution computerized tomographic (HRCT) scanning of the chest, or detailed bronchoalveolar lavage (BAL) analysis. We report six patients with EMS who had dyspnea. The diffusing capacity for carbon monoxide was decreased in five patients tested. Exercise testing with arterial blood gas sampling in three patients was consistent with pulmonary vascular or parenchymal disease. Serial exercise testing in two of these patients demonstrated marked improvement temporally associated with corticosteroid treatment. In four patients, HRCT scanning of the chest was abnormal. One of these patients showed no abnormality on routine chest roentgenogram. Two patients undergoing BAL exhibited increased eosinophils in the lavage fluid; a third had elevated lymphocytes. Serial measurements of fibroblast proliferation-stimulating-activity in samples of BAL fluid obtained from serial examinations in two patients exhibited heightened pretreatment activity that returned to the normal range following corticosteroid therapy. In these two patients, increased proportions of T-suppressor/cytolytic (CD8+) cells were observed in the BAL fluid. Despite aggressive immunosuppressive therapy, one of the patients died of respiratory failure. Another remains markedly dyspneic with pulmonary hypertension. Of the remaining four patients, two exhibited resolution of pulmonary symptoms after systemic corticosteroid therapy, and two experienced partial improvement.