Cardiopulmonary Pathology Research Articles

Identification of novel TTN gene variant in a patient exhibiting severe dilated cardiomyopathy co-occurring with acute fibrinoid organizing pneumonia.

Dilated cardiomyopathy (DCM) is often hereditary, with 20% to 40% of nonischemic cases showing familial linkage, yet genetic testing is underused. This report describes an unreported pathogenic nonsense variant in the Titin (TTN) gene (NM_001267550.2:c.92603G>A) in a 24-year-old man with severe DCM and acute fibrinoid organizing pneumonia, highlighting a unique cardiopulmonary pathology. We conducted detailed gross, histopathologic, immunophenotypic, and exome-based DNA sequencing analysis in the workup of this case. We also included the patient's clinical and radiologic findings in our study. With rapid clinical deterioration and complex comorbidities, including substance abuse and psychiatric conditions, which precluded transplantation, the patient's cardiac function progressively worsened. Autopsy findings included extreme cardiomegaly, biventricular hypertrophy, and acute and chronic pericarditis. Significant pulmonary pathology consistent with acute fibrinoid organizing pneumonia was also noted. Molecular testing confirmed a deleterious maternally inherited TTN variant that was absent in the sibling of the proband and the extant medical literature, highlighting its rarity and significance. This case contributes to the ongoing body of work on the impact of TTN variants on DCM. It suggests a potential link between genetic variants and complex cardiac injury patterns, emphasizing the need for further investigation into the interplay between cardiomyopathy and pulmonary pathology.

Clinical exome sequencing uncovers genetic disorders in neonates with suspected hypoxic-ischemic encephalopathy: A retrospective analysis.

Hypoxic-ischemic encephalopathy (HIE) occurs in up to 7 out of 1000 births and accounts for almost a quarter of neonatal deaths worldwide. Despite the name, many newborns with HIE have little evidence of perinatal hypoxia. We hypothesized that some infants with HIE have genetic disorders that resemble encephalopathy. We reviewed genetic results for newborns with HIE undergoing exome or genome sequencing at a clinical laboratory (2014-2022). Neonates were included if they had a diagnosis of HIE and were delivered ≥35 weeks. Neonates were excluded for cardiopulmonary pathology resulting in hypoxemia or if neuroimaging suggested postnatal hypoxic-ischemic injury. Of 24 patients meeting inclusion criteria, six (25%) were diagnosed with a genetic condition. Four neonates had variants at loci linked to conditions with phenotypic features resembling HIE, including KIF1A, GBE1, ACTA1, and a 15q13.3 deletion. Two additional neonates had variants in genes not previously associated with encephalopathy, including DUOX2 and PTPN11. Of the six neonates with a molecular diagnosis, two had isolated HIE without apparent comorbidities to suggest a genetic disorder. Genetic diagnoses were identified among neonates with and without sentinel labor events, abnormal umbilical cord gasses, and low Apgar scores. These results suggest that genetic evaluation is clinically relevant for patients with perinatal HIE.

Hepatic hydrothorax.

Hepatic hydrothorax (HH) refers to the presence of a pleural effusion that develops in the context of underlying liver cirrhosis and portal hypertension. It carries a high risk of morbidity and mortality, with a median survival of 8-12 months. Diagnosis is usually confirmed by pleural aspiration, demonstrating typical features of a transudative effusion in the absence of co-existent cardio-pulmonary or renal pathology. The clinical presentation is quite variable, with some patients remaining relatively asymptomatic in the presence of small or incidental effusions, while others present with frank respiratory failure requiring pleural intervention. The development of spontaneous bacterial empyema (SBEM) is a significant and not infrequent complication, requiring prompt recognition and treatment. While the mainstay of management is focused on optimising fluid balance through dietary salt restriction and diuretic therapy, liver transplantation remains the definitive treatment option. As such, it is crucial to adopt a multi-disciplinary approach-involving pulmonologists, hepatologists, dieticians, and palliative care physicians-in order to optimise care for this often complex group of patients. This review will discuss the basic pathophysiology of HH, its clinical presentation and diagnosis, as well as the approach to management of HH in clinical practice, focussing on both interventional and non-interventional treatment modalities.

POTENTIAL FOR PATHOGENETIC CORRECTION OF PROTEASE-ANTIPROTEASE SYSTEM IMBALANCE IN PATIENTS WITH COMORBIDITY OF STABLE ANGINA PECTORIS OF THE II-III FUNCTIONAL CLASS AND STAGE II-III CHRONIC OBSTRUCTIVE PULMONARY DISEASE

The aim of this study is to assess the clinical effectiveness of the therapy including exogenous L-arginine and statins under the comorbidity of stable angina pectoris of the II-III functional class and chronic obstructive pulmonary disease of the II-III stage.
 Materials and methods. The study included 50 patients with coronary heart disease and chronic obstructive pulmonary disease (mean age 57 years; male/female ratio 78/22%). In order to assess the clinical effectiveness of the therapy for combined cardiopulmonary pathology, the patients were randomized into 2 subgroups: subgroup 1 included 25 patients who took metabolitotropic medication under high-intensity statin therapy (the basic therapy included L-arginine and rosuvastatin as a hypolipidemic agent in a dose of 20 mg/day); subgroup 2 included 25 patients who received only basic therapy under moderately intensive statin therapy (daily doses of atorvastatin 20 mg, rosuvastatin 10 mg)). The groups were comparable in terms of gender distribution and demographic characteristics. Comparative analysis of smoking experience, initial smoking age and smoking history did not differ significantly between the groups. After 12±1 weeks, a control examination was carried out.
 Results. The analysis of the ratio of the MMP-9 activity level before and after the therapy showed that the level of MMP-9 expression decreased by 43.28% (p<0.05) in the 1st subgroup and by 13.18% in the 2nd subgroup until the end of the therapy. TIMP activity after 12 weeks of the treatment was +33.11% (p<0.05) and +11.27% for the 1st and 2nd subgroups respectively. The difference between subgroups 1 and 2 in the level of the CRP marker before and after the therapy was -45.65% (p<0.05) and -9.09%, respectively. 76% of people from the 1st subgroup reached the target level of healthy people before the completion of the therapy that is significantly higher than the similar indicator in the 2nd subgroup (32%) at χ2=8.05, p<0.01.
 Conclusions: The application of L-arginine alongside high-intensity statin therapy for patients presenting with stable angina pectoris of the II-III functional class and stage II-III chronic obstructive pulmonary disease (COPD) resulted in more notable positive changes in the modulation of protease-antiprotease status disorders. This was evidenced by a reduction in the heightened expression of MMP-9 and an increase in the level of TIMP during the course of treatment.

Differential cardiopulmonary haemodynamic phenotypes in PASC-related exercise intolerance.

Post-acute sequelae of COVID-19 (PASC) affect a significant proportion of patients who have previously contracted SARS-CoV-2, with exertional intolerance being a prominent symptom. This study aimed to characterise the invasive haemodynamic abnormalities of PASC-related exertional intolerance using invasive cardiopulmonary exercise testing (iCPET). 55 patients were recruited from the Yale Post-COVID-19 Recovery Program, with most experiencing mild acute illness. Supine right heart catheterisation and iCPET were performed on all participants. The majority (75%) of PASC patients exhibited impaired peak systemic oxygen extraction (pEO2) during iCPET in conjunction with supranormal cardiac output (CO) (i.e., PASC alone group). On average, the PASC alone group exhibited a "normal" peak exercise capacity, V'O2 (89±18% predicted). ∼25% of patients had evidence of central cardiopulmonary pathology (i.e., 12 with resting and exercise heart failure with preserved ejection fraction (HFpEF) and two with exercise pulmonary hypertension (PH)). PASC patients with HFpEF (i.e., PASC HFpEF group) exhibited similarly impaired pEO2 with well compensated PH (i.e., peak V'O2 and CO >80% respectively) despite aberrant central cardiopulmonary exercise haemodynamics. PASC patients with HFpEF also exhibited increased body mass index of 39±7 kg·m-2. To examine the relative contribution of obesity to exertional impairment in PASC HFpEF, a control group comprising obese non-PASC group (n=61) derived from a historical iCPET cohort was used. The non-PASC obese patients with preserved peak V'O2 (>80% predicted) exhibited a normal peak pulmonary artery wedge pressure (17±14 versus 25±6 mmHg; p=0.03) with similar maximal voluntary ventilation (90±12 versus 86±10% predicted; p=0.53) compared to PASC HFpEF patients. Impaired pEO2 was not significantly different between PASC patients who underwent supervised rehabilitation and those who did not (p=0.19). This study highlights the importance of considering impaired pEO2 in PASC patients with persistent exertional intolerance unexplained by conventional investigative testing. Results of the current study also highlight the prevalence of a distinct high output HFpEF phenotype in PASC with a primary peripheral limitation to exercise.

Quantitative descriptive study of oxygen saturation in women living at altitudes greater than 2800 M.A.S.L. Huancavelica Peru

The objective of the research work was to determine the oxygen saturation (SpO2) in women of childbearing age who live at altitudes greater than 2800 meters above sea level (m.a.s.l) Huancavelica 2021. The study was observational, prospective, cross-sectional, in 151 healthy women of childbearing age, from 18 to 49 years old, the SpO2 was evaluated, through a pulse oximeter, to all women who attended the consultation between July and August of the year 2021, women without cardiopulmonary pathology were considered within the study group and those who accepted take part. Results: the average of the SpO2, of those who live between 2819 - 3499 m.a.s.l. is 93.72% and between 3500 - 4200 m.a.s.l., it is 90.85%; the minimum SpO2 was 85% and 83% respectively, the maximum SpO2 was 99% in both altitude floors. According to age, 92.91% were between 18 and 19 years old, 93.09% between 20 and 34 years old, and 91.74% between 35 and 49 years old. The average SpO2 of the pregnant women was 92.29% and in the non-pregnant women 92.67%, the minimum SpO2 was 88% and 83% respectively, while the maximum value was the same in both groups 99%. Conclusion: the inhabitants show lower saturations at higher altitudes, and it is observed to decrease after 35 years old, no difference is found between pregnant and non-pregnant women.

Features of echocardiographic examination in patients with COVID-19

Novel coronavirus infection has become one of urgent health problems of the 21st century. The associated disorders often result in the development of cardiopulmonary pathology, which requires creation of a new paradigm in diagnosis and treatment. Studies performed during the pandemic have demonstrated an important role of echocardiography (EchoCG) in diagnosis of right ventricular (RV) dysfunction in patients with respiratory insufficiency in COVID-19. The analysis of EchoCG parameters with a high prognostic value showed that in EchoCG, a special attention should be paid to right heart dimensions, RV contractility, and pulmonary artery (PA) systolic pressure, which are the most sensitive indexes of RV afterload and indirect markers of pulmonary disease severity. RV FAC can be recommended for evaluation of the RV systolic function as the most informative variable. Also, it was demonstrated that the RV longitudinal strain has an additional significance for early identification of signs of systolic dysfunction and risk stratification in patients with COVID-19. In addition to the effectiveness and reproducibility of this method, an important advantage of EchoCG is its availability, possibility of saving images for remote interpretation by other specialists, and tracking changes in morphological and functional parameters of the heart. Thus, the analysis of international literature suggests that EchoCG plays an important role in prediction of severe cardiopulmonary disorders and timely selection of the treatment for patients with COVID-19. For these reasons, EchoCG should serve as an additional method of clinical evaluation, particularly in persons with moderate or severe disease.

Radiomics-Guided Global-Local Transformer for Weakly Supervised Pathology Localization in Chest X-Rays.

Before the recent success of deep learning methods for automated medical image analysis, practitioners used handcrafted radiomic features to quantitatively describe local patches of medical images. However, extracting discriminative radiomic features relies on accurate pathology localization, which is difficult to acquire in real-world settings. Despite advances in disease classification and localization from chest X-rays, many approaches fail to incorporate clinically-informed domainspecific radiomic features. For these reasons, we propose a Radiomics-Guided Transformer (RGT) that fuses global image information with local radiomics-guided auxiliary information to provide accurate cardiopulmonary pathology localization and classification without any bounding box annotations. RGT consists of an image Transformer branch, a radiomics Transformer branch, and fusion layers that aggregate image and radiomics information. Using the learned self-attention of its image branch, RGT extracts a bounding box for which to compute radiomic features, which are further processed by the radiomics branch; learned image and radiomic features are then fused and mutually interact via cross-attention layers. Thus, RGT utilizes a novel end-to-end feedback loop that can bootstrap accurate pathology localization only using image-level disease labels. Experiments on the NIH ChestXRay dataset demonstrate that RGT outperforms prior works in weakly supervised disease localization (by an average margin of 3.6% over various intersection-over-union thresholds) and classification (by 1.1% in average area under the receiver operating characteristic curve). We publicly release our codes and pre-trained models at https://github.com/VITAGroup/chext.

Day-night patterns in heart rate variability and complexity: differences with age and cardiopulmonary disease.

Heart rate variability (HRV) measures provide valuable insights into physiology; however, gaps remain in understanding circadian patterns in heart rate dynamics. We aimed to explore day-night differences in heart rate dynamics in patients with chronic cardiopulmonary disease compared with healthy controls. Using 24-hour heart rate data from patients with chronic obstructive pulmonary disease (COPD) and/or heart failure (n = 16) and healthy adult controls (older group: ≥50 years, n = 42; younger group: 20-49 years, n = 136), we compared day-night differences in conventional time and frequency domain HRV indices and a multiscale-entropy-based complexity index (CI1-20) of HRV among the 3 groups. Twenty-four-hour HRV showed significant day-night differences (marked with "△") among younger healthy (mean age: 34.5 years), older healthy (mean age: 61.6 years), and cardiopulmonary patients (mean age: 68.4 years), including change in percentage of adjacent intervals that differ > 50 ms (△pNN50), high frequency (△HF), normalized low frequency (△nLF), ratio (△LF/HF), and △CI1-20. Among these, △LF/HF (2.13 ± 2.35 vs 1.1 ± 2.47 vs -0.35 ± 1.25; P < .001) and △CI1-20 (0.15 ± 0.24 vs 0.02 ± 0.28 vs -0.21 ± 0.27; P < .001) were significant in each pairwise comparison following analysis of variance tests. Average CI1-20 was highest in younger healthy individuals and lowest in cardiopulmonary patients (1.37 ± 0.12 vs 1.01 ± 0.27; P < .001). Younger healthy patients showed a heart rate complexity dipping pattern (night < day), older healthy patients showed nondipping, and cardiopulmonary patients showed reverse dipping (night > day). As measures of 24-hour variability, traditional and complexity-based metrics of HRV exhibit large day-night differences in healthy individuals; these differences are blunted, or even reversed, in individuals with cardiopulmonary pathology. Measures of diurnal dynamics may be useful indices of reduced adaptive capacity in patients with cardiopulmonary conditions. Ma Y, Chang M-C, Litrownik D, Wayne PM, Yeh GY. Day-night patterns in heart rate variability and complexity: differences with age and cardiopulmonary disease. J Clin Sleep Med. 2023;19(5):873-882.

The effectiveness of trimetazidine in the treatment of CHF patients with cardiopulmonary pathology

Introdiction. The article highlights the importance of optimizing the treatment of chronic heart failure (CHF) in patients with comorbid cardiopulmonary pathology, namely ischemic heart disease (CHD) in combination with chronic obstructive pulmonary disease (COPD). The results of our own research on the evaluation of the clinical efficacy of trimetazidine inclusion in the complex therapy of comorbid pathology are presented.Objective. To study the clinical efficacy of trimetazidine as part of the complex therapy of patients with ischemic heart failure in combination with COPD.Materials and methods. 60 patients with CHF II-III FC, left ventricular ejection fraction (LVEF) &lt;45% were studied against the background of postinfarction cardiosclerosis and COPD of 2–3 degrees of airflow restriction. The patients were divided into 2 groups: 1st (30 patients) took trimetazidine; 2nd (30 patients) received therapy without the addition of trimetazidine. The dynamics of: clinical condition with the use of SHOCK, FC CHF, test with 6-min. walking, quality of life (MLHFQ, SGRQ), indicators of 24-bifunctional monitoring, TTE, spirometry, platelet aggregation and blood viscosity.Results and conclusion. The use of trimetazidine as part of therapy led to an improvement in the clinical course of the disease, significantly increased exercise tolerance. The number and duration of ischemia episodes decreased by 34 and 39% (p &lt; 0.05). The number of angina attacks per week and the need for nitroglycerin decreased by 65% and 42% (p &lt; 0.05), respectively. There was an improvement in intracardiac and peripheral hemodynamics. Thus, LV LV increased by 21%, pulmonary artery pressure decreased by 18%, the indicators of LVD, platelet aggregation and blood rheology improved. There was a more positive dynamics of lipid peroxidation and antioxidant system indicators compared to the control group.

Impact of focused cardiac and lung ultrasound screening performed by a junior doctor during admission to the surgical ward on patients before emergency non-cardiac surgery: A pilot prospective observational study.

To assess whether pre-operative focused cardiac ultrasound and lung ultrasound screening performed by a junior doctor can change diagnosis and clinical management of patients aged ≥65 years undergoing emergency, non-cardiac surgery. This pilot prospective observational study included patients scheduled for emergency, non-cardiac surgery. The treating team completed a diagnosis and management plan before and after focused cardiac and lung ultrasound, which was performed by a junior doctor. Changes to diagnosis and management after ultrasound were recorded. Ultrasound images were assessed for image and diagnostic interpretation by an independent expert. There was a total of 57 patients at age 77 ± 8 years. Cardiopulmonary pathology was suspected after clinical assessment in 28% vs. 72% after ultrasound (including abnormal haemodynamic state in 61%, valvular lesions in 32%, acute pulmonary oedema/interstitial syndrome in 9% and bilateral pleural effusions in 2%). In 67% of patients, the perioperative management was changed. The changes were in fluid therapy in 30%, cardiology consultation in 7%, formal in- or out-patient, transthoracic echocardiography in 11% and 30% respectively. The impact of pre-operative focused cardiac and lung ultrasound on diagnosis and management of patients on the hospital ward before emergency non-cardiac surgery by a junior doctor was comparable to previous studies of anaesthetists experienced in focused ultrasound. However, the ability to recognise when image quality is insufficient for diagnosis is an important consideration for novice sonographers. Focused cardiac and lung ultrasound examination by a junior doctor is feasible and may change preoperative diagnosis and management in patients of 65 years or older, admitted for emergency non-cardiac surgery.

P.82 Case-Control cardiopulmonary exercise testing for patients with neuromuscular disease

Patients with neuromuscular diseases (NMD) present with disease-specific muscle weakness and fatigue and are largely sedentary and deconditioned. This sedentary lifestyle leads to additional weakness, fatigue and loss of function. This deconditioning cycle results in reduced cardiorespiratory fitness (CRF), which is strongly related to increased risk for cardiovascular and pulmonary diseases (e.g. hypertension, diabetes mellitus, coronary artery disease, chronic obstructive pulmonary disease). These largely preventable diseases are the leading causes of morbidity and mortality for those with and without NMD. The gold standard for the assessment of CRF is peak oxygen consumption (peak VO2), assessed with cardiopulmonary exercise testing (CPX). Several small studies have suggested a role for CPX for patients with NMD, who present with hyperventilatory and hypercirculatory patterns, but with inconsistent results. We performed CPX in 37 patients with NMD and 8 controls using a Keiser wheelchair accessible total body trainer and a CosMed K5 wearable metabolic system. We were able to perform high quality CPX by both subjective and objective measures. Compared to controls, individuals with NMD presented with reduced exercise performance as measured by peak wattage and peak VO2. Disturbed hemodynamic and ventilatory patterns were noted, with borderline chronotropic incompetence and low O2 pulse, early and marked ventilatory inefficiency and severely reduced oxygen uptake efficiency slope and a high proportion of patients displaying exercise oscillatory breathing. Importantly, we observed that relative effort as illustrated by equivalent RPE and RER was not significantly different than controls. Our data illustrate that high quality CPX can be conducted in this population and suggest that performing CPX in patients with NMD will reveal distinct physiological profiles that may lead to a better understanding of cardiopulmonary and metabolic pathology in these individuals.

Hepatic Hydrothorax: A Narrative Review.

Hepatic hydrothorax (HH) represents a distinct clinical entity within the broader classification of pleural effusion that is associated with significant morbidity and mortality. The median survival of patients with cirrhosis who develop HH is 8–12 months. The diagnosis is typically made in the context of advanced liver disease and ascites, in the absence of underlying cardio-pulmonary pathology. A multi-disciplinary approach to management, involving respiratory physicians, hepatologists, and palliative care specialists is crucial to ensuring optimal patient-centered care. However, the majority of accepted therapeutic options are based on expert opinion rather than large, adequately powered randomized controlled trials. In this narrative review, we discuss the epidemiology, pathophysiology, clinical characteristics, and management of HH, highlighting the use of salt restriction and diuretic therapy, porto-systemic shunts, and liver transplantation. We include specific sections focusing on the role of pleural interventions and palliative care, respectively.

Comprehensive clinical assessment identifies specific neurocognitive deficits in working-age patients with long-COVID.

There have been more than 425 million COVID-19 infections worldwide. Post-COVID illness has become a common, disabling complication of this infection. Therefore, it presents a significant challenge to global public health and economic activity. Comprehensive clinical assessment (symptoms, WHO performance status, cognitive testing, CPET, lung function, high-resolution CT chest, CT pulmonary angiogram and cardiac MRI) of previously well, working-age adults in full-time employment was conducted to identify physical and neurocognitive deficits in those with severe or prolonged COVID-19 illness. 205 consecutive patients, age 39 (IQR30.0-46.7) years, 84% male, were assessed 24 (IQR17.1-34.0) weeks after acute illness. 69% reported ≥3 ongoing symptoms. Shortness of breath (61%), fatigue (54%) and cognitive problems (47%) were the most frequent symptoms, 17% met criteria for anxiety and 24% depression. 67% remained below pre-COVID performance status at 24 weeks. One third of lung function tests were abnormal, (reduced lung volume and transfer factor, and obstructive spirometry). HRCT lung was clinically indicated in <50% of patients, with COVID-associated pathology found in 25% of these. In all but three HRCTs, changes were graded 'mild'. There was an extremely low incidence of pulmonary thromboembolic disease or significant cardiac pathology. A specific, focal cognitive deficit was identified in those with ongoing symptoms of fatigue, poor concentration, poor memory, low mood, and anxiety. This was notably more common in patients managed in the community during their acute illness. Despite low rates of residual cardiopulmonary pathology, in this cohort, with low rates of premorbid illness, there is a high burden of symptoms and failure to regain pre-COVID performance 6-months after acute illness. Cognitive assessment identified a specific deficit of the same magnitude as intoxication at the UK drink driving limit or the deterioration expected with 10 years ageing, which appears to contribute significantly to the symptomatology of long-COVID.

FEATURES OF LAPAROSCOPIC APPENDECTOMY WITH THE ATYPICAL LOCATION OF THE APPENDIX IN PATIENTS WITH A HIGH RISK OF CARDIOPULMONARY INSUFFICIENCY

Objectives. The purpose of the work was to expand the capabilities of laparoscopic appendectomy in the atypical location of the destructively altered appendix in patients with a high risk of cardiopulmonary pathology, through the use of new surgical techniques. Material and methods. In the clinic of Department of Surgery No. 2, Odessa National Medical University, from 2015 to 2020, there were operated on 57 patients for acute appendicitis with an atypical location of the appendix with the presence of concomitant cardiopulmonary pathology. All patients were divided into 2 groups. The first group consisted of 21 (36.8%) patients with an atypical location of the appendix and a high risk of cardiopulmonary failure, who underwent an appendectomy. The second group consisted of 36 (63.2%) patients with an atypical location of the appendix and a high risk of cardiopulmonary failure, who underwent laparoscopic appendectomy. The procedure was performed according to two methods: with the imposition of pneumoperitoneum in 24 (42.2%) patients and in 12 (21%) patients with the imposition of laparolifting, due to severe cardiopulmonary pathology. Results. Postoperative complications in group 2 were less than in patients in group 1. Average stay in the hospital of patients of the second group, after laparoscopic appendectomy, was 4.9 ± 2.35 days. In patients of the first group, with appendectomy – 10.6 ± 5.1 days. After minimally invasive interventions, patients were in the hospital on average 5 days less than patients who underwent open appendectomy. Conclusions. The use of laparoscopic and video-assisted approaches, in an atypical location of appendicitis, can reduce the incidence of postoperative complications and deaths, which generally improves the results of the treatment.

IDIOPATHIC PULMONARY ARTERIOVENOUS MALFORMATION: A RARE CAUSE OF DYSPNEA ON EXERTION

TOPIC: Lung Pathology TYPE: Fellow Case Reports INTRODUCTION: Pulmonary arteriovenous malformation (PAVM) is rare cardiopulmonary vascular abnormality caused by the abnormal connection between pulmonary arteries and venous systems, more commonly associated to congenital disorders. More than 80% are congenital, and of these 47%–80% are associated with Osler-Weber-Render disease or hereditary hemorrhagic telangiectasia (HHT). Although most patients are asymptomatic, can cause dyspnea from right-to-left shunt, and the degrees of hypoxemia will be determined by the size of the shunt. PAVM was first described in 1897 by Churton, and even though the prevalence of PAVMs may be 1 in 2600 individuals, the condition is underdiagnosed and poorly understood. PAVMs may be single or multiple in occurrence and the incidence of single PAVMs ranges from 42% to 74%. CASE PRESENTATION: Case of a 48-year-old man with hypertension, GERD, testicular leydig cell tumor status post left orchiectomy and hypogonadism presented to his gastroenterologist with persistent abdominal pain refractory to medication. Upon review of systems, stated progressive dyspnea on exertion of one-year duration after orchiectomy, with associated fatigue. Denied any history of dizziness, syncope, epistaxis, hemoptysis, chest pain, palpitations, or cough. Physical examination was unremarkable and peripheral saturation at 99% at room air. Chest X-Ray with no cardiopulmonary pathology. Given persistent abdominal pain, abdominal CT scan was ordered, and a right lower lung lobe AVM was identified. CT angiography of the chest confirmed the presence of PAVM arising from the peripheral branches of the right pulmonary artery and feeding artery measuring 4mm. Radionuclide perfusion lung scan was compatible with a right to left shunt of 12%. Pulmonary function test done with the 100% oxygen and ABGs showed normal spirometry and estimated a shunt fraction of 15%. Bubble Study with evidence of PAVM. Considering patient is symptomatic he was scheduled for embolization. DISCUSSION: For many years, PAVM has been underdiagnosed and poorly understood, other symptoms include hemoptysis, chest pain, palpitations, epistaxis, and cough. Most patient are asymptomatic, confirmed patients should be screened for cerebral malformation by contrast enhanced head CT scan or magnetic resonance imaging given the high risk of stroke and brain abscess. Treatment must be offered to all symptomatic patients whereas asymptomatic patients should be evaluated on case to case basis. The treatment of choice for PAVMs is embolization, especially if the feeding vessel is larger or equal than 3mm. Follow-up with Thoracic CT Scan at 6–12 months must be performed to detect reperfusion of PAVM and opening of other occult PAVM. CONCLUSIONS: This case is intended to raise medical awareness on possible differential diagnosis of uncommon pulmonary causes of hypoxemia and dyspnea on exertion including pulmonary arteriovenous malformation. REFERENCE #1: Gossage JR, Kanj G. Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med. 1998 Aug;158(2):643-61. REFERENCE #2: Shovlin CL. Pulmonary arteriovenous malformations. Am J Respir Crit Care Med. 2014 Dec 1;190(11):1217-28. REFERENCE #3: Shovlin CL, Condliffe R, Donaldson JW, Kiely DG, Wort SJ; British Thoracic Society. British Thoracic Society Clinical Statement on Pulmonary Arteriovenous Malformations. Thorax. 2017 Dec;72(12):1154-1163. DISCLOSURES: No relevant relationships by Onix Cantres-Fonseca, source=Web Response No relevant relationships by Vanessa Fonseca Ferrer, source=Web Response No relevant relationships by SULIMAR MORALES, source=Web Response

Acute carbon monoxide poisoning with low saturation of carboxyhaemoglobin: a forensic retrospective study in Shanghai, China

Carbon monoxide (CO) poisoning is a common cause of death, leading to morbidity and mortality worldwide. Features of the CO poisoning with low carboxyhemoglobin (COHb) levels remain to be characterized. This study collected a total of 307 CO poisoning cases from Shanghai Public Security Bureau, an official organization that handles the most complicated and life-threatening cases across Shanghai municipality in China, and regrouped these cases into three categories: group 1, 10% < COHb% < 30% (n = 58); group 2, 30% ≤ COHb% < 50% (n = 79); group 3, COHb% ≥ 50% (n = 170). Epidemiological, demographic, and forensic aspects of the CO poisoning cases, particularly those with low COHb levels, were analyzed. Our results showed that group 2 and 3 were mostly observed in younger victims (≤ 30 years), while group 1 equally distributed to all age groups (p = 0.03). All the CO poisoning from group 2 and 3 occurred in enclosed spaces, whereas cases from group 1 died additionally in outdoor spaces (p = 0.01). 81.03% of group 1 cases died in fire circumstances, while only 45.57% from group 2 and 30.59% from group 3 were fire-related (p = 0.00). Accordingly, group 1 was mostly related with fire burns, while group 2 or 3 were largely associated with gas leakage (p = 0.00). A combination with alcohol, but not other psychotropic drugs, associated with significant higher levels of blood COHb% in fire-unrelated (p = 0.021) but not fire-related cases (p = 0.23). Five extremely low COHb% (< 30%)-related poisoning deaths were negative of any cardiopulmonary pathology and psychoactive substances. In conclusion, CO poisoning with low COHb% significantly associates with fire circumstances and outdoor spaces and has no age preference. Further diagnostic markers mandates to be identified in order to avoid disputes in cases of extremely low COHb%-related poisoning.

Irritable Infant with Bilateral Leg Swelling.

Irritable Infant with Bilateral Leg Swelling.

Postmortem Cardiopulmonary Pathology in Patients with COVID-19 Infection: Single-Center Report of 12 Autopsies from Lausanne, Switzerland.

We report postmortem cardio-pulmonary findings including detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in formalin-fixed paraffin embedded tissue in 12 patients with COVID-19. The 5 women and 7 men (median age: 73 years; range 35–96) died 6–38 days after onset of symptoms (median: 14.5 days). Eight patients received mechanical ventilation. Ten patients showed diffuse alveolar damage (DAD), 7 as exudative and 3 as proliferative/organizing DAD. One case presented as acute fibrinous and organizing pneumonia. Seven patients (58%) had acute bronchopneumonia, 1/7 without associated DAD and 1/7 with aspergillosis and necrotic bronchitis. Microthrombi were present in 5 patients, only in exudative DAD. Reverse transcriptase quantitative PCR detected high virus amounts in 6 patients (50%) with exudative DAD and symptom-duration ≤14 days, supported by immunohistochemistry and in-situ RNA hybridization (RNAscope). The 6 patients with low viral copy levels were symptomatic for ≥15 days, comprising all cases with organizing DAD, the patient without DAD and one exudative DAD. We show the high prevalence of DAD as a reaction pattern in COVID-19, the high number of overlying acute bronchopneumonia, and high-level pulmonary virus detection limited to patients who died ≤2 weeks after onset of symptoms, correlating with exudative phase of DAD.

Cardiopulmonary Exercise Testing in Athletes: Expect the Unexpected.

Cardiopulmonary exercise testing (CPET) is a tool designed to assess the integrated function of the cardiac, pulmonary, vascular and musculoskeletal systems to produce an exercise effort. CPET may be performed for performance purposes as part of optimizing a training program or for clinical purposes in athletes with established cardiovascular disease or in those with symptoms suggestive of cardiopulmonary pathology. Most normative values used for CPET parameters have been derived in the general population, in whom there will be expected differences in exercise physiology as compared to a trained athlete. In this review, our goal is to examine current available data on expected findings on CPET in athletes, highlight how these differ from the general population-derived normative values, and identify areas in need of further research to optimize the application of CPET in athletes. Athletes demonstrate differences in exercise hemodynamic and gas exchange profiles as compared to non-athletes including: higher cardiac output, faster heart rate recovery, higher peak V̇O2, higher prevalence of exercise-induced arterial hypoxemia, and lower breathing reserve. CPET is an important tool to optimize performance and assess for underlying pathology in an athletic population. The impact of routine, vigorous physical activity on exercise physiology should be integrated into determination of what constitutes a normal CPET result in an athletic individual.