Prior Pulmonary Disease Research Articles

IL-1 receptor antagonist attenuates proinflammatory responses to rhinovirus in airway epithelium

Rhinoviruses (RVs) are the most common trigger for asthma exacerbations, and there are currently no targeted therapies for viral-induced asthma exacerbations. RV infection causes neutrophilic inflammation, which is often resistant to effects of glucocorticoids. IL-1 receptor antagonist (IL-1RA) treatment reduces neutrophilic inflammation in humans challenged with inhaled endotoxin and thus may have therapeutic potential for RV-induced asthma exacerbations. We sought to test the hypothesis that IL-1RA treatment of airway epithelium reduces RV-mediated proinflammatory cytokine production, which is important for neutrophil recruitment. Human bronchial epithelial cells from deceased donors without prior pulmonary disease were cultured at air-liquid interface and treated with IL-13 to approximate an asthmatic inflammatory milieu. Human bronchial epithelial cells were infected with human RV-16 with or without IL-1RA treatment. RV infection promoted the release of IL-1α and the neutrophil-attractant cytokines IL-6, IL-8, and CXCL10. Proinflammatory cytokine secretion was significantly reduced by IL-1RA treatment without significant change in IFN-β release or RV titer. In addition, IL-1RA reduced MUC5B expression after RV infection without impacting MUC5AC. These data suggest that IL-1RA treatment significantly reduced proinflammatory cytokines while preserving the antiviral response. These results provide evidence for further investigation of IL-1RA as a novel targeted therapy against neutrophil-attractant cytokine release in RV-induced airway inflammatory responses.

Pulmonary Complications and Mortality in Patients with SARS-CoV-2 Undergoing Elective and Emergent Hand Surgery

Background Patients acutely infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may have increased risk for postsurgical pulmonary complications and mortality, particularly with general anesthesia. Surgery is often delayed to mitigate risk; however, excessive delays may result in morbidity. Optimal criteria for delaying surgery in patients with or without symptoms are unknown. This study aimed to evaluate any complications following hand surgery in patients testing positive for SARS-CoV-2.Methods We retrospectively reviewed patients with a positive polymerase chain reaction test within 60 days before or after hand surgery between March 31, 2020 and March 31, 2021. Patients were telephoned also to supplement records. Type of surgery, type of anesthesia, comorbidities, timing of surgery, onset of symptoms, and complications were recorded.Results We identified 21 patients undergoing 26 procedures, of which 21 (81%) were emergency procedures and 5 (19%) were elective. Mean age was 37 years (range: 17–71). General anesthesia was used in 88% of cases, with mean duration of 110 minutes. SARS-CoV-2 was diagnosed on average 6 days preoperatively (range: 39 days preop–14 days postop). Positive tests were usually identified preoperatively (50%), versus day-of-surgery (25%) or postoperatively (25%). Patients were symptomatic in only 27% of cases, and completely asymptomatic in 73%. No asymptomatic patients developed complications. One patient suffered a fracture malunion after delayed surgery. Pulmonary complications were noted in 3 patients; all had prior pulmonary disease and underwent emergency surgeries under general anesthesia. Overall mortality rate was 0%.Conclusion Pulmonary complications and mortality are low following hand surgery in asymptomatic patients with a positive SARS-CoV-2 test.

Risk Stratification Models for Stroke in Patients Hospitalized with COVID-19 Infection

ObjectivesTo derive models that identify patients with COVID-19 at high risk for stroke. Materials and MethodsWe used data from the AHA's Get With The Guidelines® COVID-19 Cardiovascular Disease Registry to generate models for predicting stroke risk among adults hospitalized with COVID-19 at 122 centers from March 2020-March 2021. To build our models, we used data on demographics, comorbidities, medications, and vital sign and laboratory values at admission. The outcome was a cerebrovascular event (stroke, TIA, or cerebral vein thrombosis). First, we used Cox regression with cross validation techniques to identify factors associated with the outcome in both univariable and multivariable analyses. Then, we assigned points for each variable based on corresponding coefficients to create a prediction score. Second, we used machine learning techniques to create risk estimators using all available covariates. ResultsAmong 21,420 patients hospitalized with COVID-19, 312 (1.5%) had a cerebrovascular event. Using traditional Cox regression, we created/validated a COVID-19 stroke risk score with a C-statistic of 0.66 (95% CI, 0.60–0.72). The CANDLE score assigns 1 point each for prior cerebrovascular disease, afebrile temperature, no prior pulmonary disease, history of hypertension, leukocytosis, and elevated systolic blood pressure. CANDLE stratified risk of an acute cerebrovascular event according to low- (0–1: 0.2% risk), medium- (2–3: 1.1% risk), and high-risk (4–6: 2.1–3.0% risk) groups. Machine learning estimators had similar discriminatory performance as CANDLE: C-statistics, 0.63–0.69. ConclusionsWe developed a practical clinical score, with similar performance to machine learning estimators, to help stratify stroke risk among patients hospitalized with COVID-19.

Pulmonary Pathology of End-Stage COVID-19 Disease in Explanted Lungs and Outcomes After Lung Transplantation.

ObjectivesPatients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may develop end-stage lung disease requiring lung transplantation. We report the clinical course, pulmonary pathology with radiographic correlation, and outcomes after lung transplantation in three patients who developed chronic respiratory failure due to postacute sequelae of SARS-CoV-2 infection.MethodsA retrospective histologic evaluation of explanted lungs due to coronavirus disease 2019 was performed.ResultsNone of the patients had known prior pulmonary disease. The major pathologic findings in the lung explants were proliferative and fibrotic phases of diffuse alveolar damage, interstitial capillary neoangiogenesis, and mononuclear inflammation, specifically macrophages, with varying numbers of T and B lymphocytes. The fibrosis varied from early collagen deposition to more pronounced interstitial collagen deposition; however, pulmonary remodeling with honeycomb change was not present. Other findings included peribronchiolar metaplasia, microvascular thrombosis, recanalized thrombi in muscular arteries, and pleural adhesions. No patients had either recurrence of SARS-CoV-2 infection or allograft rejection following transplant at this time.ConclusionsThe major pathologic findings in the lung explants of patients with SARS-CoV-2 infection suggest ongoing fibrosis, prominent macrophage infiltration, neoangiogenesis, and microvascular thrombosis. Characterization of pathologic findings could help develop novel management strategies.

Impact of Platelet Transfusion on Pulmonary Function of Hematology Oncology Patients: The Piper Study

Background. Platelet transfusion is a critical therapy for hematology-oncology patients at risk of transfusion-transmitted infection (TTI) and pulmonary injury. Amotosalen-UVA pathogen reduction (PR) treatment of apheresis platelet components (PC) in plasma or additive solution (INTERCEPT Blood System for Platelets, Cerus, Concord, CA) is FDA approved to reduce risk of TTI and transfusion associated graft vs. host disease (TA-GVHD). PRPC meet the FDA bacteria risk reduction guidance, and approximately 50% of U.S. PC are PRPC. Amotosalen-UVA PR replaces bacteria screening, gamma irradiation, and CMV serology. PR is performed within 24 hours of collection enabling early release of PRPC with 5-day storage. We tested the hypothesis that PRPC were not inferior to conventional PC(CPC) for the incidence of pulmonary injury. Methods. An open-label sequential cohort study in platelet transfusion dependent hematology-oncology patients was conducted under routine practice conditions in 15 clinical centers. Each site enrolled a CPC cohort followed by a PRPC cohort using 4 primary therapy strata matched ± 10%: chemotherapy without hematopoietic cell transplant (HCT), HCT with myeloablation, HCT with non-myeloablative conditioning, and HCT with reduced intensity conditioning (RIC). Patients were supported with the assigned PC type for up to 21 days with 7 days of surveillance after the last PC exposure. Patients participated in only one cohort. The primary endpoint was treatment emergent assisted mechanical ventilation (TEAMV) by intubation or tight mask with positive end expiration pressure (5cm H 2O) after initiation of study PC. All endpoint patients were adjudicated by a blinded pulmonary expert panel (PEP) for diagnosis of acute respiratory distress syndrome (ARDS) by the Berlin Criteria. Secondary endpoints included: time to initiation of TEAMV, clinically significant pulmonary adverse events (CSPAE, CTCAE ≥ Grade 2), transfusion reactions, and mortality. The incidence of TEAMV by non-inferiority (margin = 2.3%), and secondary endpoints were analyzed by modified intention to treat (mITT) and per protocol (PP). Sensitivity analyses with propensity score matching for key variables were conducted for the primary endpoint. The associations between PC and categorical variables were tested by stratified Cochran-Mantel-Haenszel and continuous variables by ANOVA for two-sided significance p = 0.05. results. A total of 2291 pediatric and adult patients (1068 PRPC and 1223 CPC) were enrolled in the respective cohorts with transfusion of 5,277 PRPC and 5,491 CPC. PC assignment compliance and study completion were > 94%. For the mITT data set, the cumulative incidence of TEAMV was lower for the PRPC cohort (log rank p = 0.039) than the CPC cohort (2.9% versus 4.6%, HR = 0.633: 95% CI 0.408-0.982). PRPC by mITT were non-inferior to CPC for the incidence of TEAMV due to all indications, and for TEAMV with pulmonary dysfunction (PD) by PEP (Table). PP analyses were consistent with mITT. Relative risk (RR) of TEAMV showed significantly (p<0.05) decreased RR of PRPC respectively for baseline covariates: age < 65 (0.53), male (0.54), non-white (0.32), chemotherapy (0.40), prior pulmonary disease (0.55), and prior cardiac disease (0.58). Least squares (LS) mean days to initiation of TEAMV for patients with PD were longer for PRPC recipients. PEP adjudicated incidence of ARDS was not significantly different between cohorts (Table). Total and serious CSPAE were not different between the cohorts. There were no significant differences between cohorts in Respiratory, Thoracic, and Mediastinal Disorders, the most frequent system organ class event. Mortality was not different between cohorts. Multivariate analysis (mITT) for the probability of CSPAE or transfusion associated cardiac overload (TACO) showed PC type had no effect. The odds ratio (OR) of CSPAE or TACO during PC support was significantly increased (p< 0.05) in both cohorts for history of cardiac disease (1.35), history of pulmonary disease (2.57), diagnosis of Myelodysplasia (1.88), and diagnosis of Myelodysplasia/Myeloproliferative disease (2.27). There was a significant treatment interaction (p= 0.043) between PC type and acute myelogenous leukemia (AML), increased OR = 1.49 for CPC versus PRPC. Conclusions. PRPC did not potentiate pulmonary injury during PC support; and their use may decrease TEAMV risk with benefit of reduced TTI risk. [Display omitted] DisclosuresWheeler: Novo Nordisk A/S: Consultancy; Bayer: Consultancy; BioMarin: Consultancy; HEMA Biologics: Consultancy; Spark: Consultancy; Takeda: Consultancy; UniQure: Consultancy. Nooka: Janssen Oncology: Consultancy, Research Funding; Takeda: Consultancy, Research Funding; Sanofi: Consultancy; Oncopeptides: Consultancy; Amgen: Consultancy, Research Funding; Bristol-Myers Squibb: Consultancy; Adaptive technologies: Consultancy; GlaxoSmithKline: Consultancy, Other: Travel expenses; Karyopharm Therapeutics: Consultancy. Uhl: UpToDate: Patents & Royalties; Abbott: Consultancy, Speakers Bureau; Grifols: Consultancy, Speakers Bureau. Spinella: Secure Transfusion Services: Current Employment, Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company; Cerus Corporation: Consultancy, Research Funding. Liu: Cerus Corporation: Current Employment, Current equity holder in publicly-traded company. Benjamin: Cerus Corporation: Current Employment, Current equity holder in publicly-traded company. Corash: Cerus Corporation: Current Employment, Current equity holder in publicly-traded company.

Real-world Clinical Implementation of Lung Cancer Screening-Evaluating Processes to Improve Screening Guidelines-Concordance.

Lung cancer screening (LCS) requires complex processes to identify eligible patients, provide appropriate follow-up, and manage findings. It is unclear whether LCS in real-world clinical settings will realize the same benefits as the National Lung Screening Trial (NLST). To evaluate the impact of process modifications on compliance with LCS guidelines during LCS program implementation, and to compare patient characteristics and outcomes with those in NLST. Retrospective cohort study. Kaiser Permanente Colorado (KPCO), a non-profit integrated healthcare system. A total of 3375 patients who underwent a baseline lung cancer screening low-dose computed tomography (S-LDCT) scan between May 2014 and June 2017. Among those receiving an S-LDCT, proportion who met guidelines-based LCS eligibility criteria before and after LCS process modifications, differences in patient characteristics and outcomes between KPCO LCS patients and the NLST cohort, and factors associated with a positive screen. After modifying LCS eligibility confirmation processes, patients receiving S-LDCT who met guidelines-based LCS eligibility criteria increased from 45.6 to 92.7% (P < 0.001). Prior to changes, patients were older (68 vs. 67years; P = 0.001), less likely to be current smokers (51.3% vs. 52.5%; P < 0.001), and less likely to have a ≥ 30-pack-year smoking history (50.0% vs. 95.3%; P < 0.001). Compared with NLST participants, KPCO LCS patients were older (67 vs. 60years; P < 0.001), more likely to currently smoke (52.3% vs. 48.1%; P < 0.001), and more likely to have pulmonary disease. Among those with a positive baseline S-LDCT, the lung cancer detection rate was higher at KPCO (9.4% vs. 3.8%; P < 0.001) and was positively associated with prior pulmonary disease. Adherence to LCS guidelines requires eligibility confirmation procedures. Among those with a positive baseline S-LDCT, comorbidity burden and lung cancer detection rates were notably higher than in NLST, suggesting that the study of long-term outcomes in patients undergoing LCS in real-world clinical settings is warranted.

Foil Smoking/Heroin Inhalation

Foil Smoking/Heroin Inhalation Abstract. Foil smoking is generally heroin consumption by inhalation. By heating an aluminum foil with a fire lighter the heroin on top of the foil starts melting and the smoke is then inhaled using a straw. Foil smoking is the second most common form of heroin consumption after the intravenous use. In contrast to the IV administration, heroin inhalation effects are delayed by a few minutes and the risk of transmission of HIV, Hepatitis or other infectious diseases is not relevant. Severe bronchospasms can occur in patients with or without prior pulmonary disease such as asthma bronchiale. One cerebral consequence of foil smoking is leukoencephalopathy, a spongiform degeneration of the white matter. This is likely triggered by the pyrolysate generated during the heating process. Multiple drug use and concomitant cigarette smoking in heroin addicts make cause-effect relationships difficult to assess. In general, the history of inhalative heroin consumption should be considered in patients presenting with any unkown pulmonary disease with severe bronchospasms as may happen in a severe asthma exacerbation.

Journal of Vascular Surgery: Venous and Lymphatic Disorders – May 2017 Audiovisual Summary

Hi, I am Peter Gloviczki from Mayo Clinic, Editor in Chief of the Journal of Vascular Surgery: Venous and Lymphatic Disorders. We are pleased to introduce to you the latest issue of our journal with several excellent papers on venous and lymphatic diseases. The Editors’ Choice article in May is on the “First 10-month results of the Vascular Quality Initiative Varicose Vein Registry,” a multicenter study written by Andrea Obi, Thomas Wakefield, and colleagues. The study is important, since this is the first report of early data gathered through the new VQI Varicose Vein Registry, cosponsored by the American Venous Forum and the Society for Vascular Surgery. A total of 1803 limbs from 1406 patients were studied. Most patients had C2 or C3 chronic venous disease, and 130 limbs had healed or active venous ulcers. The procedure was an outpatient procedure in 99.9%; most frequently, in 54.4%, it was performed in the office, and in 37%, it was performed in a hospital setting. Seventy-four percent of the procedures were done under tumescent anesthesia, and 18% were done under general anesthesia. The most frequent vein treated was the great saphenous vein in the thigh (in 55.8%), followed by the small saphenous vein of the calf (in 17%). Most patients (55.2%) underwent radiofrequency ablation, 33.9% had laser surgery, and open surgery was done in 8.7%. There were three hospital admissions and only a few mild complications. Follow-up was short (mean, 45 days), but both Venous Disease Severity Scores and patient-reported outcomes improved after interventions. Based on these early results, the authors concluded that modern-day varicose vein surgery is characterized by predominantly endovenous treatment of axial vein reflux, phlebectomy of clusters, and substantial early improvements in both physician- and patient-reported outcomes. As you probably know, in 2017, you can earn your CME credit by reading one of the papers in our venous journal, which you can also download this month free of charge. Our CME paper is entitled “Predictors of failure and complications of catheter-directed interventions for pulmonary embolism,” written by Dr Avgerinos and colleagues from the University of Pittsburgh. In this single-center retrospective study, 102 patients were treated with catheter-directed thrombolysis, 14 for massive, and 88 for submassive pulmonary embolism (PE). Catheter-directed thrombolysis failure occurred in 14.7%; in 50% with massive PE, 9.1% with submassive PE, major bleeding occurred in 6.9%, in 21.4% with massive and in 4.5% with submassive PE. Mortality of patients with massive PE was high (21.4%). Failure of catheter-directed thrombolysis to treat PE was associated with massive PE, prior pulmonary disease, and contraindication to lysis. Bleeding was associated with age >70 years and with contraindications. Based on their results, the authors suggest avoiding catheter-directed thrombolysis for PE in patients with a contraindication to lysis, in patients with massive PE, in those with prior pulmonary disease, and in patients over 70 years of age. The next article is entitled “VeClose trial 12-month outcomes of cyanoacrylate closure versus radiofrequency ablation for incompetent great saphenous veins” by Nick Morrison and colleagues. This is a prospective randomized multicenter trial that compared results of two interventions in 222 patients with symptomatic varicose veins and saphenous incompetence. In this multicenter prospective randomized study, early complications were mild and similar in both groups, days to complete occlusions were significantly less in the cyanoacrylate groups, while days to recanalization were not significantly different. At 1 year, physician- and patient-reported outcomes were similar in both groups. The authors concluded that cyanoacrylate-based chemical ablation had similar efficacy compared to radiofrequency ablation thermal ablation in terms of occlusion, durability, relief from symptoms, and quality of life at 1 year after the interventions. The final paper we would like to introduce you is entitled “Outcomes of iliac vein stents after pregnancy,” authored by Dr Dasari and colleagues from Pittsburgh and Bradford in Pennsylvania and Jackson, Mississippi. In this retrospective study, 12 of 310 women of reproductive age had at least one pregnancy after iliac vein stenting. One patient had asymptomatic stent compression after two deliveries, which was treated successfully with balloon angioplasty. At a mean follow-up of 61 months, all stents were patent without structural damage or thrombosis. The authors suggest that iliocaval stenting is not contraindicated in women of reproductive age, although close follow-up of this subset of patients, especially during and after pregnancy, is warranted. These were just a few of the many excellent articles from our May issue. To access these articles free this month, please download them on www.jvsvenous.org. Enjoy reading all JVS journals, let us know if you have a good idea how to improve our publications, and see you next time for the Highlights of the July issue of the JVS Venous and Lymphatic Disorders. https://www.jvsvenous.org/cms/asset/df554123-1e72-4bd5-8a21-77ede2a6bf30/mmc1.mp4Loading ... Download .mp4 (115.68 MB) Help with .mp4 files Video

Incidence of hospitalization in patients with head and neck cancer treated with intensity-modulated radiation therapy.

Patients with primary head and neck cancer managed with radiation therapy (RT) +/- chemotherapy may experience significant treatment-related toxicities. We assessed hospitalization as a metric for severe treatment-related toxicities and evaluated patient and treatment factors for possible association. A retrospective review was performed on 147 patients with head and neck cancer treated with definitive or adjuvant intensity-modulated radiation therapy (IMRT) +/- chemotherapy. Multiple Poisson regression model was used to analyze relationships between patient or treatment factors and number of hospital stays during RT and within 8 weeks after RT. Multivariate analysis showed preexisting diabetes or pulmonary disease, primary carcinoma of oral cavity, and prescribed radiation dose (p < .05) were associated with increased number of patient hospital stays during or shortly after RT. We found that 34.7% of patients experienced a chemoradiation toxicity-related hospitalization during or shortly after treatment. Prior pulmonary disease, diabetes, and increasing prescribed radiation dose were associated with increased hospital stays.

Influence of Early Ambulation in Postoperative Hospitalization Following Cardiac Surgery

Heart disease has one of the highest mortality rates in the world. According to DATASUS1, in January 2014 Brazil reported a mortality rate of 10.20% related to acute myocardial infarction (AMI) and heart failure (HF) on an emergency basis. From January to June 2008, 10,652 coronary artery bypass grafting and/or valve replacement surgeries were held in Brazil1. Despite the technological advances aimed to extend the quality of life of patients undergoing cardiac surgery, such a highly complex procedure favors the emergence of peripheral and lung function changes2. Among the most common respiratory complications are atelectasis, pneumonia, pleural effusion, pulmonary edema, pulmonary embolism, phrenic nerve injury, pneumothorax, acute respiratory failure and prolonged mechanical ventilation3. Some factors can influence the onset of pulmonary disorders, such as prior pulmonary disease, presence of cardiopulmonary bypass (CPB), general anesthesia, pleural drains, and duration of mechanical ventilation2,3.

Pneumopathies interstitielles diffuses médicamenteuses au cours des maladies systémiques

Immunosuppressants and immunomodulators are designed to regulate excessive immune response responsible for inflammatory lesions and are prescribed more and more in internal medicine. These drugs are known for their efficiency but with a significant toxicity including interstitial lung disease (ILD). Some factors liable to pulmonary toxicity include advanced age, genetic polymorphism and the existence of prior pulmonary disease. Cytotoxicity and hypersensitivity are the main mechanisms of pulmonary toxicity. There is no universal classification of drug induced-lung disease. Theoretically, drugs may be responsible for all histological aspects of ILD. Methotrexate is the most well-known drug as a provider of ILD with a prevalence of 0.3 to 11.6%. Some cases of ILD have also been reported with the new biologics used in systemic diseases. The diagnostic approach to the suspicion of drug ILD is to eliminate non-medicinal causes of pneumonia including infections and tumors before exploring the clinical symptomatology and the results of imaging and bronchoalveolar lavage cell profile. The analysis of the clinical symptomatology check the compatibility of the chronology of clinical and/or radiological pneumonia with the medication suspected. Subsequently, data from the clinical case are compared with those of the literature. Treatment involves stopping the suspected drug. The use of corticosteroids may be required in case of signs of severity or a lingering evolution.

Infección por virus pandémico (H1N1) 2009 en Andalucía

In April 2009, in response to the WHO's alert due to the existence of human infection cases with a new AH1N1 influenza virus, known as swine flu, Andalusian Health Authorities trigger an specific action plan. The surveillance actions developped provided us with appropriate clinical, epidemiological and virological characteristics of the disease. During the first few days, contingency plans were set up based on epidemiological surveillance and outbreak control measures were adopted through early alert and rapid response systems. After phase 6 was declared, influenza sentinel and severe cases surveillance were used in order to plan healthcare services, to reduce transmission and to identify and protect the most vulnerable population groups. Behaviour of pandemic influenza in Andalusia was similar to that observed in the rest of the world. Atack rate was similar to a seasonal flu and the peak was reached at the 46th/2009 week. Most of them were mild cases and affected particularly to young people. The average age of hospitalised patients was 32. Prior pulmonary disease, smoking and morbid obesity (BMI > 40) were the most common pathologies and risk factors in severe cases. An impact scenario of pandemic wave in Andalusia, with an expected attack rate from 2 to 5%, was prepared considering watt observed in the southern hemisphere. Characteristics of the epidemic concerning its extent, severity and mortality rate were adjusted to this scenario.

A 27-Year-Old Man With Pleuritic Chest Pain and Hemoptysis After a Rugby Game

A healthy 27-year-old man was seen after blunt trauma to his right chest while playing rugby. He was complaining of mild pleuritic right lower chest pain and some streaky hemoptysis. There was no history of fever, chills, night sweats, and dyspnea. He had no prior pulmonary disease. He was not receiving therapy with any medication, and he denied alcohol abuse or the use of recreational drugs.

Esophageal Carcinoma Histology Affects Perioperative Morbidity Following Open Esophagogastrectomy

Background. Esophagectomy for esophageal cancer is being practiced routinely with favorable results at many centers. We sought to determine if tumor histology is a powerful surrogate marker for perioperative morbidity. Methods. Seventy three consecutive patients managed operatively were reviewed from our prospectively maintained database. Results. Adenocarcinoma (AC) was present in 52 (71%) and squamous cell (SCC) in 21 (29%). The use of neoadjuvant therapy was similar for the AC (34.62%) and SCC (42.86%) groups. The SCC group had a higher incidence of prior pulmonary disease than the AC group (23.8% versus 5.8%, resp.; P = .03). SCC patients were more likely to have a prolonged ICU stay than AC patients (P = .004) despite similar complication rates, EBL, and prognostic nutritional index. The SCC group did, however, experience higher grades of complications (P = .0053). Conclusions. Presence of SCC was the single best predictor of prolonged ICU stay and more severe complications as defined by this study. Only a past history of pulmonary disease was different between the two histologic subgroups.

Pulmonary Changes in Myeloma Patients Following High Dose Melphalan.

Background: Eligibility for high dose chemotherapy and autologous stem cell rescue often includes adequate pulmonary function. While high dose melphalan has been noted to cause significant pulmonary toxicity in a small percentage of patients with adequate pulmonary function, there are little published data on risk factors and use in lung impaired patients. We retrospectively reviewed the charts of 50 patients with myeloma who received a fixed dose of melphalan (200 mg/m2) and who had pre-melphalan and at least one post-melphalan spirometry (FVC and FEV1) and diffusing capacity (DLco) measurement. Comparisons were made with Pearson correlations and one-way ANOVA. Patients receiving melphalan showed no significant differences in mean FVC (p=0.40), FEV1 (p=0.48) or hemoglobin corrected DLco (p=0.40) comparing baseline to 3-month and 1-year results with 1-way ANOVA. There was a consistent increase in mean FVC(L), FEV1(L) and DLco (ml CO/min/mmHg) from pre to 3 months post (3m) and to one-year post (1y): FVC: pre=3.89, 3m= 4.02, 1y=4.24; FEV1: pre=2.92, 3m=2.95, 1y=3.14; DLco: pre=24.3, 3m=25.1, 1y=26.5. However, individual changes in DLco showed a wide distribution. Therefore, we examined a number of potential risk factors for change in DLco at 3 months. No detrimental effects were discernable for age, gender, history of prior pulmonary disease including smoking, pre-melphalan lung function, the use of high dose cyclophosphamide in the mobilization regimen, amount of prior chemotherapy or chest radiation, disease stage or response, or renal function. CD34+ cell dose (p=0.017, r = −0.344) and immunoglobulin type (IgA worse than IgG) (p=0.029, r = 0.316) were correlated and were independent factors on regression analysis (p<0.0018, r2=0.36). We conclude that on average, high dose melphalan produces little pulmonary toxicity and may be considered for selected patients with impaired baseline pulmonary function. It may be of value to avoid higher CD34+ cell doses in patients with a low pre-melphalan DLco. More work should be directed at identifying the factors that contribute to pulmonary function compromise following high dose regimens.

Long‐term outcome after 60 days of intensive care

Patients with a long stay in the intensive care unit because of chronic critical illness consume many resources, and yet their outcome may be poor. We evaluated the long-term outcome of patients spending more than 60 days in the intensive care unit. We performed a retrospective cohort and prospective follow-up study of 78 patients staying more than 60 days in the 19-26 bed mixed intensive care unit of a university hospital from November 1995 to January 2003. The mortality in the intensive care unit was 38%; at 1 and 5 years it was 56% and 67%, respectively. Advanced age, prior pulmonary disease, long duration of renal replacement therapy, a low oxygenation ratio and platelet count and high Simplified Acute Physiology Score II and Sequential Organ Failure Assessment scores on day 60 influenced long-term mortality. A Simplified Acute Physiology Score II of 50 or a Sequential Organ Failure Assessment score of 8 or higher was associated with 100% mortality during follow-up. The overall 5-year survival rate of 33% suggests that prolonged intensive care may be worth the effort in certain patients.

Additional work of breathing and breathing patterns in spontaneously breathing patients during pressure support ventilation, automatic tube compensation and amplified spontaneous pattern breathing

Additional work of breathing and breathing patterns in spontaneously breathing patients during pressure support ventilation, automatic tube compensation and amplified spontaneous pattern breathing

Chronic Cavitary and Fibrosing Pulmonary and Pleural Aspergillosis: Case Series, Proposed Nomenclature Change, and Review

We describe 18 nonimmunocompromised patients with chronic pulmonary aspergillosis. Duration of the disease ranged from several months to >12 years. All 18 patients had prior pulmonary disease. Weight loss, chronic cough (often with hemoptysis and shortness of breath), fatigue, and chest pain were the most common symptoms. All 18 patients had cavities, usually multiple and in 1 or both upper lobes of the lung, that expanded over time, with or without intraluminal fungal balls. All had detectable Aspergillus precipitins and inflammatory markers. Elevated levels of total immunoglobulin E were seen in 78% of patients and of Aspergillus-specific immunoglobulin E in 64%. Directed lung biopsies showed chronic inflammation, necrosis, or granulomas without hyphal invasion. Antifungal therapy with itraconazole resulted in 71% of patients improved or stabilized, with relapse common. Interferon-gamma treatment was useful in 3 patients. In azole nonresponders, modest responses to intravenous amphotericin B (80%) followed by itraconazole were seen. Surgery removed disease but postoperative pleural aspergillosis was inevitable. Indicators of good long-term medical outcomes were mild symptoms, thin-walled quiescent cavities, residual pleural fibrosis, and normal inflammatory markers.

Prevalence and clinical characteristics of lymphangioleiomyomatosis (LAM) in patients with tuberous sclerosis complex.

The true prevalence of pulmonary lymphangioleiomyomatosis (LAM) in patients with tuberous sclerosis complex (TSC) is unknown. The prevalence of LAM, radiological features, and lung function in patients with TSC was measured. The presence of LAM, as defined by the presence of cysts by high-resolution chest computed tomography (HRCT) scan, was determined in patients with TSC without prior pulmonary disease (Group 1). To determine the significance of early detection, severity of disease in screened patients (Group 1) was compared with that in patients with TSC with a prior diagnosis of LAM (Group 2). Forty-eight patients with TSC and no prior history of LAM were screened. Of the 38 females, 13 (34%) had LAM; LAM was absent in males. Lung function was preserved in patients with TSC who were found to have LAM by screening. In patients previously known to have LAM, FEV(1) and DL(CO) correlated inversely with severity of disease as assessed by CT scan. The prevalence of LAM in women with TSC was 34%, approximately 10-fold that previously reported, consistent with a large hitherto unrecognized subclinical population of patients at risk for pulmonary complications.

Ectasis and pallor of peripheral airways during mechanical ventilation

Study Objective: To evaluate morphologic changes in peripheral airways associated with positive-pressure ventilation (PPV). Design: Single-blind study. Setting: Intensive care unit of a university hospital. Patients: Ten patients who required mechanical ventilation due to acute respiratory failure but had no history of prior pulmonary disease. Interventions: Seventeen fiberoptic bronchoscopy procedures were performed using a fine fiberoptic bronchoscope of 1.8 mm outside diameter. Measurements and Main Results: The main morphologic findings were pallor and ectasts. Increased secretions, pigmentation, and stenosis or collapse in peripheral airways also were observed. Patients with ectasis were more likely to have had prolonged mechanical ventilation (17 ± 9 days) as compared with those patients without ectasis (9 ±5 days). Conclusion: The structural alterations in peripheral airways noted in patients on prolonged PPV suggest that barotrauma may be more widespread than previously recognized.