Prolonged Clinical Course Research Articles

227. CAUSES OF IN-HOSPITAL MORTALITY FOLLOWING TRANSTHORACIC ESOPHAGECTOMY FOR CANCER

Abstract Background Rates of peri-operative mortality following esophagectomy for cancer have markedly decreased over the last few decades, with a 90-day mortality rate below 5% considered a benchmark for quality of care. Although studies have focused on mortality rates, little is known about the causality. The aim of this study was to perform a multicenter, in-depth analysis of peri-operative mortality following esophagectomy for cancer. Methods Data was obtained multicenter, from prospective databases, between January 2010 – June 2020. All patients with a lethal postoperative course (Clavien-Dindo V) following elective transthoracic esophagectomy were included. Data collection included baseline characteristics, preoperative comorbidities, surgical procedures, postoperative complications and their management. In each participating center, two surgeons independently reassessed patient work-up and the management of intra-operative and postoperative complications to finally classify the management of each section as adequate, non-adequate or undetermined. Statistics encompassed descriptive analysis. Results One-hundred and twenty-one out of 3899 patients died in-hospital following oesophagectomy; a mortality rate of 3.1%. Patients deceased on a median of 32 days after surgery (IQR: 18-60). In preoperative work up: 24 patients (19.7%) had a Charlson-Comorbidity-Index (CCI) of 5 of higher; with cardiac comorbidity reported most often, in 39% of patients. Reassessment revealed work-up was not adequate in two patients (1.4%). During surgery, 6 patients (4.6%) suffered complications, all managed adequately in reassessment. Following surgery, a total of 343 major complications were identified in the 121 patients (mean 2.4 ± 1.2) with anastomotic leakage (AL) reported most often, in 65 patients (53.7%). AL was reported as cause of death in 44 patients (36.5 %). In eight patients (6.6 %) postoperative management was reassessed to be non-adequate, in these cases recognition and initiation of treatment for AL (n=7) or conduit necrosis (n=1) was delayed. Conclustion In contrast to other published series, reassessment of this homogenous patient cohort with a lethal clinical course in expert centers revealed only a low rate of preventable mortality with respect to the preoperative patient selection and postoperative complication management. However, anastomotic leakage was identified to be the leading cause of death following esophagectomy contributing to a significantly prolonged clinical course and lethal outcome. As the development of surgical procedures with complex anastomotic techniques is inevitably associated with an increasing leakage rate expressed by prolonged learning curves, modification of complication management might be considered in order to reduce overall death rates.

A Comparison of Clear Cell Sarcoma to Jaw and Salivary Tumors Bearing EWS Fusions.

To review tumors identified as "clear cell sarcoma" in order to determine similarities to the rare EWS fusion positive jaw and salivary gland tumors clear cell odontogenic carcinoma (CCOC) and clear cell carcinoma of the salivary gland (CCC). PubMed was used to collect all reports of clear cell sarcoma (CCS). Search parameters were "clear cell sarcoma" and "CCS." References in the publications were screened and cross-referenced. Data extracted included demographic characteristics, presenting signs and symptoms, radiographic findings, histological and immunohistochemical features and known molecular/genetic aberrations. Clear cell sarcoma has several similarities to CCOC and CCC. All three tumor types have similar histologic appearances including the presence of clear cells, as well as similar genetic profiles in that all harbor an EWSR1-CREB family fusions. Additionally, these tumors appear in soft tissue as well as bone, and can have a prolonged clinical course. CCS can appear anywhere in the body, including the head and neck region. All three tumors appear to have a predilection to women, although CCS may have a slight younger age of onset as compared to CCOC and CCC (3rd vs 5th decade of life, respectively). Gaining a better understanding of the similarities and differences between these three tumors may lead to a better understanding of each one.

Blast Phase of Myeloproliferative Neoplasm Resembles Acute Myeloid Leukemia, Myelodysplasia-Related, in Clinical Presentation, Cytogenetic Pattern, and Genomic Profile, and Often Undergoes Reversion to Second Chronic Phase Status After Induction Chemotherapy.

BCR::ABL-negative myeloproliferative neoplasm (MPN) has a prolonged clinical course, and some cases eventually undergo transformation to blast phase; its pathogenesis remains to be elucidated. To evaluate the clinicopathologic characteristics of MPN in blast phase. The study aimed to retrospectively analyze the clinical and laboratory data of 24 cases. Median latency to blast phase was 48 months (range, 7-384 months). Complex karyotypes were seen in 12 of the 24 cases (50%). Overall, 16 cases (66.7%) exhibited high allele burdens of MPN driver mutations along with increased blasts, consistent with linear clonal evolution, whereas the remainder (8; 33.3%) showed loss or partial loss of the driver mutation suggestive of a parallel evolution. Additional mutations were noted in 23 cases (100%), including TP53 mutations in 10 of 24 cases (41.7%). Following chemotherapy, 15 of the 24 patients (62.5%) reverted to a second chronic phase while retaining or regaining MPN driver mutations and losing blast-related mutations, although 9 of the 15 patients (60%) later died of disease progression. Median overall survival was 10 months (CI, 4.6-15.4), with those harboring complex karyotypes demonstrating decreased survival (6 versus 29 months; P = .004). MPN-blast phase resembles acute myeloid leukemia, myelodysplasia-related, in cytogenetic pattern, mutation profile, and clinical outcome. Two patterns of clonal evolution are inferred by dynamic analysis of mutation profiles: linear and parallel evolutions. Although overall survival was dismal, 62.5% of our cases achieved second chronic phase, and they showed better survival than those without second chronic phase.

Survival disparities in rural versus urban patients with pancreatic neuroendocrine tumor: A multi-institutional study from the US neuroendocrine tumor study group

BackgroundPancreatic Neuroendocrine Tumors (PNETs) are indolent malignancies that often have a prolonged clinical course. This study assesses disparities in outcomes between PNET patients who live in urban (UA) and rural areas (RA). MethodsA retrospective cohort study was performed using the US Neuroendocrine Tumor Study Group database. PNET patients with a home zip code recorded were included and categorized as RA or UA according to the Federal Office of Rural Health Policy. Overall survival (OS) was analyzed by Kaplan-Meier method, log-rank test, and logistical regression. ResultsOf the 1176 PNET patients in the database, 1126 (96%) had zip code recorded. While 837 (74%) lived in UA, 289 (26%) lived in RA. RA patients had significantly shorter median OS following primary PNET resection (122 vs 149 months, p ​= ​0.01). After controlling for income, local healthcare access, distance from treatment center, ASA class, BMI, and T/N/M stage, living in a RA remained significantly associated with worse OS (HR 1.60, 95%CI 1.08–2.39, p ​= ​0.02). ConclusionRural patients have significantly shorter OS following PNET resection compared to their urban counterparts.

Elevated hyaluronic acid levels in severe SARS-CoV-2 infection in the post-COVID-19 era.

Human identical sequences of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) promoted the coronavirus disease 2019 (COVID-19) progression by upregulating hyaluronic acid (HA) via NamiRNA-enhancer network, based on previous experimental research. This study aimed to investigate the predictive value of HA for the severity of SARS-CoV-2 infection in the post-COVID-19 era. A total of 217 consecutive patients with COVID-19 were enrolled at Beijing Ditan Hospital between July 2023 and October 2023. HA levels were analyzed using biochemical detector. Logistic regression analysis was used to screen independent factors for severe COVID-19. The predictive performance of HA for severe infection was assessed by ROC curve. Furthermore, the relationship between HA levels and COVID-19 severity was investigated using multivariate logistic regression models after adjustment for potential confounders. According to the cut-off value of HA, COVID-19 patients were divided into HA < 90 ng/mL group (80 cases) and HA ≥ 90 ng/mL group (137 cases). High HA levels were positively associated with the severe SARS-CoV-2 infection, including elevated inflammatory indicators, severe lung involvement, prolonged clinical course, and higher incidence of respiratory failure and death (P < 0.05). Logistic regression analysis suggested that HA was an independent predictor of severe COVID-19 (OR = 4.540, 95% CI = 2.105-9.790, P < 0.001). ROC curve analysis showed that the AUC of HA for severe infection was 0.724. HA levels were significantly higher in COVID-19 cases compared to the healthy population (123.9 (82.6, 174.1) vs. 50.5 (37.8, 66.8), P < 0.001), but similar to those with non-SARS-CoV-2 lung infection (121.6 (78.5, 175.6) vs. 106.0 (66.5, 149.7), P = 0.244). We also found that the first COVID-19 infections had higher HA levels (118.8 (79.5, 174.3) vs. 85.0 (61.1, 128.8), P < 0.001) and a higher proportion of severe infection (37.1% vs. 21.3%, P = 0.043) than re-infections. However, HA expression failed to fully return to normal levels with infection recovery (204.7 (152.9, 242.2) vs. 97.0 (69.3, 137.3), P < 0.001). HA was associated with severe SARS-CoV-2 infection and could be used as a novel serum biomarker to predict the risk of COVID-19 progression in the post-COVID-19 era.

Preoperatively Confirmed Idiopathic Myointimal Hyperplasia of the Mesenteric Veins: A Case Report

Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is a rare cause of colonic ischemia. First documented in the literature in 1991, this condition has remained exceedingly rare, with only a limited number of case reports since its initial mention. It involves proliferation of intimal smooth muscle within the mesenteric veins, resulting in colonic ischemia due to venous constriction and non-thrombotic occlusion. Patients experience a prolonged clinical course and adverse outcomes due to its rarity and nonspecific symptoms. The definitive diagnosis is typically confirmed after surgical resection of the affected colon, as initial biopsies are not deep enough to confirm the diagnosis. Histological examination of these biopsies reveals arteriolization of capillaries, subendothelial hyaline deposits, and fibrin thrombi. We present a case of a patient with a one-year history of diarrhea and abdominal pain. Biopsy samples obtained during colonoscopy showed colitis and proliferation of muscularized capillaries, consistent with IMHMV, prior to colon resection. The patient ultimately underwent laparoscopic total abdominal colectomy to the distal one-third of the rectum with end ileostomy. IMHMV is commonly treated surgically and mismanagement of this condition involving corticosteroids and immunomodulatory agents may result in unfavorable outcomes. This case report is one of the few cases of IMHMV diagnosed preoperatively within existing literature, which highlights a rare etiology of nonspecific colitis, emphasizing the critical divergence in its management approach.

Fatal eosinophilic myocarditis and submassive hepatic necrosis in lamotrigine induced DRESS syndrome

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a rare but severe and sometimes fatal adverse drug reaction that is known to occur with a number of antiepileptic drugs. It often follows a prolonged clinical course, which can worsen even after discontinuing the causative drug and administering steroid treatment. Failure to promptly identify the delayed involvement of vital organs, such as the heart and liver, may result in irreversible organ failure and death. We report a case of a presumed sudden death of a young woman who had a documented history of a protracted intermittent hypersensitivity reaction to lamotrigine. Postmortem examination revealed the presence of eosinophilic myocarditis and submassive hepatic necrosis diagnostic of fatal DRESS syndrome that progressed despite early discontinuation of the medication and improvement of dermatologic and hematologic symptoms following steroid therapy.

Explantation of a light-adjustable intraocular lens: case report with laboratorial analyses

Introduction: A case in which a light-adjustable lens (LAL) underwent explantation and extensive laboratory analyses is reported. Patient and Clinical Findings: A 61-year-old man underwent uneventful cataract surgery with in-the-bag implantation of a first-generation LAL in the right eye. Examination on the second postoperative day revealed limbus-to-limbus corneal edema, moderate anterior chamber cells, and a mid-dilated, minimally responsive pupil, suggesting toxic anterior segment syndrome (TASS). Diagnosis, Intervention, and Outcomes: Endothelial keratoplasty was performed 2 months after LAL implantation. The patient reported noncompliance with required UV-protective eyewear, and an attempted light adjustment confirmed macromer reserve depletion, likely secondary to ambient UV contamination. Gross and microscopic examinations of the explanted LAL showed a decentered round elevation on the optic. The light transmittance (%T) curve was normal, with 95.9%T on average in the visible spectrum. Optical coherence tomography revealed irregular curvatures of the anterior and posterior optic surfaces. Wavefront analysis displayed aberrations and large power variations, which corresponded to decreased focus and contrast through the optic. Conclusions: To the authors' knowledge, this is the first reported case of LAL implantation complicated by TASS, leading to a prolonged clinical course and nonadherence to proprietary UV-protective spectacles. Extensive laboratory analyses of the explanted LAL demonstrated findings that can be expected with uncontrolled polymerization of the LAL.

Immune system dysfunction in purulent inflammatory diseases of the maxillofacial area in pediatric patients

The issues of treatment of purulent inflammatory diseases of the maxillofacial region (PMMA) are quite urgent, due to increasing number of such patients. Their clinical course is getting worse, and the efficiency of antibiotic therapy is decreasing. Clinical outcomes of purulent maxillofacial pathology in children are complicated by potential severe local deformities at the growth areas of the jaw bones which are difficult to eliminate. The number of cases of prolonged and chronic inflammatory processes, development of local and general complications is increased. The reason for these complications may be an impaired susceptibility to infectious agents, which is determined by the state of the immune system. Therefore, our aim was to reveal some features of immune functions in children with purulent-inflammatory diseases of maxillofacial area.&#x0D; The study included a group of pediatric patients 8-17 years old with maxillofacial inflammatory diseases of the maxilla (the study group), and 13 conditionally healthy children (the comparison group). The contents of T cells (CD3+CD19-, CD3+CD4+, CD3+CD8+, CD3+CD4+/CD3+CD8+), and В cells (CD3-CD19+), NK (CD3-CD16+CD56+) was determined using Cytomics FC-500 (Beckman Coulter, USA);concentrations of serum IgA, IgM, IgG were determined by ELISA technique (Vector-Best, Russia). Phagocytic activity of neutrophilic granulocytes (NG) was evaluated as percentage of actively phagocytic NGs, capturing processes were assessed by appropriate phagocytic indices, and the digestive activity was evaluated against S. aureus (strain 209).&#x0D; Combined defects of immune response in children with maxillofacial hypertension were established: decrease of T lymphocytes contents along with decrease of T helpers and CTL ratio along with unchanged content of NK cells and B lymphocytes. Increase of IgA and IgG levels was also found. Defects of phagocytosis were revealed, primarily connected with the processes of completed phagocytosis and increased content of actively phagocytizing NG.&#x0D; Treatment of children suffering with purulent inflammatory diseases of maxillofacial region is still an urgent problem in dentistry. The revealed dysfunction of immune response to pathogens in the purulent maxillofacial disorders may explain a prolonged clinical course of inflammatory processes, thus determining a need for usage of immunotropic therapy in complex treatment schedules including operative aid as well as conventional drug and physiotherapeutic treatment aiming for increase of rehabilitation efficiency and prevention of postoperative complications in these patients.

Simultaneous isolation of hormone receptor–positive breast cancer organoids and fibroblasts reveals stroma-mediated resistance mechanisms

Recurrent hormone receptor-positive (HR+) breast cancer kills more than 600,000 women annually. Although HR+ breast cancers typically respond well to therapies, approximately 30% of patients relapse. At this stage, the tumors are usually metastatic and incurable. Resistance to therapy, particularly endocrine therapy is typically thought to be tumor intrinsic (e.g., estrogen receptor mutations). However, tumor-extrinsic factors also contribute to resistance. For example, stromal cells, such as cancer-associated fibroblasts (CAFs), residing in the tumor microenvironment, are known to stimulate resistance and disease recurrence. Recurrence in HR+ disease has been difficult to study due to the prolonged clinical course, complex nature of resistance, and lack of appropriate model systems. Existing HR+ models are limited to HR+ cell lines, a few HR+ organoid models, and xenograft models that all lack components of the human stroma. Therefore, there is an urgent need for more clinically relevant models to study the complex nature of recurrent HR+ breast cancer, and the factors contributing to treatment relapse. Here, we present an optimized protocol that allows a high take-rate, and simultaneous propagation of patient-derived organoids (PDOs) and matching CAFs, from primary and metastatic HR+ breast cancers. Our protocol allows for long-term culturing of HR+ PDOs that retain estrogen receptor expression and show responsiveness to hormone therapy. We further show the functional utility of this system by identifying CAF-secreted cytokines, such as growth-regulated oncogene α , as stroma-derived resistance drivers to endocrine therapy in HR+ PDOs.

Does primary urethral realignment improve the outcome of pediatric pelvic fracture urethral injury? A randomized controlled trial.

To assess the efficacy of primary urethral realignment in the prevention of urethral stenosis and in simplifying delayed urethroplasty after complete pelvic fracture urethral injury in male children. This randomized comparative trial included 40 boys <18 years with complete pelvic fracture urethral injury. The initial management was a primary urethral realignment in 20 boys and suprapubic cystostomy alone in the remaining 20 boys. The boys who underwent primary urethral realignment were assessed regarding thedevelopment of urethral stenosis. Boys who needed to be delayed urethroplasty in the two groups were compared regarding urethral defect length, intraoperative details, postoperative outcomes, number of procedures, and time to achieve normal voiding. Although 14 (70%) patients were able to void after primary urethral realignment, all of them developed urethral stenosis and needed delayed urethroplasty. No statistically significant difference between the two groups was found regarding urethral defect length, intraoperative details, and postoperative outcomes. Patients in the primary urethral realignment group underwent significantly more procedures (p < 0.001) and took a significantly longer time to achieve normal voiding (p = 0.002). Primary urethral realignment is neither able to prevent urethral stenosis nor effective in simplifying later urethroplasty after complete pelvic fracture urethral injury in male children. It exposes the patients to more surgical procedures and a prolonged clinical course.

Retinoids in Lichen Planus Pigmentogenes

Lichen planus pigmentosum (LPP) is an uncommon variant of Lichen plan clinically characterized by lichenoid lesions of photoexposed. Pruritus may be present in the early active phase, and the disease often has a prolonged clinical course [1]. There is no effective treatment for LPP. Various therapeutic modalities such as topical tacrolimus, topical and systemic corticosteroids, high-dose vitamin A and lasers have been tried with no prometting results [2-6]. Isotretinoin is a first generation retinoid discovered in 1952 and was approved by the FDA for the treatment of nodulokystic acne in 1982. Isotretinoin anti-inflammatory properties have allowed it to be used in disorders other than acne. Its adverse effects range from simple xerosis to teratogenicity. There have been a few isolated reports of isotretinoin (topical/systemic) efficiency in the treatment of LPP but its role in LPP has not yet been totally elucidated [7,8]. The objective of this study was to evaluate the efficiency and safety of low-dose isotretinoin in the treatment of LPP

Health-related quality of life and cognitive failures in patients with lower-grade gliomas treated with radiotherapy

PurposePatients with lower grade (grade 2 and 3) glioma (LGG) frequently experience prolonged clinical course after multimodal therapy (including surgery, radiotherapy (RT), and chemotherapy). There is therefore significant concern about the potential long-term impact of the disease and treatments on quality of life (QOL) and cognitive functioning. In this context, we evaluated health related QOL and cognitive failures in LGG patients previously treated in our RT department. Patients and methodsAdult LGG patients previously treated with RT were prospectively included. Patients were evaluated based on standardized questionnaires [i.e., EORTC QLQ-C30, EORTC QLQ-BN20, and cognitive failures questionnaire (CFQ)]. ResultsForty-eight patients were included. Median time elapsed since the end of RT was 59.5 months (range: 4–297). Based on EORTC QLQ-C30 and QLQ-BN20, the most prevalent HRQOL issues were impaired cognitive functioning (50% of the patients), impaired emotional functioning (47.9%), financial difficulties (43.7%), fatigue (43.7%), future uncertainty (39.6%), and impaired physical functioning (35.4%). Based on the CFQ, 35.4% of the patients showed increased tendency to cognitive failures. ConclusionPatients with LGG frequently experience impairments in HRQOL and cognitive failures after treatment (including RT). Further efforts are therefore warranted to improve the QOL and cognitive outcome of these patients.

Increased Incidence of Ulcerative Laryngitis During Spring 2022 Omicron-Variant Wave of COVID19

Ulcerative laryngitis is a distinctive condition which typically follows illness with severe cough, and is characterized by dysphonia, ulcerative lesions of the vocal folds, and a prolonged clinical course. We present four patients with ulcerative laryngitis who presented in close succession amid the surge in omicron-variant COVID19 cases. Retrospective review. Patient records for patients with ulcerative laryngitis from April and May 2022 were reviewed and compared with patients who presented with the same diagnosis from January 2017 through March 2022. Incidence, patient demographics, occupation, vaccination status, disease history, and treatment were obtained and compared. Four patients presented with ulcerative laryngitis over six weeks. Compared to the previous 4 years, this represented an eight-fold increase in monthly incidence. Average time from symptom onset to presentation was 15 days. All patients presented with dysphonia, with an average VHI10 of 23 and SVHI10 of 28. Two patients were COVID positive, one negative, and one had unknown COVID status. Three patients were fully vaccinated while one patient had only received one dose. Treatments included voice rest, steroids, antibiotics, antireflux medicine, and cough suppressants. Clinical course tended to be shorter and outcomes similar to the comparison group. The incidence of ulcerative laryngitis appeared to increase markedly with the prevalence of omicron-variant COVID19. Potential explanations include the apparent upper airway focus of omicron infection in contrast with prior variants and/or change in COVID19 infection characteristics in a vaccinated population.

Diagnosis and Treatment of a Nonhealing Wound Secondary to a Reepithelialized Hair Tourniquet With Ultrasound.

A 9-month-old girl presented with a chronic wound on the dorsal surface of her toe that failed 6 months of medical management. Due to the prolonged clinical course, there was a concern for a foreign body. Intraoperative ultrasound was utilized to identify linear echogenic structures, which were excised and consistent with reepithelialized hairs secondary to hair-thread tourniquet syndrome. There were also erosive changes to the underlying phalanx. Intraoperative ultrasound was also used to guide the incision size and confirm the complete removal of the hairs.

Complicated appendicitis wrongly diagnosed as nonspecific diarrhea: ways to decrease this continuous threat

The diagnostic assessment of right lower quadrant pain in children and adolescents is still a challenge. The aim of this study was to analyze the cases of complicated appendicitis wrongly diagnosed as nonspecific diarrhea, and based on the information obtained suggest a clear and simple policy in order to decrease misdiagnosis in the future. Three groups of patients were analyzed: children who underwent appendectomy (group 1); those with gastroenteritis (group 2), and those who underwent appendectomy following hospitalization under the wrong diagnosis of gastroenteritis (group 3). Group 3 presented a more prolonged and complicated clinical course, higher fever, diffuse abdominal pain, repeat vomiting, higher C-reactive protein values, longer surgery duration and recovery. When the etiology of right lower quadrant abdominal pain is not immediately evident and associated with atypical diarrhea, high fever, repeat vomiting, and significantly increased CRP values, early surgical consultation is required. If the clinical findings are unclear, an abdominal US should be performed as soon as possible. A limited abdominal computed tomography scan CT should follow those cases not resolved by history, physical examination, blood tests, and abdominal ultrasound.

Complete Resolution of Chronic Postdural Puncture Headache from Cervical Decompression After Lumbar Epidural Blood Patch Administration: A Case Report

Background: Neuraxial procedures have the risk of causing dural compromise that leads to postdural puncture headaches (PDPH). PDPH is normally treated conservatively with oral agents, such as nonsteroidal anti-inflammatory drugs and caffeine, or invasively with epidural blood patches (EBP). There is a paucity of evidence for the use of lumbar EBP in cases where the suspected chronic dural defect is at the cervical level. Case Report: A 47-year-old patient who underwent C4-C6 posterior extension of fusion as well as right-sided C5-C6 foraminotomy subsequently developed chronic PDPH symptoms that were refractory to conservative interventions. A lumbar EBP was performed for suspected cervical dura compromise, with near-immediate resolution of symptoms that lasted for multiple months. Conclusion: Lumbar EBP should be considered in patients with suspected PDPH from cervical dural compromise, especially in the context of a prolonged clinical course or failure of conservative means. Key words: Case report, cervical dura compromise, lumbar epidural patch, postdural puncture headache

Idiopathic Pericardial Effusions in Children: Workup and Final Diagnoses.

Pediatric idiopathic pericardial effusions are common and often have a prolonged clinical course. We hypothesized that these effusions have no standardized diagnostic workup, and ultimately have a final etiology not initially appreciated. To test these hypotheses, a hospital system-wide retrospective (1/1/1990-10/1/2019) cohort study of pericardial effusions in children (< 18years) was conducted. Effusions were grouped by etiology and patients receiving an initial idiopathic diagnosis were further analyzed. Effusion size, diagnostic workup, final diagnosis, and time to resolution were abstracted. In total, 42/366 effusions were initially diagnosed as idiopathic. Workup was not standardized and included up to six laboratory tests including pericardial fluid analysis and infectious, metabolic, rheumatologic and thyroid workups. Treatment course involved 1 readmission in 24%, and > 1 readmission in 12%. Resolution of effusion occurred in 83% of patients within a median of 1 admission (range 1-4). Of those effusions initially deemed idiopathic, 12/42 (29%) were later found to have an underlying etiologic diagnosis including: autoimmune (7, 58%), neoplastic (2, 16%), infectious (2, 16%), and renal (1, 8%). Children initially diagnosed with idiopathic pericardial effusions have an underlying etiologic diagnosis 29% of the time, and a standardized workup may prevent delays in definitive diagnosis and treatment.

A multidisciplinary approach to the work up and management of pulmonary carcinoid tumors and DIPNECH: a narrative review.

Low and intermediate grade neuroendocrine tumors of the lung are uncommon malignancies representing 2% of all lung cancers. These are termed typical and atypical pulmonary carcinoid tumors. These can arise in the setting of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH). The presentation, workup, management and outcomes of patients with these tumors can overlap with more common lung cancers but differ in that many of these patients have a prolonged clinical course. The objective of this narrative review is to summarize the literature and provide evidence and expert-based algorithms for work up and treatment of pulmonary carcinoids and DIPNECH. A search of PubMed and Web of Science databases ending April 15, 2022, with the following keywords "lung carcinoid", "DIPNECH", "lung neuroendocrine," and "bronchopulmonary carcinoid". Pulmonary carcinoid tumors benefit from a multidisciplinary approach. Pre-treatment imaging with contrast-enhanced computed tomography, and DOTATATE positron emission tomography is required. Surgical resection is the gold standard for curative intent, and possibly including sublobar resections. Patients can recur or develop new primaries thus emphasizing the importance of surveillance; national guidelines recommend at least a 10-year follow up. A growing body of literature support the use of endobronchial therapy, with long responses documented. Systemic therapy consists of everolimus, somatostatin analogs, peptide receptor radionuclide therapy, and chemotherapy. Diffuse idiopathic pulmonary neuroendocrine tumor cell hyperplasia is rare, but series suggest somatostatin analogs may confer clinical benefit. Pulmonary carcinoid tumors and DIPNECH are rare. Despite lack of regulatory approvals for advanced disease, multiple options are available but should be sequenced according to the clinical status and disease biology. Each patient should be discussed in a multidisciplinary setting and clinical trials should be considered if available.

CASE OF ESCHERICHIA COLI NECROTIZING PNEUMONIA WITH CAVITARY LESIONS

CASE OF ESCHERICHIA COLI NECROTIZING PNEUMONIA WITH CAVITARY LESIONS