Periprocedural Complications With Balloon Pulmonary Angioplasty: Analysis of Global Studies

BACKGROUND

Balloon pulmonary angioplasty (BPA) was introduced as a treatment modality for patients with inoperable, medically refractory chronic thromboembolic pulmonary hypertension decades ago; however, reports of high rates of pulmonary vascular injury have led to considerable refinement in procedural technique.

OBJECTIVES

The authors sought to better understand the evolution of BPA procedure-related complications over time.

METHODS

The authors conducted a systematic review of original articles published by pulmonary hypertension centers globally and performed a pooled cohort analysis of procedure-related outcomes with BPA.

RESULTS

This systematic review identified 26 published articles from 18 countries worldwide from 2013 to 2022. A total of 1,714 patients underwent 7,561 total BPA procedures with an average follow up of 7.3 months. From the first period (2013-2017) to the second period (2018-2022), the cumulative incidence of hemoptysis/vascular injury decreased from 14.1% (474/3,351) to 7.7% (233/3,029) (P < 0.01); lung injury/reperfusion edema decreased from 11.3% (377/3,351) to 1.4% (57/3,943) (P < 0.01); invasive mechanical ventilation decreased from 0.7% (23/3,195) to 0.1% (4/3,062) (P < 0.01); and mortality decreased from 2.0% (13/636) to 0.8% (8/1,071) (P < 0.01).

CONCLUSIONS

Procedure-related complications with BPA, including hemoptysis/vascular injury, lung injury/reperfusion edema, mechanical ventilation, and death, were less common in the second period (2018-2022), compared with first period (2013-2017), likely from refinement in patient and lesion selection and procedural technique over time.

Pneumothorax in Intubated Patients With COVID-19: A Case Series

Pneumothorax is a rare complication among mechanically ventilated patients since low tidal volumes are used nowadays instead of traditional high tidal volumes, but the incidence is slightly higher in patients with high positive end-expiratory pressure (PEEP). Herein we describe a case series of nine patients who were on mechanical ventilation due to acute respiratory distress syndrome (ARDS) secondary to coronavirus disease 2019 (COVID-19) and developed pneumothorax in due course. A retrospective analysis was done on COVID-19 intubated patients from March 2020 to June 2020 in a community hospital in Central New Jersey, which was one of the early hit states in the United States at the beginning of the pandemic. Outcomes were studied. The demographics of patients like age, gender, and body mass index (BMI); risk factors like smoking, comorbidities especially chronic lung disease, and the treatment they received were compared. We compared the total number of days on the ventilator, the highest PEEP they received, and the ventilator day when pneumothorax developed. All the patients who developed pneumothorax had a chest tube inserted to treat it. The mortality was noted to be 100% indicating that pneumothorax is a life-threatening complication of COVID-19 and COVID-19 by itself is a risk factor for pneumothorax likely due to a change in lung mechanics. There is a need for large-scale studies to confirm that these outcomes are related to COVID-19.

Hemodynamic indices in pulmonary hypertension: a narrative review

Background and Objective

Pulmonary hypertension (PH) is defined as a mean pulmonary artery pressure (mPAP) >20 mmHg and its presence is associated with worse outcomes. A comprehensive hemodynamic evaluation of the pulmonary circulation is essential for diagnosis, hemodynamic classification, and prognostication. A multitude of indices assess different aspects of the pulmonary circulation but there are no reviews that describe their specific value in PH.

Methods

We performed a thorough literature search of relevant articles in English from 1970–2021 using PubMed.

Key Content and Findings

In this article, we present both static and dynamic indices used for the hemodynamic assessment of PH. While some of these indices are routinely used in clinical practice, including cardiac index (CI), stroke volume (SV), and pulmonary vascular resistance (PVR); others such as pulmonary artery compliance (PAC), pulmonary effective arterial elastance (Ea), and pulmonary artery pulsatility index (PAPi) are gaining popularity by enhancing the understanding of different aspects of the pulmonary circulation. We described the advantages and pitfalls of various indices, including when to use them in the hemodynamic evaluation of patients with PH.

Conclusions

A variety of indices measuring different aspects of the right ventricle (RV)-pulmonary arteries (PA) system provide valuable information in patients with PH. However, it remains important to develop and validate indices that provide a comprehensive hemodynamic evaluation to improve outcomes in patients with PH.

Solitary fibrous tumor of the urinary bladder: An unusual case report with literature review

Solitary fibrous tumor is neoplasm of mesenchymal origin commonly involving visceral pleura however we are presenting an unusual case with involvement of urinary bladder. It is generally indolent in nature therefore proper diagnosis is required for complete characterization to avoid unnecessary extensive surgical resection. Our patient was a 64-year-old female who presented with lower abdominal fullness with change in her bowel movement pattern. On imaging partially necrotic mass with heterogenous enhancement was found which was later biopsied and resected with clean surgical margin. Solitary fibrous tumor is overall a benign tumor with satisfactory outcome. Physicians should keep it in a differential of pelvic masses and with the risk recurrence, 6 monthly follow up imaging are usually required after resection.

Foreign body aspiration

The clinical manifestations of foreign body (FB) aspiration can range from an asymptomatic presentation to a life-threatening emergency. Patients may present with acute onset cough, chest pain, breathlessness or sub-acutely with unexplained hemoptysis, non-resolving pneumonia and at times, as an incidental finding on imaging. Patients with iatrogenic FB such as an aspirated broken tooth during difficult intubation or a broken instrument are more common scenarios in the intensive care unit (ICU). Patients with post-obstructive pneumonia with or without sepsis, or variable degree of hemoptysis often require ICU level of care and bronchoscopic interventions. Rigid bronchoscopy has traditionally been the modality of choice; however, with the innovation in instrumentation and wider availability of flexible bronchoscopes, most of the FB removal is now successfully performed using flexible bronchoscopy. Proceduralists choose instruments in accordance with their training and expertise. We describe the use of most common instruments including forceps, balloon catheters, and baskets. Role of cryoprobe and LASER in FB removal is reviewed as well. In general, larger working channel bronchoscopes are preferred; however, smaller working channel bronchoscopes may be used in situations when the patients are intubated with a smaller diameter endotracheal or tracheostomy tubes. Large size FB are removed en bloc with the grasping tool, bronchoscope, and endotracheal or tracheostomy tube, requiring preparation to safely re-establish the airway. After FB removal, bronchoscopy is re-performed to identify any residual FB, assess any injury to the airway, suction post-obstructive secretions or pus, control any active bleeding and remove granulation tissue that may be obstructing the airway. Additional interventions like balloon dilatation may be required to dislodge an impacted FB or to maintain patency of bronchial lumen. If bronchoscopic methods fail, surgery may be required for retrieval of FB in symptomatic patients or to resect suppurative or necrotizing lung process. Multidisciplinary approach involving intensivists, surgeons, and anesthesiologists is the key to optimal patient outcomes.

Pneumothorax in critically ill patients with COVID-19 infection: Incidence, clinical characteristics and outcomes in a case control multicenter study

Background

The clinical features and outcomes of mechanically ventilated patients with COVID-19 infection who develop a pneumothorax has not been rigorously described or compared to those who do not develop a pneumothorax.

Purpose

To determine the incidence, clinical characteristics, and outcomes of critically ill patients with COVID-19 infection who developed pneumothorax. In addition, we compared the clinical characteristics and outcomes of mechanically ventilated patients who developed a pneumothorax with those who did not develop a pneumothorax.

Methods

This study was a multicenter retrospective analysis of all adult critically ill patients with COVID-19 infection who were admitted to intensive care units in 4 tertiary care centers in the United States.

Results

A total of 842 critically ill patients with COVID-19 infection were analyzed, out of which 594 (71%) were mechanically ventilated. The overall incidence of pneumothorax was 85/842 (10%), and 80/594 (13%) in those who were mechanically ventilated. As compared to mechanically ventilated patients in the non-pneumothorax group, mechanically ventilated patients in the pneumothorax group had worse respiratory parameters at the time of intubation (mean PaO₂:FiO₂ ratio 105 vs 150, P<0.001 and static respiratory system compliance: 30ml/cmH₂O vs 39ml/cmH₂O, P = 0.01) and significantly higher in-hospital mortality (63% vs 49%, P = 0.04).

Conclusion

The overall incidence of pneumothorax in mechanically ventilated patients with COVID-19 infection was 13%. Mechanically ventilated patients with COVID-19 infection who developed pneumothorax had worse gas exchange and respiratory mechanics at the time of intubation and had a higher mortality compared to those who did not develop pneumothorax.

Incidence of pancreatitis with the use of immune checkpoint inhibitors (ICI) in advanced cancers: A systematic review and meta-analysis

BACKGROUND

Systemic immune side effects including pancreatitis have been reported with the use of Immune Checkpoint Inhibitors (ICI) (CTLA-4, PD-1 and PDL-1). However, the true incidence, risk, causes (tumor or drug specific) of pancreatitis and relation to other immune side effects, especially diabetes mellitus (DM) are unknown.

METHODS

We performed a systematic review and meta-analysis of all clinical trials using ICI for the incidence of any grade lipase elevation, pancreatitis or DM.

RESULTS

The incidence of asymptomatic lipase elevation after ICI use is 2.7% (211/7702) and grade 2 pancreatitis is 1.9% (150/7702). No pancreatitis related mortality has been reported in these clinical trials. Patients treated with CTLA-4 inhibitors have increased incidence of pancreatitis when compared to patients treated with PD1 inhibitors 3.98% (95% CI: 2.92 to 5.05) vs 0.94% (95% CI: 0.48 to 1.40); P value < 0.05. Patients treated with ICI for melanoma have increased incidence of pancreatitis when compared to non-melanoma cancers. We also noted an additive increase in incidence of pancreatitis with combination of CTLA4 and PD-1 inhibitors (10.60; 95% CI: 7.89 to 13.32) compared with either CTLA-4 or PD-1 inhibitors alone.

CONCLUSIONS

Our study provides precise data for the incidence of pancreatitis among patients using ICI based on tumor types and ICI regimens. ICI use for solid tumors is associated with increased incidence of all grades of lipase elevation and pancreatitis, especially for CTLA-4 agents and ICI combination. Although it does not appear to be associated with mortality, ICI related pancreatitis should be recognized early for appropriate treatment and to potentially reduce long term complications.

Organizing pneumonia co-existing with carcinoid tumour: complete resolution with bronchoscopic tumour resection

Organizing pneumonia is a well-known clinical entity resulting in response to noxious stimuli causing lung injury. It is known to occur with infectious disease processes, neoplasms, post lung surgery or radiation therapy and when idiopathic, is called cryptogenic organizing pneumonia. We present an unusual case of a 48-year-old woman who presented with chronic cough and progressive dyspnoea while being on macrolide therapy for Lyme disease. Computerized tomography of chest demonstrated a well-circumscribed nodule in the lingula and bilateral central ground glass opacities. Transbronchial biopsies were consistent with carcinoid tumour in the lingula and organizing pneumonia in bilateral lung fields. Bronchoscopic relief of obstruction was performed by mechanical debulking of the tumour, with subsequent complete resolution of bilateral opacities, consistent with resolution of organizing pneumonia without the need for steroid therapy.

Intraventricular empyema caused by Neisseria meningitidis

Meningitis is defined as an inflammation of the protective covering of brain and spinal cord collectively called as meninges. Meningeal infection can be complicated by intraventricular empyema. There are 9 cases of intraventricular empyema described in the literature out of which only three are described to be caused by Neisseria meningitidis. We report the fourth rare case.

A 61-year-old female with past medical history of diabetes and hypertension presented with the chief complaint of fever with chills and headache of 1-day duration. CT head did not reveal any acute abnormalities. Lumbar puncture was obtained and empiric IV antimicrobial agents were started. CSF analysis showed gram negative diplococci with culture growing Neisseria meningitidis suggesting meningococcal meningitis. Due to persistent headache and lethargy after complicated meningitis was suspected and MRI of brain was obtained which reflected a diagnosis of intraventricular empyema.

Pyogenic ventriculitis also known as intraventricular empyema or ependymitis, is a defined as an inflammation of the ependymal lining of the cerebral ventricular system and is characterized by the presence of suppurative fluid in the ventricles. It is a health care associated complication and is often confused with meningitis due to the similar presentation. Therefore, persistent symptoms despite optimal antimicrobial therapy (therapeutic failure) should alarm the presence of pyogenic ventriculitis.

This is the fourth case of intraventricular empyema reported secondary to Neisseria meningitidis. Our case reiterates that clinicians should maintain an index of suspicion for complicated meningitis in patients not responding to standard antimicrobial therapy.

Idiopathic Internal Jugular Vein and Subclavian Vein Thrombosis: A Rare Case Report

Venous thrombosis is a vascular disorder which is a consequence of Virchow's triad: hypercoagulability, venous stasis, and endothelial injury. While lower extremity deep venous thrombosis is common, upper torso thrombosis is a rare clinical condition and usually a complication of central venous catheterization or malignancy-related paraneoplastic syndromes. Herein, we present a rare case of a 64-year-old male who presented with right upper extremity and right facial swelling who was found to have a thrombus in the right internal jugular vein and right subclavian vein with no predisposing factors. He was successfully treated with anticoagulation without any complications.

Recreational Nitrous Oxide Abuse Causing Ischemic Stroke in a Young Patient: A Rare Case Report

Hyperhomocysteinemia has been associated with an increased risk of systemic atherosclerosis, cardiovascular disease, and stroke. It can result from an impaired homocysteine metabolism resulting from a dietary deficiency of folic acid, vitamin B6, and vitamin B12 or as a result of genetic predispositions due to impaired gene function involved in the methionine and homocysteine metabolism. Nitrous oxide use can also lead to hyperhomocysteinemia by irreversibly oxidizing the cobalt atom of vitamin B12, which results in an inhibition of the enzyme methionine synthase. Here, we report a rare case of a young patient who presented with acute ischemic stroke after years of recreational nitrous oxide use.

I have heard about it for the first time from you! Implementation of tobacco control law by police personnel in India

Setting and Objetives: Police personnel, alongside other key stakeholders, are responsible for implementing the Cigarettes and Other Tobacco Products Act (COTPA) in India. This study aimed to assess knowledge and attitudes about COTPA among police personnel and explore enablers and barriers in implementing it. Design: This convergent parallel mixed-methods study used a self-administered questionnaire (quantitative) and key informant interviews (qualitative). Of 300 police personnel across all eight police stations in Daman, 155 participated. Quantitative data were analysed using descriptive statistics and the χ² test. Qualitative data from in-depth interviews of six key informants from all coordinating departments were analysed thematically. Results: Overall, 63.2% of responders were aware of any tobacco control law in India, and only 12.9% were trained in its implementation. One person had conducted inspections for COTPA compliance in the last 12 months. The majority (78.1%) of the police personnel, and significantly more tobacco non-users than users (81.2% vs. 52.9%, P = 0.016), felt that enforcing anti-tobacco regulations is one of their most important functions. Perceived benefits of the act and formal authority to act were the two main enablers of COTPA implementation. Lack of awareness and coordination, competing priorities, concentration of authority with higher-ranking officials and evasion of the law by retailers and the public hampered effective implementation of the law. Conclusion: Knowledge about the COTPA was average and implementation poor. Sensitisation and training of implementers, systematic transparent reporting and creating awareness among public are recommended for effective implementation.

Bilateral External Auditory Exostoses Causing Conductive Hearing Loss: A Case Report and Literature Review of the Surfer's Ear

In patients with repeated exposure to cold water, such as cold water surfers and kayakers, the reactive exostoses can occur in the external auditory canal. The external auditory canal exostoses are multiple, benign bony growths. They can cause external auditory canal stenosis, leading to repeated otitis externa and potentially conductive hearing loss. It is vital to consider this entity in susceptible patients who report hearing loss, as timely intervention such as proper ear protection equipment can lower the risk of developing severe external auditory canal exostoses. We present a case of a 42-year-old male, cold water surfer with conductive hearing loss and bilateral external auditory canal (EAC) stenosis demonstrated on the computed tomography.

Epidemiology of Dyspepsia and Irritable Bowel Syndrome (IBS) in Medical Students of Northern India

BACKGROUND

Dyspepsia and Irritable Bowel Syndrome (IBS) are perhaps one of the most common gastrointestinal diseases universally. The prevalence of dyspepsia ranges from 7-40% while the prevalence of IBS ranges between 3-22% in population based studies worldwide.

AIM

This study was conducted to estimate the prevalence, socio-demographic and lifestyle associated risk factors of Dyspepsia and IBS among medical college students of urban Delhi, Northern India.

SETTINGS AND DESIGN

It is a cross-sectional study and was carried out from January to March 2014 at Maulana Azad Medical College, New Delhi, India.

MATERIALS AND METHODS

A total of 210 students from a Medical College were asked to complete a semi-structured questionnaire based on identification and socio-demographic data, questions pertaining to lifestyle and Rome III criteria.

RESULTS

Of the valid 200 subjects, 90(45%) were males and 110(55%) were females, with a mean age of 20.43± 1.05 y. Majority of the subjects (diagnosed with uninvestigated dyspepsia and IBS) were in the age group of 18-20 y with female gender having higher odds for both. The prevalence of dyspepsia was 18% while that of IBS was 16.5%.Consumption of fatty food, cigarettes and low physical activity were observed as most significant correlates.

CONCLUSION

Rome III criteria enables symptom based diagnosis of dyspepsia and IBS.The prevalence of dyspepsia and IBS in college students from Delhi is observed to be higher. Association with lifestyle related factors highlights the importance of modifications in their prevention.

FATIGUE OF BIOMATERIALS: HARD TISSUES

The fatigue and fracture behavior of hard tissues are topics of considerable interest today. This special group of organic materials comprises the highly mineralized and load-bearing tissues of the human body, and includes bone, cementum, dentin and enamel. An understanding of their fatigue behavior and the influence of loading conditions and physiological factors (e.g. aging and disease) on the mechanisms of degradation are essential for achieving lifelong health. But there is much more to this topic than the immediate medical issues. There are many challenges to characterizing the fatigue behavior of hard tissues, much of which is attributed to size constraints and the complexity of their microstructure. The relative importance of the constituents on the type and distribution of defects, rate of coalescence, and their contributions to the initiation and growth of cracks, are formidable topics that have not reached maturity. Hard tissues also provide a medium for learning and a source of inspiration in the design of new microstructures for engineering materials. This article briefly reviews fatigue of hard tissues with shared emphasis on current understanding, the challenges and the unanswered questions.

Aging and the reduction in fracture toughness of human dentin

An evaluation of the crack growth resistance of human coronal dentin was performed on tissue obtained from patients between ages 18 and 83. Stable crack extension was achieved over clinically relevant lengths (0< or = a < or =1mm) under Mode I quasi-static loading and perpendicular to the nominal tubule direction. Results distinguished that human dentin exhibits an increase in crack growth resistance with extension (i.e. rising R-curve) and that there is a significant reduction in both the initiation (K(o)) and plateau (K(p)) components of toughness with patient age. In the young dentin (18< or =age< or =35) there was a 25% increase in the crack growth resistance from the onset of extension (K(o)=1.34 MPa m(0.5)) to the maximum or "plateau" toughness (K(p)=1.65 MPa m(0.5)). In comparison, the crack growth resistance of the old dentin (55< or =age) increased with extension by less than 10% from K(o)=1.08 MPa m(0.5) to K(p)=1.17 MPa m(0.5). In young dentin toughening was achieved by a combination of inelastic deformation of the mineralized collagen matrix and microcracking of the peritubular cuffs. These mechanisms facilitated further toughening via the development of unbroken ligaments of tissue and posterior crack-bridging. Microstructural changes with aging decreased the capacity for near-tip inelastic deformation and microcracking of the tubules, which in turn suppressed the formation of unbroken ligaments and the degree of extrinsic toughening.

An examination of fatigue striations in human dentin: in vitro and in vivo

Although striations are often used in evaluating fatigue crack growth in engineering materials, they have not been used in studying the mechanics of fracture in hard tissues. The primary objective of this study was to evaluate the striations resulting from fatigue crack growth in the dentin of human teeth. Compact tension (CT) specimens obtained from the coronal dentin of molars from young (17 < or = age < or = 37 years) and senior (age > or = 50 years) patients were subjected to cyclic Mode I loads. Striations evident on the fracture surfaces were examined using a scanning electron microscope (SEM) and contact profilometer. Fatigue crack growth striations that developed in vivo were also examined on fracture surfaces of restored molars. A power spectrum analysis of surface profiles from the CT specimens showed that the striation spacing ranged from 50 to 170 microm. The average spacing in the dentin of seniors (130 +/- 23 microm) was significantly larger (p < 0.001) than that in young dentin (88 +/- 13 microm). Fatigue striations in the restored teeth exhibited features that were consistent with those that developed in vitro and a spacing ranging from 59 to 95 microm. Unlike metals, the striations in dentin developed after a period of cyclic loading that ranged from 1 x 10(3) to 1 x 10(5) cycles. A quantitative evaluation of the striation spacing using the Bates-Clark equation suggested that cyclic crack growth within the restored teeth occurred at a stress intensity range near 0.7 MPa x m(0.5), and a stress range of approximately 12 MPa.

Transition behavior in fatigue of human dentin: structure and anisotropy

The influence of tubule orientation on the transition from fatigue to fatigue crack growth in human dentin was examined. Compact tension (CT) and rectangular beam specimens were prepared from the coronal dentin of molars with three unique tubule orientations (i.e., 0 degrees , 45 degrees and 90 degrees). The CT specimens (N=25) were used to characterize fatigue crack initiation and steady-state cyclic extension, whereas the rectangular beams (N=132) were subjected to 4-pt flexure and used in quantifying the stress-life fatigue response. The transition behavior was analyzed using both the Kitagawa-Takahashi and El Haddad approaches. Results showed that both the fatigue crack growth and stress-life responses were dependent on the tubule orientation. The average Paris Law exponent for crack growth perpendicular (90 degrees) to the tubules (m=13.3+/-1.1) was significantly greater (p<0.05) than that for crack growth oblique (45 degrees) to the tubules (m=11.5+/-1.87). Similarly, the fatigue strength of dentin with 90 degrees tubule orientation was significantly lower (p<0.05) than that for the other two orientations, regardless of the range of cyclic stress. The apparent endurance strengths of specimens with 0 degrees (44MPa) and 45 degrees (53MPa) orientations were nearly twice that of the 90 degrees (24MPa) orientation. Based on these results, human dentin exhibits the largest degree of anisotropy within the stress-life regime and the transition from fatigue to fatigue crack growth occurs under the lowest cyclic stress range when the tubules are aligned with the cyclic normal stress (90 degrees orientation).