Malignant Airway Obstruction and Endobronchial Stent Placement: A Systematic Review on the Efficacy and Safety

The systematic review aims to evaluate the efficacy and safety of endobronchial stent placement for malignant airway obstruction.  A comprehensive search was conducted across multiple databases to identify relevant studies. Cohort studies, randomized controlled trials, and case-control studies examining the outcomes of endobronchial stent placement in patients with malignant airway obstruction were included. Data on pre-treatment evaluation, such as pulmonary function testing, dyspnea severity scoring systems, arterial blood gas parameters, imaging, and degree of obstruction, were also collected. Primary outcomes of interest included post-procedure stenosis, pulmonary function testing evaluation, blood gas parameters, and survival outcomes. Secondary outcomes encompassed improvements in clinical status, dyspnea grade, and procedure-related complications. A total of 27 studies met the inclusion criteria and were included in the systematic review. The included studies demonstrated promising outcomes of endobronchial stent placement in managing malignant airway obstruction. Post-procedure airway diameters, pulmonary function testing, and blood gas parameters improved significantly. Survival outcomes varied among studies. Furthermore, endobronchial stent placement was associated with improvements in clinical status and dyspnea grade. Procedure-related complications ranged from pain, hemoptysis and mucus plugging to stent obstruction, migration and pneumothorax.  This systematic review suggests that endobronchial stent placement is an effective and safe intervention for managing malignant airway obstruction. It offers significant improvements in post-procedure stenosis, pulmonary function testing, blood gas parameters, and clinical outcomes. However, further studies with larger sample sizes and standardized reporting are warranted to better evaluate the long-term efficacy and safety of endobronchial stent placement for malignant airway obstruction.

Cryotherapy for the Treatment of Tracheal Stenosis: A Systematic Review

Tracheal stenosis (TS) is an iatrogenic sequela after intubation or tracheostomy that is increasing despite technological improvement and skilled respiratory care in the ICU. According to the studies, the rate of TS varies from 10 to 22%, but only 1-2% of these stenoses are severe and present with inspiratory dyspnea that does not respond to medical management. Bronchoscopy is considered the most appropriate diagnostic test, and laser surgery and tracheobronchial stenting are the most commonly performed procedures for tracheal stenosis. However, alternative treatment options, including cryotherapy for inoperable patients, have yet to be studied widely. As the number of patients requiring ICU admission with mechanical intubation is increasing, it is crucial to acknowledge this complication and consider alternative management options. Here we present a review of the use of cryotherapy for post-intubation tracheal stenosis.  Pubmed, Cochrane, and EMBASE databases were inquired for studies performed using the keywords 'airway stricture' OR 'airway obstruction' AND 'post-intubation' OR 'post-extubation' OR 'tracheostomy' AND 'cryotherapy'. After the primary and secondary screening, five studies were included in the analysis.  We included 67 patients were included in the analysis, with a mean age of 50.2 (range: 42-55) years. Tracheal stenosis and subglottic stricture were the most common sites of stenosis. Twenty-nine patients were treated with cryotherapy only, while the rest 38 patients had cryotherapy followed by balloon dilation. After the intervention, 48 patients experienced improvement, five experienced no change in the symptoms, 13 patients were asymptomatic before the treatment, and one died. No complication was reported in 65 patients, with only minor complications reported in rest.  Although, there is no clear treatment protocol for patients with inoperable tracheal stenosis. Our review demonstrates that cryotherapy for inoperable tracheal stenosis can be an acceptable alternative treatment with significant clinical improvement. Additionally, cryotherapy has fewer adverse effects compared to other treatment options.

Impact of erythropoietin therapy on cardiorenal syndrome: A systematic review with meta-analysis

BACKGROUND

Heart and kidney dysfunction frequently coexist in patients with acute heart failure due to the overlap between these two organ systems. Cardiorenal syndrome (CRS) results from pathology occurring in the heart and kidneys along with the consequences of dysfunction in one organ contributing to dysfunction in the other and vice versa.

AIM

To evaluate the use of erythropoietin (EPO) in patients with CRS and its effects on hemoglobin (Hb), major cardiovascular (CV) events, and hospitalization rates.

METHODS

On February 24, 2022, searches were conducted using PubMed, MEDLINE, and EMBASE, and 148 articles were identified. A total of nine studies were considered in this systematic review. We assessed the included articles based on the National Heart, Lung, and Blood Institute quality assessment tools for controlled intervention and observational cohort or cross-sectional studies. An assessment of bias risk was conducted on the chosen studies, and data relevant to our review was extracted.

RESULTS

The systematic review of these studies concluded that most existing literature indicates that EPO improves baseline Hb levels and decreases myocardial remodeling and left ventricular dysfunction without reducing CV mortality. In addition, the effect of EPO on the hospitalization rate of patients with CRS needs to be further studied since this relationship is unknown. Future studies, such as randomized controlled clinical trials and prospective cohort studies, should be conducted to enhance the literature on the potential of EPO therapy in patients with CRS.

CONCLUSION

Our systematic review suggests that EPO therapy may have a significant role in managing CRS. The review highlights the potential benefits of EPO in improving baseline Hb levels, reducing the risk of major CV events, improving cardiac remodeling, myocardial function, New York Heart Association class, and B-type natriuretic peptide levels. However, the effect of EPO treatment on hospitalization remains unclear and needs further exploration.

The Efficacy and Safety of Autologous Blood Patch for Persistent Air Leaks: A Systematic Review and Meta-Analysis

Persistent air leaks (PALs) are associated with prolonged hospital stays, contamination and sustained infection of the pleural space, and significant morbidity. A fistulous tract between the alveoli and the pleural space is referred to as an alveolar-pleural fistula (APF), whereas a fistulous tract between the bronchiole and the pleural space is referred to as a bronchopleural fistula (BPF). There is no consensus on the treatment, and multiple modalities exist for the management of persistent air leak (PAL). Autologous blood patch (ABP) is a relatively safe and inexpensive method that has been used for many years for the treatment of PALs. We conducted an electronic database search between 08/24/2022 and 08/27/2022 in PubMed, Embase, and Cochrane using keywords. The following keywords were used: "Blood patch" OR "Autologous blood patch" AND "pleurodesis." Our study included all original studies with the prime focus on the etiology of PALs, clinical characteristics, procedural details of ABP, and outcomes of the proposed treatment. The primary outcomes that were the focus of our study were the time to seal the air leak, the time to remove the chest tube after air leak cessation, and the time to discharge from the hospital. To determine the safety of ABP, we also evaluated the procedural outcomes. Our findings suggest a statistically significant decrease in the time to air leak cessation when compared to the control group (mean difference of -3.75 {95% CI: -5.65 to -1.85; P=0.001}) with considerable heterogeneity of I²=85% and P=0.001. However, the difference was not statistically significant when a lower dose of ABP (50 mL) was compared to a higher dose (100 mL) (mean difference of 1.48 {95% CI: -0.07 to 3.02; P=0.06}) and considerable heterogeneity of I²=80% and P=0.03. There was no statistically significant difference in the time to discharge when compared to the control group (mean difference of -2.12 {95% CI: -4.83 to 0.59; P=0.13}) and considerable heterogeneity (I²=95% and P<0.001). When compared to the control group, ABP did not provide any statistically significant difference in the risk ratio for infection (1.18 {95% CI: 0.52 to 2.65; P=0.70} and moderate heterogeneity {I²=33% and P=0.20}), pain (1.18 {95% CI: 0.52 to 2.65; P=0.70} and moderate heterogeneity {I²=33% and P=0.20}), and fever (0.54 {95% CI: 0.27 to 1.10; P=0.09} and no heterogeneity {I²=0% and P=0.50}). Our study concludes that using ABP caused a statistically significant decrease in the time to air leak cessation when compared to the control group. However, the procedure does not provide a statistically significant difference in the time to discharge from the hospital when compared to conservative treatment. Similarly, there was no statistically significant difference in the risk ratio for complications such as infection, pain, and fever when compared to conservative management. More studies need to be conducted to fully understand the efficacy and safety of ABP in the management of PALs.

Malignant Airway Obstruction and the Use of Nd:YAG Laser: A Systematic Review on Its Efficacy and Safety

Endobronchial malignancies with significant airway obstruction can lead to multiple complications including pneumonia, and atelectasis over a period of time. Various intraluminal treatments have proven their value in palliative treatment for advanced malignancies. Nd:YAG (neodymium-doped yttrium aluminum garnet; Nd:Y3Al5O12) laser has established its role as a major palliative intervention due to its minimal side effects and improvement in quality of life by relieving local symptoms. The systematic review was conducted with the goal of elucidating the patient characteristics, pre-treatment parameters, clinical outcomes, and possible complications resulting from the use of the Nd:YAG laser. A thorough literature search for relevant studies was conducted on PubMed, Embase, and Cochrane Library from the inception of the idea to November 24, 2022. Our study included all original studies including retrospective studies and prospective trials, but excluded case reports, case series with less than 10 patients, and studies with incomplete or irrelevant data. A total of 11 studies were included in the analysis. The primary outcomes focused on the evaluation of pulmonary functional tests, postprocedural stenosis, blood gas parameters after the procedure, and survival outcomes. Improvement in clinical status, improvement in objective scale for dyspnea, and complications were the secondary outcomes. Our study shows that Nd:YAG laser treatment is an effective form of palliative treatment to provide subjective and objective improvement in patients with advanced and inoperable endobronchial malignancies. Due to the heterogeneous study populations in the studies reviewed and the presence of many limitations, more studies are still warranted to reach a definitive conclusion.

Miliary Tuberculosis: A Case Report Highlighting the Diagnostic Challenges Associated With the Condition

End-stage renal disease requiring chronic dialysis is an immunocompromised state which increases the risk of tuberculosis development and its spread. Due to the high frequency of non-specific or “decoy” symptoms at presentation and frequent extrapulmonary involvement, diagnosis of tuberculosis is a significant challenge. Therefore, it is correctly labeled as ‘Tuberculosis; the great imitator’ as it can mimic various other disease processes, causing confusion and testing of subsystems involved in the disease process, which come back as abnormal, leading to a vicious cycle. Missing the diagnosis leads to grave consequences, especially in a patient with a miliary form of tuberculosis, as the prognosis with any delay in treatment is poor. High diagnostic suspicion is required to promptly diagnose and treat the condition, especially in a resource-rich setting where tuberculosis is uncommon. Here, we report a patient with miliary tuberculosis who presented with a chief complaint of chronic diarrhea and fecal continence, with prior recent negative interferon-gamma release assay testing. Due to every organ system involved, multiple subspecialties were on board, with a broad differential in mind, including malabsorption syndromes, neoplasia, infections, amyloidosis, and autoimmune disorders, and therefore, numerous tests were performed. However, despite all efforts, the diagnosis was delayed significantly, leading to the unfortunate demise of the patient. The case report sheds light on unique clinical features of miliary tuberculosis, diagnostic findings, and a reminder to always keep tuberculosis high in the differential in an appropriate clinical setting.

Group A Beta-Hemolytic Streptococcus-Induced Tic-Like Movement Disorder in an Adult: A Case Report

A tic is a sudden, repeated, quick, and uncontrollable movement of a part of the body. Tic disorders have a multifactorial etiology, including genetic predisposition, autoimmunity, and environmental factors. Movement disorders following streptococcal infection are rare and typically present in the pediatric population. We present a unique case of a 31-year-old female admitted with involuntary movements of the upper extremities of three weeks duration. Her movements start as twitching before progressing to one hand hitting the other or hitting her face. She had a strong urge before giving in to complete the action. However, the movements were partially distractable, with considerable overlap between clinical features of organic and functional tics. After a detailed workup, including a negative magnetic resonance imaging (MRI) of the brain with and without contrast, MRI of the spine, computed tomography of the chest, abdomen, and pelvis for neoplasia, as well as blood work for autoimmunity, infections, and paraneoplastic syndrome, the serology came back strongly positive for antistreptolysin O and antideoxyribonuclease B titers. Additionally, a detailed psychiatric assessment ruled out conversion disorder leading to a diagnosis of streptococcus-induced movement disorder. After a failed inpatient trial of aripiprazole, the plan included initiating deutetrabenazine with close outpatient neurology follow-up after discharge.

Stenotrophomonas Maltophilia and Urinary Tract Infections: A Systematic Review

Stenotrophomonas maltophilia, a gram-negative bacillus well known to cause respiratory tract infections, is increasingly being reported to cause urinary tract infections (UTI). In our review of the literature comprising six articles, males were more prone to developing UTIs, with the mean age of the patients being 62.5 ±18.9 years. While several risk factors have been associated with the development of the disease, patients with underlying urological or nephrological diseases tend to develop a more severe illness. The organism was sensitive to trimethoprim-sulfamethoxazole (TMP-SMX) in the majority of cases. This systematic review also aims to shed light on the possible mechanisms of resistance adopted by the bacteria, modes of transmission, and strategies to prevent the transmission and development of the disease.

Carcinoma Ex Pleomorphic Adenoma of the Parotid Gland: A Rare Case

Cancer is a major cause of morbidity and mortality worldwide, with squamous cell carcinoma (SCC) being the most common type. Even though SCC is the major type of cancer found in the head and neck region, the salivary glands contribute to about 1/20 cases, of which 1/10 are said to be carcinoma ex pleomorphic adenoma (CXPA) type, and the parotid gland is found to be the most common origin of such cases. Although it usually arises later in life, it can grow rapidly, with local symptoms being late findings, if any. Even though fine needle aspiration cytology has low sensitivity for diagnosing such cancer, multiple/repeated biopsies can increase the yield and the accuracy of the test. Surgical resection is the main choice for treatment with postoperative radiation for select cases. Our case presented with CXPA with distant metastasis to multiple sites.

The Impact of COVID-19 Infection on a Neurologically Compromised Male With Fahr’s Disease Presenting With Acute Delirium and Aspiration Pneumonia: A Case Report

Fahr’s disease or idiopathic basal ganglia calcification is a rare, sporadic, genetically dominant, and inherited neurological condition that manifests with dysphagia and Parkinson’s disease. The computed tomography (CT) scan is the method of choice to diagnose basal ganglia calcifications seen in Fahr’s disease. This case report elaborates on the emergency management of a 58-year-old male patient with acute respiratory distress, acute delirium, schizophrenia, Fahr’s syndrome, and history of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019 or COVID-19) infection. The patient’s chest X-ray, laboratory workup, and vital signs were suggestive of aspiration pneumonia-induced sepsis and acute hypoxemic respiratory failure. Post-admission antibiotic management reduced sepsis complications without improving the altered mental status. A comprehensive clinical assessment suggested the attribution of Fahr’s disease to the patient’s aspiration pneumonia and other clinical complications. In addition, COVID-19 infection, sepsis-induced inflammatory processes, and pre-existing neurological compromise possibly deteriorated the patient’s neurological outcomes, overall prognosis, and recovery.

New-Onset Atrial Fibrillation in COVID-19 Infection: A Case Report and Review of Literature

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, many cases of arrhythmias have been reported in patients with COVID-19 infection. We present the case of a 66-year-old female with no known cardiovascular history who presented with worsening shortness of breath and productive cough and tested positive for COVID-19 infection in the ED. The patient had a recent hospitalization for COVID-19 infection during which she was treated with dexamethasone and remdesivir therapy and her course remained uncomplicated at that time. Following this, she developed worsening shortness of breath at home for which she presented to the ED. During this hospitalization, she was treated with dexamethasone, remdesivir, and supplemental oxygen. On day six of hospitalization, the patient became tachycardic and had palpitations. Cardiac monitor and EKG showed evidence of new-onset atrial fibrillation (NOAF). Initially patient received metoprolol and diltiazem, both of which failed to achieve adequate rate control. Following this, the patient was started on carvedilol 30 mg every six hours, which attained good rate control. Her CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74, and sex category) score was 4 for which she was started on apixaban 5mg twice daily. The patient was discharged on the same medications. Despite increasing reported incidences of NOAF in COVID-19 infection, only little is known about the optimal management strategies and possible etiopathology. The aim of our review is to highlight the possible mechanisms triggering atrial fibrillation in COVID-19 infection and go over the management strategies while reviewing the available literature.

Lactulose-Induced Ischemic Colitis: A Rare Presentation and an Overview of Possible Etiologies of the Disease

Ischemic colitis is one of the most common ischemic pathologies of the gastrointestinal system and can be divided into non-gangrenous and gangrenous forms. The pathophysiology involves restricted blood supply to the colonic mucosa. Several risk factors have been implicated in the development of ischemic colitis. Lactulose, one of the mainstay therapies for the treatment of hepatic encephalopathy in patients with cirrhosis, has been rarely reported as a cause of ischemic colitis. To the best of our knowledge, there has been only one case report associating lactulose use with the development of ischemic colitis. The exact pathophysiology is unknown but might be associated with the fermentation of lactulose by intestinal bacteria, causing gaseous distention and increasing the intraluminal pressure. We present the case of a 77-year-old African American male, a known case of non-alcoholic liver cirrhosis with portal hypertension and esophageal varices, brought in by his family to the emergency department for altered mental status, non-bilious vomiting, abdominal distension, and pain for one day. On physical examination, the patient had upper extremity asterixis and was alert but disoriented to place and person. Diagnostic paracentesis was performed, which revealed leukocytosis, predominantly neutrophils. The patient was admitted for spontaneous bacterial peritonitis and hepatic encephalopathy with decompensated liver cirrhosis. The patient was started lactulose with a goal of three to four bowel movements per day. Despite adequate treatment, the patient continued to develop worsening mental function and abdominal distension. This was later followed by a bloody bowel movement. Laboratory assessment showed an elevated white blood cell count, worsening kidney function, and high anion gap metabolic acidosis. CT scan revealed dilated loops of bowel with air and fluid along with submucosal wall edema, findings suggestive of ischemic colitis. Given the poor prognosis and the patient's condition, colonoscopy was deferred. Lactulose was discontinued, as it was thought to be a contributing cause of the patient's ischemic colitis. His condition continued to deteriorate, and he passed away on Day 18 of admission.

Large-Cell Esophageal Neuroendocrine Tumor Leading to Hepatorenal Syndrome

Neuroendocrine tumors are tumors that arise from the enterochromaffin cells in the neuroendocrine tissue found throughout the body, particularly the digestive tract, pancreas, and thymus. Neuroendocrine tumors of the esophagus are extremely rare and highly aggressive in nature. We present the case of a 55-year-old Hispanic male who initially presented to the emergency department with right-sided abdominal pain. Imaging revealed innumerable lesions occupying half of the liver parenchyma. Subsequent endoscopy with biopsy of the esophageal and liver lesions along with immunohistochemistry staining was suggestive of a large cell neuroendocrine tumor. He later presented with generalized weakness and right-sided abdominal pain with worsening hepatic and renal function. Over the course of the patient's stay in the hospital, his mental status progressively deteriorated. Given the deranged hepatic and renal function, chemotherapy could not be initiated. The patient's family decided against hemodialysis considering his poor prognosis and the patient expired on day 15 of admission. The case report highlights the aggressiveness of one of the rare esophageal malignancies. It is crucial to establish diagnosis at the earlier stages of the disease with prompt treatment in order to avoid serious complications such as hepatorenal syndrome, which resulted in rapid deterioration of our patient's clinical status. More research is necessary in order to establish guidelines to treat neuroendocrine tumors of the esophagus.

Bronchopleural Fistula and Endobronchial Valve Placement in a Patient With COVID-19 Pneumonia: A Case Report With Literature Review

Bronchopleural fistulas (BPFs) are associated with high morbidity and mortality. Though most commonly seen after surgical interventions, they are increasingly reported as complications of COVID-19 infection. We present the case of an 86-year-old man with COVID-19 pneumonia and subsequent bronchopleural fistula (BPF) with persistent air leak. Endobronchial valves were placed in apical and posterior segments of the right upper lobe resulting in successful cessation of the air leak. The purpose of the case report and literature review is to help guide the management of persistent air leak.

Sickle Cell Disease and COVID-19 Infection: Importance of COVID-19 Testing and Approach to Management

Sickle cell disease is an autosomal recessive disorder resulting in the substitution of CTG by CAG in the sixth codon of the beta-globin gene. As a result of this, the hydrophilic glutamic acid residue is replaced by hydrophobic valine residue, leading to the formation of hemoglobin tetramer HBS. This alteration in the beta-globin chain makes the red blood cells prone to sickling, especially in the presence of risk factors such as stress, hypoxia, and infection. These sickled red blood cells have the tendency to adhere to the endothelium and lead to vessel occlusion and distal tissue ischemia. The recent coronavirus disease 2019 (COVID-19) outbreak has impacted millions across the globe, putting individuals with co-morbidities at particularly high risk, and patients with sickle cell disease are no exception.

We present the case of a 47-year-old African American male presenting to the emergency department with subjective fevers and a two-day history of pain in the arms, legs, and chest. A diagnosed case of sickle cell disease, the patient was on hydromorphone for pain management but ran out of his medications a few weeks before presentation. On examination, the patient was saturating well with mild tenderness upon palpation of the arms, legs, and chest. On complete blood count, the patient had a hemoglobin of 11.3 g/dL and a white cell count of 13.1 x10(3)/mcL. The patient had a normal mean corpuscular volume with reticulocytosis, hypochromia, ovalocytosis, poikilocytosis, polychromasia, and target cells. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) was positive. The chest X-ray did not reveal any significant findings. He was admitted to the medicine floor for the management of sickle cell crisis and was placed under airborne and droplet precautions. The patient was started on hydromorphone for pain management and intravenous fluid hydration. On the second day of admission, the patient reported increasing shortness of breath. He was saturating 90% on room air and 94% on 2 liters of supplemental oxygen. The white blood cell count increased to 18.42 x10(3)/mcL and the chest X-ray revealed reticular densities with patchy alveolar opacities in the left lung. Given the decline in respiratory status, the patient was started on remdesivir. Over the course of his hospital stay, the patient's pain and respiratory status improved, with the patient saturating 97% on room air. He was discharged home with instructions to follow isolation precautions for at least two weeks, folic acid, and adequate pain management. An appointment was also scheduled for the patient to follow with a sickle cell nurse practitioner upon discharge.

Correlation of biochemical constituents of seminal plasma with semen quality in Teddy goat (Capra hircus) bucks

This study was planned to determine the relationship between semen quality parameters and the levels of biochemical constituents of seminal plasma of Teddy (Capra hircus) buck semen. For this purpose, semen ejaculates were collected from five mature healthy Teddy bucks. All the experimental bucks were kept under natural environmental conditions. Semen was collected twice in a week for the duration of 6 weeks by Artificial Vagina (AV) in the breeding season (February-April). Two successive ejaculates of single buck were pooled at time of collection, and a total of 60 semen samples were processed for semen analysis. Sperm per cent motility, sperm concentration, dead sperm percentage, morphological abnormal spermatozoa, plasma membrane integrity were correlated with biochemical constituents of seminal plasma. The mean per cent motility (89.18% ± 0.37%), sperm concentration (1.86 ± 0.04 × 10⁹ /ml), dead sperm percentage (8.08% ± 0.29%), morphological abnormal spermatozoa (6.05% ± 0.29%) and plasma membrane integrity (88.22% ± 0.34%) were recorded. The seminal plasma contained Na⁺ (144.12 ± 1.59 mEq/L), K⁺ (27.38 ± 0.49 mEq/L), Cl^- (65.73 ± 0.45 mEq/L), Ca⁺⁺ (9.34 ± 0.22 mg/dl), P (19.32 ± 0.97 mg/dl), aspartate aminotransferase (AST; 26.48 ± 1.30 IU/L), alanine aminotransferase (ALT; 168.47 ± 5.18 IU/L), lactate dehydrogenase (LDH; 215.98 ± 6.06 IU/L), albumin (1.90 ± 0.10 g/dl), globulins (2.08 ± 0.11 g/dl) and total protein (3.98 ± 0.20 g/dl). The collected data were analysed by applying Pearson's correlation coefficients. Dead sperm percentage had negative correlation with sodium (r = -.278, p < .05), albumin (r = -.294, p < .05), globulin (r = -.266, p < .05) and total protein (r = -.295, p < .05). Phosphorus was negatively associated with sperm concentration (r = -.262, p < .05). AST was negatively correlated with plasma membrane integrity (r = -.292, p < .05). It was concluded that most of the semen quality parameters of Teddy bucks were positively correlated with biochemical constituents, but opposite trends were found in case of dead sperm percentage. The seminal biochemical constituents dynamically interact with each other.