Community-Acquired Pneumonia in the Immunocompromised Host: Epidemiology and Outcomes

Background

The epidemiology and outcomes of community-acquired pneumonia (CAP) in immunocompromised hosts (ICHs) are not well defined. The objective of this study was to define the epidemiology and outcomes of CAP in ICHs as compared with non-ICHs.

Methods

This ancillary study included a prospective cohort of hospitalized adult Louisville residents with CAP from 1 June 2014 to 31 May 2016. An ICH was defined per the criteria of the Centers for Disease Control and Prevention. Geospatial epidemiology explored associations between ICHs hospitalized with CAP and income level, race, and age. Mortality for ICHs and non-ICHs was evaluated during hospitalization and 30 days, 6 months, and 1 year after hospitalization.

Results

A total of 761 (10%) ICHs were identified among 7449 patients hospitalized with CAP. The most common immunocompromising medical conditions or treatments were advanced-stage cancer (53%), cancer chemotherapy (23%), and corticosteroid use (20%). Clusters of ICHs hospitalized with CAP were found in areas associated with low-income and Black or African American populations. Mortality by time point for ICHs vs non-ICHs was as follows: hospitalization, 9% vs 5%; 30 days, 24% vs 11%; 6 months, 44% vs 21%; and 1 year, 53% vs 27%, respectively.

Conclusions

Approximately 1 in 10 hospitalized patients with CAP is immunocompromised, with advanced-stage cancer being the most frequent immunocompromising condition, as seen in half of all patients who are immunocompromised. Risk for hospitalization may be influenced by socioeconomic disparities and/or race. ICHs have a 2-fold increase in mortality as compared with non-ICHs.

Hereditary Thrombophilia Testing Among Hospitalized Patients: Is It Warranted?

Background

Hereditary thrombophilias (HTs) are a group of inherited disorders that predispose the carrier to venous thromboembolism (VTE). It is estimated that 7% of the population has some form of HT. Although testing for HT has become routine for many hospitalized patients, knowing when to order the tests and how to interpret the results remains challenging. In the United States, there are no clear guidelines regarding testing for HT. We conducted a study to evaluate the utilization of HT testing among hospitalized patients to examine its impact on immediate management decisions and overall cost burden. In addition, we discuss the common reasons for healthcare providers to order these tests and review the data behind these reasons in the literature.

Methodology

A retrospective analysis of 2,402 patients who underwent HT testing between February 1, 2016, and January 31, 2018, was conducted. Eligible patients had at least one HT test ordered during hospitalization. The primary outcome was to determine the incidence of positive actionable tests. A positive actionable test was defined as a positive result that changed the anticoagulation intensity, type, or duration. Patients with a history of previous VTE, ongoing medical conditions requiring life-long anticoagulation, or unprovoked VTE were considered non-actionable.

Results

Among the 2,402 patients, 954 patients met the inclusion criteria with a mean age of 54 years. A total of 397 (41.6%) tests were ordered for acute VTE, while the rest were for non-VTE conditions, such as stroke, pregnancy complications, peripheral artery diseases, and others. Only 89 positive tests were actionable (14% of the positive tests, and 9.3% of the total ordered tests). There was a statistically significant association between increasing age and having both a positive test result (p = 0.006) and an actionable test (p = 0.046). The total cost of ordering these tests was estimated to be $566,585.

Conclusions

HT testing in the inpatient setting did not alter management in many cases and was associated with increased healthcare costs. The decision to order these tests should be individualized based on the clinical scenario.

Cone-Beam Computed Tomography-Guided Electromagnetic Navigation for Peripheral Lung Nodules

BACKGROUND

Electromagnetic navigation bronchoscopy (ENB) is a minimally invasive technology for the diagnosis of peripheral pulmonary nodules. However, ENB is limited by the lack of real-time confirmation of various biopsy devices. Cone-beam computed tomography (CBCT) could increase diagnostic yield by allowing real-time confirmation to overcome the inherent divergence of nodule location.

OBJECTIVES

The aim of this study was to assess the diagnostic yield of ENB plus CBCT as compared with ENB alone for biopsy of peripheral lung nodules.

METHOD

We conducted a retrospective study of patients undergoing ENB before and after the implementation of CBCT. Data from 62 consecutive patients with lung nodules located in the outer two-thirds of the lung who underwent ENB and combined ENB-CBCT were collected. Radial endobronchial ultrasound was used during all procedures as well. Diagnostic yield was defined as the presence of malignancy or benign histological findings that lead to a specific diagnosis.

RESULTS

Thirty-one patients had ENB-CBCT, and 31 patients had only ENB for peripheral lung lesions. The median size of the lesion for the ENB-CBCT group was 16 (interquartile range (IQR) 12.6-25.5) mm as compared to 21.5 (IQR 16-27) mm in the ENB group (p = 0.2). In the univariate analysis, the diagnostic yield of ENB-CBCT was 74.2% and ENB 51.6% (p = 0.05). Following multivariate regression analysis adjusting for the size of the lesion, distance from the pleura, and presence of bronchus sign, the odds ratio for the diagnostic yield was 3.4 (95% CI 1.03-11.26, p = 0.04) in the ENB-CBCT group as compared with ENB alone. The median time for the procedure was shorter in patients in the ENB-CBCT group (74 min) than in those in the ENB group (90 min) (p = 0.02). The rate of adverse events was similar in both groups (6.5%, p = 0.7).

CONCLUSIONS

The use of CBCT might increase the diagnostic yield in ENB-guided peripheral lung nodule biopsies. Future randomized clinical trials are needed to confirm such findings.

BMI is Associated with Coronavirus Disease 2019 Intensive Care Unit Admission in African Americans

OBJECTIVE

Coronavirus disease 2019 (COVID-19) has disproportionately impacted the African American community. This study aims to identify the risk factors for severe COVID-19 disease in African American patients.

METHODS

This was a retrospective cross-sectional analysis of African American patients with COVID-19 treated between March 12 and April 9, 2020, at a single tertiary center. The primary outcome of interest was severe disease defined as those requiring intensive care unit (ICU) admission.

RESULTS

The study included 158 consecutive patients. The mean age was 57 years, and 61% were women. The mean (SD) of BMI was 33.2 (8.6) kg/m² . Overall, patients admitted to the ICU were older (62 vs. 55 years, P = 0.003) and had higher BMI (36.5 kg/m² vs. 31.9 kg/m² , P = 0.002). In unadjusted and adjusted analysis, the factors most associated with ICU admission in this sample were age (adjusted odds ratio [aOR]: 1.073; 95% CI: 1.033-1.114), BMI (aOR: 1.115; 95% CI: 1.052-1.182), and lung disease (aOR: 3.097; 95% CI: 1.137-8.437).

CONCLUSIONS

This study identified risk factors for severe disease in COVID-19, specifically in an African American population. Further inclusive research aimed at optimizing clinical care relevant to the African American population is critical to ensure an equitable response to COVID-19.

An Unusual Case of Diffuse Alveolar Hemorrhage as a Clinical Manifestation of Atypical Hemolytic Uremic Syndrome: A Case Report

Hemolytic uremic syndrome (HUS) is a constellation of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal injury. HUS is subcategorized into primary or secondary HUS. Primary HUS is synonymous with atypical HUS (aHUS) and is attributed to genetic complement deficiency. Diffuse alveolar hemorrhage (DAH) is a serious condition complicating multiple systemic conditions. aHUS presenting as DAH is exceedingly rare. In this case, we present a 75-year-old male patient who presented with generalized weakness, malaise, and hemoptysis. He was found to have hemolytic anemia and thrombocytopenia, with elevated creatinine. Bronchoscopy confirmed DAH. He was started on plasmapheresis with a suboptimal response. aHUS was suspected and the patient was started on eculizumab with subsequent laboratory and clinical improvement. HUS and aHUS can present as DAH. It is very important to recognize both conditions as both are life threatening with high morbidity and mortality.

Xanthogranulomatous Pyelonephritis Causing Renocolic Fistula Presenting as Symptomatic Anemia

Renocolic fistula is a rare clinical finding that is most commonly iatrogenic after surgical intervention. Herein, we present a case of renocolic fistula secondary to xanthogranulomatous pyelonephritis (XGP) with a subtle presentation as anemia. A 40-year-old female was found to have a hemoglobin of 6.5 g/dL after presenting for worsening fatigue. A urinalysis was remarkable for numerous white blood cell (WBC), positive bacteria, and nitrite. As part of her anemia workup, an esophagogastroduodenoscopy (EGD) was done which was normal while a colonoscopy showed a fistula opening with surrounding nodularity close to the splenic flexure of the colon. A computed tomography (CT) scan of the abdomen and pelvis with contrast showed chronic left kidney pyelonephritis with multiple contiguous abscesses in the inferior left kidney in addition to a staghorn calculus concerning for XGP. The patient was started on antibiotics and underwent laparotomy with repair of the renocolic fistula, partial omentectomy, and left nephrectomy. She tolerated the surgery well and was discharged with a stable hemoglobin. XGP is a rare type of chronic pyelonephritis that is usually a result of chronic obstruction by an infected stone. Spontaneous renocolic fistulas are rare nowadays with the advancement in antibiotics and renal stones treatment.

Angiotensin converting enzyme inhibitors use and development of lung cancer: A systematic review and meta-analysis

e13093

Background: Angiotensin-converting enzyme inhibitors (ACEIs) are commonly prescribed medications for hypertension and heart failure. Generally, ACEIs are well-tolerated medications with reasonable safety profile making them a favorable choice by many clinicians. However, several studies with conflicting results have signaled an association between ACEIs use and the development of lung cancer. We sought to systematically review the literature and perform the first meta-analysis to study the risk of lung cancer among ACEI users. Methods: We performed a literature review by searching multiple databases. A random effect meta-analysis approach was used to pool the data and relative risk was used to calculate the overall effect estimate. Results: A total of 423 articles were identified but only 6 observational studies were included with a total of 872,220 patients (634,672. ACEIs users). The relative risk of lung cancer development among ACEIs users was 1.02 (CI 0.89-1.16) compared to non-ACEIs users. Conclusions: Current systematic review and meta-analysis show no significant association between ACEIs use and the development of lung cancer. The result of our meta-analysis provides further assurance to the health care providers regarding ACEIs use.

Pylephlebitis Caused by Actinomyces Bacteremia

Pylephlebitis is a thrombophlebitis of the portal vein or its branches, which usually occurs as a complication of intra-abdominal infections that are drained by the portal vein, most commonly as a result of diverticulitis or appendicitis. Diagnosis of pylephlebitis is achieved by visualizing a portal vein thrombosis in a patient with bacteremia or a recent intra-abdominal infection. Many microorganisms have been reported to cause this infection. However, Actinomyces has never been reported before as a cause of pylephlebitis. Here, we describe a case of a 56-year-old female who had pylephlebitis that was caused by Actinomyces bacteremia and was treated with intravenous antibiotics.

Metastatic Lung Adenocarcinoma Presenting with Hypereosinophilia

Lung cancer is one of the most common malignancies in both male and female patients. It is classified into small cell lung cancers and non-small cell lung cancers. Lung adenocarcinoma is a subtype of non-small cell lung cancer and accounts for the highest prevalence of lung cancer. Eosinophils are white blood cells (WBCs) that originate from the granulocytic lineage. Hypereosinophilia is a rare condition characterized by an absolute eosinophil count (AEC) of more than 1500 cells/µL. This is different from eosinophilia, which is defined as an absolute eosinophil count of more than 500 cells/µL. Hypereosinophilia is associated with several conditions, including allergic disorders, helminth infections, rheumatologic disorders, and hematologic malignancies. Paraneoplastic eosinophilia is a rare finding in solid malignancies. Herein, we report the case of a 55-year-old male who presented with shortness of breath and chest pain and whose workup showed metastatic lung adenocarcinoma associated with hypereosinophilia in the absence of a primary bone marrow disorder.

Characteristics of cardiothoracic surgeons practicing at the top-ranked US institutions

BACKGROUND

We aimed to determine which factors distinguish cardiothoracic (CT) surgeons practicing at the top-ranked US institutions from their peers.

METHODS

Using online resources, we collected demographics, training information and academic metrics of 694 cardiac (n=489; 70%) and thoracic (n=205; 30%) surgeons practicing at 57 preeminent US institutions, including those with the highest US News & World Report ranking ("top CT centers").

RESULTS

Two hundred and ninety-nine (43.1%) CT surgeons were practicing at the 18 "top CT centers" and had higher academic productivity (publications, citations) than their peers. While there was no difference in the proportion of international medical graduates (IMGs) (21.4% overall) or of surgeons with a PhD degree (9.4% overall) across institutions, the "top CT centers" had a higher proportion of faculty who received their entire CT training abroad (10.4% vs. 5.8%; P=0.038) or at highly-ranked US institutions. Those who published more during their early career years (residency, fellowship and first 5 years as faculty) were more likely to attain academic (professorship) and institutional leadership (division/department chair) positions and to practice at the "top CT centers". Women represented a minority (7.3% overall; 5.1% of cardiac vs. 12.7% of thoracic surgeons, P<0.001), but with growing prevalence among younger faculty and without differences across institutions.

CONCLUSIONS

CT surgeons of the best US centers have a more international background and received their training at highly-ranked institutions. Early academic productivity is associated with life-long career achievements, with special importance of the first 5 years as faculty. Women represent a growing proportion of the CT surgical workforce.

Management of thermal injury in pregnancy--an analysis of 16 patients

Sixteen patients at various stages of pregnancy suffered burns covering between 10 and 80 per cent of the body surface area. This review highlights the management problems of these patients during the first, second and third trimesters. Only two mothers (both with 80 per cent TBSA burns) died. There were five fetal deaths, three of them intrauterine.