Clinical and echocardiographic predictors of mortality in acute pulmonary embolism

Purpose: The aim of this study was to evaluate the utility of adding quantitative assessments of cardiac function from echocardiography to clinical factors in predicting the outcome of patients with acute pulmonary embolism (PE). Methods: Patients with a diagnosis of acute PE, based on a positive ventilation perfusion scan or computed tomography (CT) chest angiogram, were identified using the Duke University Hospital Database. Of these, 69 had echocardiograms within 24–48 h of the diagnosis that were suitable for offline analysis. Clinical features that were analyzed included age, gender, body mass index, vital signs and comorbidities. Echocardiographic parameters that were analyzed included left ventricular (LV) ejection fraction (EF), regional, free wall and global RV speckle-tracking strain, RV fraction area change (RVFAC), Tricuspid Annular Plane Systolic Excursion (TAPSE), pulmonary artery acceleration time (PAAT) and RV myocardial performance (Tei) index. Univariable and multivariable regression statistical analysis models were used. Results: Out of 69 patients with acute PE, the median age was 55 and 48 % were female. The median body mass 2 index (BMI) was 27 kg/m . Twenty-nine percent of the cohort had a history of cancer, with a significant increase in cancer prevalence in non-survivors (57 % vs 29 %, p = 0.02). Clinical parameters including heart rate, respiratory rate, troponin T level, active malignancy, hypertension and COPD were higher among non-survivors when compared to survivors (p ≤ 0.05). Using univariable analysis, NYHA class III symptoms, hypoxemia on presentation, tachycardia, tachypnea, elevation in Troponin T, absence of hypertension, active malignancy and chronic obstructive pulmonary disease (COPD) were increased in non-survivors compared to survivors (p ≤ 0.05). In multivariable models, RV Tei Index, global and free (lateral) wall RVLS were found to be negatively associated with survival probability after adjusting for age, gender and systolic blood pressure (p ≤ 0.05). Conclusion: The addition of echocardiographic assessment of RV function to clinical parameters improved the prediction of outcomes for patients with acute PE. Larger studies are needed to validate these findings

Multimodality bronchoscopic approach in management of stump dehiscence after pneumonectomy.

The occurrence of bronchopleural fistula (BPF) after pneumonectomy is associated with infection and high mortality. Thus, the closure of BPF and chest tube drainage is recommended. Case presentation: A 56 year old male with history of steroid-dependent rheumatoid arthritis and non-small cell lung cancer of the left lung. Patient underwent pneumonectomy. Two months after the surgery, patient developed gradual onset hypoxemic respiratory distress. CT scan of the chest showed bronchopleural fistula (BPF) of left bronchial stump and large air-fluid content in the left hemithorax. Large bore chest tube was placed and broad spectrum antibiotics were started. Patient was found to have persistent air leak from the chest tube. Bronchoscopic evaluation showed a long left main stem stump (54 mm from main carina) with a presence of 4 mm BPF at lateral wall of the stump. Rigid bronchoscopy was performed with the plan for BPF closure. There are three steps in this procedure. Firstly, an allograft bone chip was grinned in a cone shape (4mm) and it was plugged inside the BPF. Secondly, 5 mL of fibrin sealant was instilled into the distal end of the stump. Lastly, a 16 mm Dumon stent with 50 mm length was clipped each side and one end was closed with a nylon suture. An alloderm graft was cut and wrapped around the stent so it covered the end of the stent. After the wrapping, a suture was used to sew the alloderm to the stent. The modified stent was deployed by using the Storz Y-system. Upon completion of the procedure, the air leak had resolved. Then, patient underwent Video assisted thoracoscopic surgery with debridement of chest cavity and insertion of indwelling pleural catheter for management of infection. Patient was discharged home with six-week course of intravenous antibiotics. Discussion: The use of fibrin sealant for a closure of BPF of the central airways is usually not effective as the sealant spills into the pleural space. Fibrin sealant and Alloderm patch have been used for a closure of BPF. However, the alloderm patch is difficult to deploy and to stabilize in the desired location. We used a bone chip to clog the fistula which delayed the spillage of fibrin sealant into pleural cavity. We also report the use of Dumon stent as the splint to hold the alloderm patch in place. This method will allow the granulation tissue to heal and completely close the fistula. (Figure presented)

Metastatic small round blue cell tumor. A genetic puzzle.

Small round blue cell tumor represents a group of the aggressive solid tumors which are mostly found in pediatric and young adolescent population. Case presentation: A 26 year old male with history of enlarging right groin mass for several months with no recent work up who presented with progressively worsening shortness of breath over the past two weeks. CT chest revealed mediastinal lymphadenopathy with diffuse pulmonary nodules and septal thickening throughout both lungs. Patient developed spontaneous pneumothorax of left lung which was managed by 28 Fr chest tube placement. Bronchoscopy was performed which revealed diffuse whitish nodules throughout endobronchial mucosa (Figure1). Endobronchial biopsy showed small round blue cell tumor (SRBCT). The biopsy of right groin mass also confirmed the diagnosis of SRBCT. Immunohistochemical staining was positive for CAM 5.2 and Desmin, but negative for CD56 and leukocyte common antigen. RT-PCR for EWS-Fli1 and EWS-ERG were negative. Break apart FISH for EWSR1 was positive. Follow-up PCR was positive for Ewing sarcoma gene (EWS) and Wilms\u27 tumor gene (WT1) rearrangement, indicating presence of t(11;22)(p13;q12). These findings are consistent with desmoplastic small round cell tumor (DSRCT). Patient received the first round chemotherapy regimen with vincristine, cyclophosphamide, and doxorubicin. Discussion: Malignant small round blue cell tumors (SRBCT) is a group of morphologically similar rare tumors that include: Ewing sarcoma family of tumors (EFT), peripheral primitive neuroectodermal tumor (PNET), small cell osteosarcoma, mesenchymal chondrosarcoma and DRSCT among others. Therefore, accurate sub-typing is essential because therapeutic options and prognoses very widely depending on the diagnosis. These cancers are difficult to distinguish by light microscopy, and currently no single test can precisely distinguish these cancers. To confirm the diagnosis, pathologists rely on several techniques, including immunohistochemistry, cytogenetics, interphase fluorescence in situ hybridization, and reverse transcription-polymerase chain reaction (RT-PCR). The presence of the specific cytogenetic abnormality t(11;22)(p13;q12) involving EWS- WT1 fusion confirms the diagnosis. The prognosis of DSRCT remains very poor with 5-year survival rate of 15%. The treatment with intense alkylator therapy (P6 protocol), and gross total resection and external beam radiotherapy seemed to improve overall survival. (Figure Presented)

Machine learning models to predict failure in administration of intrapleural tPA/DNase in patients with complicated parapneumonic effusions/empyema: A multicenter study

Chest 2021 Annual Meetin

Machine learning models to predict failure in administration of intrapleural tPA/DNase in patients with complicated parapneumonic effusions/empyema: A multicenter study

The American Association for Bronchology and Interventional Pulmonology Annual Conferenc