An Internist\u27s Approach to a Case of Negative Pressure Pulmonary Edema: A Rare Cause of Noncardiogenic Pulmonary Edema

Negative-pressure pulmonary edema (NPPE) is a rare cause of noncardiogenic pulmonary edema, which usually presents postoperatively. Its pathophysiology is mostly described as a profound negative intrathoracic pressure caused by an airway obstruction such as laryngospasm, which may occur during extubation. But, there are other hypotheses about it, such as catecholamines release causing an elevated hydrostatic pressure in the cardiopulmonary circuit and, consequently, a major capillary leak to the interstitium. Its natural course varies, from prompt recovery to intensive care unit escalation and prolonged mechanical ventilation. Although anesthesiologists often detect this condition, this case\u27s objective is to bring awareness of this condition to internists as a potential differential diagnosis for hypoxia in the postoperative setting

Taking the pulse of Earth's tropical forests using networks of highly distributed plots

Tropical forests are the most diverse and productive ecosystems on Earth. While better understanding of these forests is critical for our collective future, until quite recently efforts to measure and monitor them have been largely disconnected. Networking is essential to discover the answers to questions that transcend borders and the horizons of funding agencies. Here we show how a global community is responding to the challenges of tropical ecosystem research with diverse teams measuring forests tree-by-tree in thousands of long-term plots. We review the major scientific discoveries of this work and show how this process is changing tropical forest science. Our core approach involves linking long-term grassroots initiatives with standardized protocols and data management to generate robust scaled-up results. By connecting tropical researchers and elevating their status, our Social Research Network model recognises the key role of the data originator in scientific discovery. Conceived in 1999 with RAINFOR (South America), our permanent plot networks have been adapted to Africa (AfriTRON) and Southeast Asia (T-FORCES) and widely emulated worldwide. Now these multiple initiatives are integrated via ForestPlots.net cyber-infrastructure, linking colleagues from 54 countries across 24 plot networks. Collectively these are transforming understanding of tropical forests and their biospheric role. Together we have discovered how, where and why forest carbon and biodiversity are responding to climate change, and how they feedback on it. This long-term pan-tropical collaboration has revealed a large long-term carbon sink and its trends, as well as making clear which drivers are most important, which forest processes are affected, where they are changing, what the lags are, and the likely future responses of tropical forests as the climate continues to change. By leveraging a remarkably old technology, plot networks are sparking a very modern revolution in tropical forest science. In the future, humanity can benefit greatly by nurturing the grassroots communities now collectively capable of generating unique, long-term understanding of Earth's most precious forests. Resumen Los bosques tropicales son los ecosistemas más diversos y productivos del mundo y entender su funcionamiento es crítico para nuestro futuro colectivo. Sin embargo, hasta hace muy poco, los esfuerzos para medirlos y monitorearlos han estado muy desconectados. El trabajo en redes es esencial para descubrir las respuestas a preguntas que trascienden las fronteras y los plazos de las agencias de financiamiento. Aquí mostramos cómo una comunidad global está respondiendo a los desafíos de la investigación en ecosistemas tropicales a través de diversos equipos realizando mediciones árbol por árbol en miles de parcelas permanentes de largo plazo. Revisamos los descubrimientos más importantes de este trabajo y discutimos cómo este proceso está cambiando la ciencia relacionada a los bosques tropicales. El enfoque central de nuestro esfuerzo implica la conexión de iniciativas locales de largo plazo con protocolos estandarizados y manejo de datos para producir resultados que se puedan trasladar a múltiples escalas. Conectando investigadores tropicales, elevando su posición y estatus, nuestro modelo de Red Social de Investigación reconoce el rol fundamental que tienen, para el descubrimiento científico, quienes generan o producen los datos. Concebida en 1999 con RAINFOR (Suramérica), nuestras redes de parcelas permanentes han sido adaptadas en África (AfriTRON) y el sureste asiático (T-FORCES) y ampliamente replicadas en el mundo. Actualmente todas estas iniciativas están integradas a través de la ciber-infraestructura de ForestPlots.net, conectando colegas de 54 países en 24 redes diferentes de parcelas. Colectivamente, estas redes están transformando nuestro conocimiento sobre los bosques tropicales y el rol de éstos en la biósfera. Juntos hemos descubierto cómo, dónde y porqué el carbono y la biodiversidad de los bosques tropicales está respondiendo al cambio climático y cómo se retroalimentan. Esta colaboración pan-tropical de largo plazo ha expuesto un gran sumidero de carbono y sus tendencias, mostrando claramente cuáles son los factores más importantes, qué procesos se ven afectados, dónde ocurren los cambios, los tiempos de reacción y las probables respuestas futuras mientras el clima continúa cambiando. Apalancando lo que realmente es una tecnología antigua, las redes de parcelas están generando una verdadera y moderna revolución en la ciencia tropical. En el futuro, la humanidad puede beneficiarse enormemente si se nutren y cultivan comunidades de investigadores de base, actualmente con la capacidad de generar información única y de largo plazo para entender los que probablemente son los bosques más preciados de la tierra. Resumo Florestas tropicais são os ecossistemas mais diversos e produtivos da Terra. Embora uma boa compreensão destas florestas seja crucial para o nosso futuro coletivo, até muito recentemente os esforços de medições e monitoramento foram amplamente desconexos. É essencial formarmos redes para obtermos respostas que transcendem fronteiras e horizontes de agências financiadoras. Neste estudo nós mostramos como uma comunidade global está respondendo aos desafios da pesquisa de ecossistemas tropicais, com equipes diversas medindo florestas, árvore por árvore, em milhares de parcelas monitoradas à longo prazo. Nós revisamos as maiores descobertas científicas deste trabalho, e mostramos também como este processo está mudando a ciência de florestas tropicais. Nossa abordagem principal envolve unir iniciativas de base a protocolos padronizados e gerenciamento de dados a fim de gerar resultados robustos em escalas ampliadas. Ao conectar pesquisadores tropicais e elevar seus status, nosso modelo de Rede de Pesquisa Social reconhece o papel-chave do produtor dos dados na descoberta científica. Concebida em 1999 com o RAINFOR (América do Sul), nossa rede de parcelas permanentes foi adaptada para África (AfriTRON) e Sudeste asiático (T-FORCES), e tem sido extensamente reproduzida em todo o mundo. Agora estas múltiplas iniciativas estão integradas através de uma infraestrutura cibernética do ForestPlots.net, conectando colegas de 54 países de 24 redes de parcelas. Estas iniciativas estão transformando coletivamente o entendimento das florestas tropicais e seus papéis na biosfera. Juntos nós descobrimos como, onde e por que o carbono e a biodiversidade da floresta estão respondendo às mudanças climáticas, e seus efeitos de retroalimentação. Esta duradoura colaboração pantropical revelou um grande sumidouro de carbono persistente e suas tendências, assim como tem evidenciado quais direcionadores são mais importantes, quais processos florestais são mais afetados, onde eles estão mudando, seus atrasos no tempo de resposta, e as prováveis respostas das florestas tropicais conforme o clima continua a mudar. Dessa forma, aproveitando uma notável tecnologia antiga, redes de parcelas acendem faíscas de uma moderna revolução na ciência das florestas tropicais. No futuro a humanidade pode se beneficiar incentivando estas comunidades basais que agora são coletivamente capazes de gerar conhecimentos únicos e duradouros sobre as florestas mais preciosas da Terra. Résume Les forêts tropicales sont les écosystèmes les plus diversifiés et les plus productifs de la planète. Si une meilleure compréhension de ces forêts est essentielle pour notre avenir collectif, jusqu'à tout récemment, les efforts déployés pour les mesurer et les surveiller ont été largement déconnectés. La mise en réseau est essentielle pour découvrir les réponses à des questions qui dépassent les frontières et les horizons des organismes de financement. Nous montrons ici comment une communauté mondiale relève les défis de la recherche sur les écosystèmes tropicaux avec diverses équipes qui mesurent les forêts arbre après arbre dans de milliers de parcelles permanentes. Nous passons en revue les principales découvertes scientifiques de ces travaux et montrons comment ce processus modifie la science des forêts tropicales. Notre approche principale consiste à relier les initiatives de base à long terme à des protocoles standardisés et une gestion de données afin de générer des résultats solides à grande échelle. En reliant les chercheurs tropicaux et en élevant leur statut, notre modèle de réseau de recherche sociale reconnaît le rôle clé de l'auteur des données dans la découverte scientifique. Conçus en 1999 avec RAINFOR (Amérique du Sud), nos réseaux de parcelles permanentes ont été adaptés à l'Afrique (AfriTRON) et à l'Asie du Sud-Est (T-FORCES) et largement imités dans le monde entier. Ces multiples initiatives sont désormais intégrées via l'infrastructure ForestPlots.net, qui relie des collègues de 54 pays à travers 24 réseaux de parcelles. Ensemble, elles transforment la compréhension des forêts tropicales et de leur rôle biosphérique. Ensemble, nous avons découvert comment, où et pourquoi le carbone forestier et la biodiversité réagissent au changement climatique, et comment ils y réagissent. Cette collaboration pan-tropicale à long terme a révélé un important puits de carbone à long terme et ses tendances, tout en mettant en évidence les facteurs les plus importants, les processus forestiers qui sont affectés, les endroits où ils changent, les décalages et les réactions futures probables des forêts tropicales à mesure que le climat continue de changer. En tirant parti d'une technologie remarquablement ancienne, les réseaux de parcelles déclenchent une révolution très moderne dans la science des forêts tropicales. À l'avenir, l'humanité pourra grandement bénéficier du soutien des communautés de base qui sont maintenant collectivement capables de générer une compréhension unique et à long terme des forêts les plus précieuses de la Terre. Abstrak Hutan tropika adalah di antara ekosistem yang paling produktif dan mempunyai kepelbagaian biodiversiti yang tinggi di seluruh dunia. Walaupun pemahaman mengenai hutan tropika amat penting untuk masa depan kita, usaha-usaha untuk mengkaji dan mengawas hutah-hutan tersebut baru sekarang menjadi lebih diperhubungkan. Perangkaian adalah sangat penting untuk mencari jawapan kepada soalan-soalan yang menjangkaui sempadan dan batasan agensi pendanaan. Di sini kami menunjukkan bagaimana sebuah komuniti global bertindak balas terhadap cabaran penyelidikan ekosistem tropika melalui penglibatan pelbagai kumpulan yang mengukur hutan secara pokok demi pokok dalam beribu-ribu plot jangka panjang. Kami meninjau semula penemuan saintifik utama daripada kerja ini dan menunjukkan bagaimana proses ini sedang mengubah bidang sains hutan tropika. Teras pendekatan kami memberi tumpuan terhadap penghubungan inisiatif akar umbi jangka panjang dengan protokol standar serta pengurusan data untuk mendapatkan hasil skala besar yang kukuh. Dengan menghubungkan penyelidik-penyelidik tropika dan meningkatkan status mereka, model Rangkaian Penyelidikan Sosial kami mengiktiraf kepentingan peranan pengasas data dalam penemuan saintifik. Bermula dengan pengasasan RAINFOR (Amerika Selatan) pada tahun 1999, rangkaian-rangkaian plot kekal kami kemudian disesuaikan untuk Afrika (AfriTRON) dan Asia Tenggara (T-FORCES) dan selanjutnya telah banyak dicontohi di seluruh dunia. Kini, inisiatif-inisiatif tersebut disepadukan melalui infrastruktur siber ForestPlots.net yang menghubungkan rakan sekerja dari 54 negara di 24 buah rangkaian plot. Secara kolektif, rangkaian ini sedang mengubah pemahaman tentang hutan tropika dan peranannya dalam biosfera. Kami telah bekerjasama untuk menemukan bagaimana, di mana dan mengapa karbon serta biodiversiti hutan bertindak balas terhadap perubahan iklim dan juga bagaimana mereka saling bermaklum balas. Kolaborasi pan-tropika jangka panjang ini telah mendedahkan sebuah sinki karbon jangka panjang serta arah alirannya dan juga menjelaskan pemandu-pemandu perubahan yang terpenting, di mana dan bagaimana proses hutan terjejas, masa susul yang ada dan kemungkinan tindakbalas hutan tropika pada perubahan iklim secara berterusan di masa depan. Dengan memanfaatkan pendekatan lama, rangkaian plot sedang menyalakan revolusi yang amat moden dalam sains hutan tropika. Pada masa akan datang, manusia sejagat akan banyak mendapat manfaat jika memupuk komuniti-komuniti akar umbi yang kini berkemampuan secara kolektif menghasilkan pemahaman unik dan jangka panjang mengenai hutan-hutan yang paling berharga di dunia

Cardiac arrest from massive PE in nephrotic syndrome successfully treated with embolectomy and ECMO

Pulmonary emboli (PE) are commonly encountered events with presentations ranging from benign incidental findings to obstructive shock. We present a case of a 20 year old male with nephrotic syndrome who suffered complete cardiovascular collapse with cardiac arrest in the setting of a massive PE, requiring open surgical embolectomy and ECMO support. We reviewed the literature on massive PE's focusing on the use of ECMO and success of the rarely performed open embolectomy for the treatment of obstructive shock from a massive PE. Keywords: ECMO, Embolectomy, PE, Shock, Nephrotic syndrom

Amiodarone-induced pulmonary toxicity presenting as pulmonary alveolar proteinosis.

Amiodarone-induced pulmonary toxicity (APT) has been described as presenting wih organizing pneumonia, diffuse alveolar damage, nodules, usual interstitial pneumonia, desquamative interstitial pneumonia and diffuse alveolar hemorrhage. We present a case of APT presenting with secondary pulmonary alveolar proteinosis (PAP). Case: A 74-year-old female, never-smoker with past medical history significant for congestive heart failure, hypertrophic obstructive cardiomyopathy and atrial fibrillation, at which time she was treated with cardioversion and amiodarone. She was readmitted 6 weeks later with dyspnea and hypoxia despite outpatient diuresis. Rheumatologic review of systems was unremarkable. She denied culprit occupational or environmental exposures or history of recurrent infections. Physical exam showed diffuse crackles and lower extremity edema. Laboratory values were notable for white blood cel count of 11.7 K/uL (neutrophil predominant), sedimentation rate 116 mm/hr, BNP 577, negative antinuclear, cyclic-citrullinated peptide and anti-neutrophilic cytoplasmic antibodies and rheumatoid factor. Chest x-ray showed interstitial opacities mildly progressed compared to chest imaging 1 and 6 months prior. Chest Computed Tomography revealed bilateral patchy ground glass opacities and consolidation, irregular septal thickening, air bronchograms, and air-trapping. Right heart catheterization revealed pulmonary artery pressure 45/16 (mean 26) mmHg, pulmonary capillary wedge pressure14 mmHg and cardiac output of 3.08 L/min. Subsequent bronchoalveolar lavage (BAL) was turbid-appearing with 329 white blood cells cu/mm (47% neutrophils, 47% macrophages, 4% eosinophils.) BAL bacterial, fungal, mycobacterial stains and cultures, pneumocystis antigen and viral cultures were negative. Transbronchial biopsies were aborted due to significant hypoxemia and hypervascular-appearing bronchial mucosa. BAL cytology was remarkable for foamy macrophages positive for Periodic-acid Schiff (PAS) staining. Electron microscopy showed uniform-appearing lamellar bodies within the macrophages. The patient declined surgical lung biopsy. She was treated with discontinuation of amiodarone and systemic corticosteroids prior to pursuing further workup for secondary PAP or whole lung lavage. She was seen in follow up two weeks later with improving dyspnea, exercise tolerance, and oxygenation. Subsequent chest imaging revealed clearing of pulmonary infiltrates. Discussion: BAL findings of foamy macrophages and lamellar bodies on electron microscopy are used to support a diagnosis of APT. These features are also seen in secondary PAP, providing a challenge to reaching a definite diagnosis. We share a case of APT with clinical features of PAP to highlight this under-recognized manifestation of APT

Risks and Outcomes Associated with Pleural Space Infections After Lung Transplantation

Purpose: Pleural space infections (PSI) are a serious complication after lung transplantation (LT) however there is limited data on the associated risk factors and outcomes of PSI. We examined: 1) risk factors associated with PSI after LT; 2) effect of PSI on LT outcomes. Methods: This is a retrospective single center cohort study of 74 consecutive LT recipients (1/2018- 6/2020). Patients were divided into infected and non-infected groups, where PSI were defined as post-LT pleural effusions with pathogen(s) isolated from pleural fluid. Data were collected and compared between two groups with two-sample t-test or Fisher-exact. Multivariable logit model was performed with estimations of odds ratio (OR) and its confidence interval [CI]. Results: Among 74 LT recipients, 38 (51%) developed pleural effusions requiring drainage; of them 16 (42%) had PSI. Baseline demographics were similar in patients with and without PSI (Table). Notably, 88% of PSI group received steroids pre-LT compared to 55% in the non-infected group (p\u3c0.05); 88% of the PSI group had an underlying diagnosis of interstitial lung disease versus 45% of the non-infected group (p\u3c0.01). Overall post-operative complications occurred more frequently in the PSI group vs. non-infected group 77% vs. 25% (p\u3c0.01) and airway complications in 86% vs. 44% (p\u3c0.01). Hospital length of stay was longer in the PSI group with the median of 78 versus 31 days in the non-infected group (p\u3c0.01). Results of logistical modeling showed high risk of PSI with presence of post-LT airway complications (OR =10.8 95% CI 1.7- 72.5) and presence of post operative complications (OR=10.6, 95% CI 1.8-63.5). There was no difference in the incidence of readmissions, acute cellular rejection or 1 year mortality between the two cohorts. Conclusion: PSI remain a prevalent yet under-studied complication. Airway or post-operative complications after LT were associated with PSI. One-year outcomes were similar in LT recipients with and without PSI

Early Outcomes of Lung Transplantation for COVID-19 Related Lung Disease. Single Center Experience

Purpose: Lung transplantation (LT) is a lifesaving treatment for Covid-19 related lung disease with early outcomes similar to other indications. Methods: Seven patients underwent LT for Covid-19 related lung disease at our center: 5 for ARDS and 2 for IPF exacerbation post SARS-CoV-2 infection. Results: Seven patients (5 men) with single organ failure underwent bilateral LT. Median age was 47 years old. All ARDS cases had poor lung mechanics on invasive mechanical ventilation with radiographic evidence of lung fibrosis: pneumatocele, GGO, consolidations, subpleural reticulations and traction bronchiectasis. vvECMO was bridge to transplant in 5 cases (bridge to recovery in 2). Median ECMO duration for ARDS was 32 days (range 7-99). Median time to LT from Covid diagnosis was 59 days (Q1-IQ3, 54-62). Two patients were post-partum women with ARDS. Explanted pathology showed UIP, DAD, diffuse hemorrhage and one case of fibrosing NSIP. Pulmonary hypertension was seen in 4 cases. One patient did not survive. Organizing pneumonia and granuloma were present in this patient. Most ARDS patients were unable to tolerate lower sedation and consent by a substitute decision-makers was obtained. Post operative ECMO decannulation was possible in all cases. Induction, maintenance immunosuppression and antimicrobials were standard for our program. Donated grafts were from deceased brain death donors and negative for 2019-nCoV. Rehabilitation potential and strong social support were absolute inclusion criteria. All survivors have excellent lung function. Conclusion: In the USA, over 130 LT have listed Covid-19 as the diagnosis indication. Although Covid-19 ARDS makes up for the majority of these LT, other diagnosis are post Covid pulmonary fibrosis and underlying fibrosis with SARS-CoV-2 induced exacerbation. LT for ARDS poses several challenges and is reserved for the minority of carefully selected patients dependent on extracorporeal life support. As others have reported, good short-term survival is described

Outcomes of SARS-CoV-2 Infection in Lung Transplant Recipients: A Single Center Experience

Purpose: Outcomes of Covid-19 in lung transplant recipients (LTr) were reported in the beginning of the pandemic. Only few centers reported on their experience since December 2020 when vaccines received emergency use authorization. We aim to investigate the outcome of SARS-CoV-2 infection in a cohort of LTr at our center in Detroit, Michigan. Methods: Retrospective chart review study of adult LTr with confirmed SARS-CoV-2 infection from March 2020 to August 2021. Results: Thirty LTr were diagnosed with SARS-CoV-2 infection confirmed by RT PCR of nasopharynx. Median age at diagnosis was 63; 53% were males; 57% Caucasians and 40% of African descendance. Most patients underwent bilateral LT for interstitial lung disease (46%) and for pulmonary sarcoidosis (23%). The median time post LT was 3.1 years. Most patients needed hospitalization for respiratory failure secondary to Covid-19 (73%). Eleven patients were initially managed as outpatient. Five patients received outpatient combination of monoclonal antibodies with three of them later requiring hospitalization for development of hypoxia. None of the patients with initial out of the hospital management died. Amongst 21 hospitalized LTr, six patients were diagnosed with severe pneumonia and ARDS requiring heated high flow and invasive mechanical ventilation (IMV) in 4 patients. 28-day mortality was 10% and ICU mortality was 25% (50% mortality in those on IMV). Twelve hospitalized patients (57%) were treated with remdesivir. Augmented systemic corticosteroids was used in 85% of cases. Cycle cell inhibitor was held in 71% of the cases. Bilateral ground glass opacities of the allografts were common. None of the patients that received at least one dose of mRNA vaccine died. Conclusion: Outcomes in LTr infected with SARS-CoV-2 varies. Early reports showed high mortality rate in severe and critical Covid-19 in LTr. Although hospitalization rate in this cohort was high, only four patients in our cohort required IMV during acute Covid-19. Two of them died; both were unvaccinated. Another unvaccinated patient died due to allograft rejection two months after testing positive to SARS-CoV-2. Most cases were mild to moderate despite frequent radiographic findings of pneumonia. Underreporting and exclusion of mild cases as well as likely protective effect of vaccination and use of monoclonal antibodies may explain our different outcomes

Clinical characteristics and outcomes of COVID-19 in solid organ transplant recipients: A case-control study

Solid organ transplant recipients (SOTr) with coronavirus disease 2019 (COVID-19) are expected to have poorer outcomes compared to nontransplant patients because of immunosuppression and comorbidities. The clinical characteristics of 47 SOTr (38 kidneys and 9 nonkidney organs) were compared to 100 consecutive hospitalized nontransplant controls. Twelve of 47 SOTr managed as outpatients were subsequently excluded from the outcome analyses to avoid potential selection bias. Chronic kidney disease (89% vs 57% P = .0007), diabetes (66% vs 33% P = .0007), and hypertension (94% vs 72% P = .006) were more common in the 35 hospitalized SOTr compared to controls. Diarrhea (54% vs 17%, P \u3c .0001) was more frequent in SOTr. Primary composite outcome (escalation to intensive care unit, mechanical ventilation, or in-hospital all-cause mortality) was comparable between SOTr and controls (40% vs 48%, odds ratio [OR] 0.72 confidence interval [CI] [0.33-1.58] P = .42), despite more comorbidities in SOTr. Acute kidney injury requiring renal replacement therapy occurred in 20% of SOTr compared to 4% of controls (OR 6 CI [1.64-22] P = .007). Multivariate analysis demonstrated that increasing age and clinical severity were associated with mortality. Transplant status itself was not associated with mortality