Be Careful What You Screen For: An Incidental Finding Of Tracheobronchial Amyloidosis

Introduction: The 2011 National Lung Screening Trial (NLST) demonstrated a reduction in morbidity and mortality with LDCT compared to CXR. In 2013 the USPSTF began recommending CT scan for lung cancer screening in appropriate patients but, the 2015 National Health Interview Survey (NHIS) demonstrated that less than 5% of eligible patients received screening. The NLST also demonstrated a high rate of false positives, incidental findings, and the need for further invasive testing. When deciding to screen, patients and providers are tasked with reconciling these risks and benefits. In this case, we explore one patient’s incidental findings, and the work-up that ensued. Our Case: Our patient is a 70-year old female with PMHX of COPD (GOLD 1) who suffers from dyspnea with exertion, and cough. The patient did not tolerate LAMA therapy but her symptoms improved with the addition of an ICS/LABA inhaler. She has had 1-2 COPD exacerbations per year. She has a 54-pack year smoking history and quit smoking 2 years ago. In accordance with USPSTF guidelines and with shared decision making, the patient was referred for lung cancer screening with LDCT. LDCT revealed thickening of the patient’s right and mainstem bronchi, and trachea. In light of this, the patient was referred to pulmonology for bronchoscopy. Bronchoscopy demonstrated irregular thickening and heaped pink mucosa. Biopsies were examined by a pathologist who determined the tissue to be amyloid. Upon follow up in primary care clinic, the tissue samples were located and again sent for amyloid sub-typing which identified AL amyloid. With this finding, the patient required subsequent testing with free light chains, SPEP, and UPEP to rule out a plasma cell dyscrasia. Finally, a fat pad biopsy was ordered to evaluate for systemic amyloidosis. With all of these tests negative, the patient could be diagnosed with localized pulmonary AL amyloidosis & specifically tracheobronchial amyloidosis. This condition is managed symptomatically and does not require systemic chemotherapy. Discussion: In this case, we explored the diagnosis of a patient with central airway obstruction due to amyloidosis found incidentally during lung cancer screening. In our patient, the incidental finding of central airway obstruction required further testing with bronchoscopy, pathology, mass spectrometry, SPEP, UPEP, serum free light chains, and a fat pad biopsy which were ultimately negative. The high rate of false positive screens and the need for subsequent testing are concerns physicians must address with their patients when recommending lung cancer screening CT. This should be balanced with the potential for reduced mortality and morbidity with CT screening, through higher cure rates, less invasive lung resection, and increased rates of smoking cessation.https://digitalcommons.psjhealth.org/ppmc_internal/1009/thumbnail.jp

SEM-EDX ANALYSIS OF ABHRAKA BHASMA PREPARED ACCORDING TO RASA RATNA SAMMUCHCHAYA

Bhasmas are the most frequently used medicines in the field of Ayurveda as it tends to act fast when compared to other modes of medication. It works on the principle of nanoparticle assimilation, which provides higher bioavailability due its higher surface area and lesser particle size. This invention was made back in ancient days, which proves that during those ages there were faster methods of medical aids for a disease proving to be fatal. Abhraka is one of the main drugs used in Ayurveda mainly in the form of a Bhasma. It is abundantly used in single / compound forms for diseases like Cold, Cough, Diabetes, Anemia, asthma, etc. For a Bhasma to act significantly without side-effects it has to be properly rendered to purifactory procedures and Incineration at optimum temperature. This article basically deals with Samanya Shodana, Dhanyabhraka nirmana and Marana of Abhraka followed by its analysis by SEM-EDX which proved that There was reduction in some of the elements present in the drug after giving successive putas, till the formation of a Bhasma.The atomic percentage of Oxygen increased when bhasma was formed, hence suggesting it to be in oxide form. There was absence of heavy metals after giving puta according to the classical reference. Microscopic images of the Churna and Bhasma could be analysed and the Particle size of bhasma could be analysed which was 580.2 nm

Use of Reflectance Confocal Microscopy for Hidrocystomas: An Emerging, Cost-Effective, and Powerful Tool

Reflectance confocal microscopy (RCM) is an emerging and noninvasive imaging tool in dermatological practice. Benefits of this modality include differentiation between benign and malignant skin lesions, prevention of unnecessary biopsies, and cost effectiveness. However, RCM findings for benign lesions are rarely reported in the literature. We describe a case of reflectance confocal microscopy findings of a hidrocystoma and review potential applications of this imaging technique in everyday clinical practice

Early-stage clear cell tubulopapillary renal cell carcinoma: imaging features and distinction from clear cell and papillary subtypes

Purpose: Clear cell tubulopapillary renal cell carcinoma (CCTPRCC) is a recently described, low grade subtype of renal cancer. We determined if imaging features could be used to distinguish early-stage CCTPRCC from stage-matched clear cell RCC (ccRCC) and papillary RCC (pRCC). Subjects and Methods: This IRB-approved retrospective study included 54 stage-Ia patients with pathologically-confirmed CCTPRCC (n=18), ccRCC (n=18), and pRCC (n=18). CT (n=48) and MRI (n=27) exams were reviewed and imaging features compared. Continuous variables were evaluated using ANOVA and Tukey's multiple comparison tests. Categorical variables were compared using Chi square test or Fisher's exact test. Results: Compared to pRCC, CCTPRCC had a lower mean attenuation value on unenhanced CT (p<0.017), was more often hyperintense on T2-weighted images (p<0.0001), showed an ill-defined margin (p=0.003), and demonstrated nonenhancing areas (p=0.0003). The presence of all three of these statistically significant features (hypoattenuation [unenhanced attenuation < 25HU], ill-defined margin, nonenhancing areas) yielded an area under the Receiver Operator Curve (ROC) of 0.92 (95% CI: 0.83-0.99) for differentiating CCTPRCC from pRCC. There were no significant differences in the imaging features of CCTPRCC and ccRCC. Conclusions: Early stage clear cell tubulopapillary renal cell carcinoma can be distinguished from papillary RCC based on low attenuation on unenhanced CT, high intensity on T2-weighted images, an ill-defined margin, and presence of nonenhancing areas, but cannot be distinguished from clear cell RCC

Bullous Pemphigoid and Other Pemphigoid Dermatoses

The pemphigoid family of dermatoses is characterized by autoimmune subepidermal blistering. The classic paradigm for pemphigoid, and the most common member, is bullous pemphigoid. Its variable clinical presentation, with or without frank bullae, is linked by significant pruritus afflicting the elderly. Mucous membrane pemphigoid is an umbrella term for a group of subepidermal blistering dermatoses that favor the mucosal membranes and can scar. Epidermolysis bullosa acquisita is a chronic blistering disorder characterized by skin fragility, sensitivity to trauma, and its treatment-refractory nature. Clinicians that encounter these pemphigoid disorders may benefit from an overview of their clinical presentation, diagnostic work-up, and therapeutic management, with an emphasis on the most frequently encountered pemphigoid disease, bullous pemphigoid

Cannabis use and medication nonadherence in bipolar disorder: A nationwide inpatient sample database analysis.

BACKGROUND: Medication nonadherence among bipolar disorder (BD) is often linked with comorbid substance use disorders. This study aims to investigate cannabis use disorder (CUD) association with medication noncompliance in hospitalized BD patients. METHODS: Using data on 266,303 BD hospitalizations between 2010 and 2014 from the US Nationwide Inpatient Sample database, we obtained medication noncompliance rates stratified by demographics and CUD. Logistic regression was used to evaluate factors associated with medication noncompliance. RESULTS: Overall mean age, the prevalence of CUD, and medication nonadherence were 41.58 (± 0.11) years, 15.0% and 16.1%, respectively. There were 56.6% females in the overall population. There was a significant difference in the characteristics of those in the medication nonadherence vs adherence groups, including age, sex, race, comorbid substance use, income, insurance type, hospital region, and hospital teaching status (p \u3c 0.001). After adjusting for other variables using multivariate analysis, there remained a statistically significant association of medication nonadherence in BD hospitalization and CUD (OR 1.42, 95% CI 1.36-1.48). LIMITATION: Confounding multiple substance use could not be accounted for, and the retrospective nature of the database which includes only inpatients is prone to possible selection and reporting bias. CONCLUSION: CUD statistically predicts increased rates of medication nonadherence among patients with BD. Given the possible association of CUD with medication nonadherence among BD patients, collaborative work between general adult psychiatry and addiction services is imperative in improving the management outcome of patients with BD and comorbid CUD