Multifocal lung adenocarcinoma is a rare more indolent process presenting as multiple lesions in variable states from ground glass to solid nodules on CT. Cryptogenic organizing pneumonia, being a more common diagnosis and having similar clinical manifestations and imaging findings, contribute to delays in diagnosis. We describe an outpatient case of lepidic type multifocal lung adenocarcinoma that was originally believed to be cryptogenic organizing pneumonia. CASE PRESENTATION: 73 year-old gentleman with a remote 40 pack year smoking history and COPD presented to the resident clinic with ongoing dyspnea for greater than one year of time. He denied fever and night sweats but repeatedly endorsed progressively worsening fatigue and chronic cough. Three chest CT scans over the past two years all demonstrated bilateral ground glass pulmonary opacities consistent with COP. Given little clinical improvement despite antibiotics and steroids, a bronchoscopy with biopsy was performed. The pathology revealed multifocal ground glass lepidic (GG/L) lung adenocarcinoma and he was referred to oncology.
Introduction:
Continuous intravenous (IV) diltiazem is one of the options for urgent management of atrial fibrillation with rapid ventricular response (RVR). This study assesses the clinical outcomes of utilizing IV diltiazem for less than or greater than 24 hours.
Methods:
A retrospective chart-review of patients receiving continuous IV diltiazem between January 1, 2017 and December 31, 2018 where adult patients were included if they had atrial fibrillation with RVR and were treated with continuous IV diltiazem. Exclusion criteria included initiation of IV diltiazem in the ICU, strict nothing by mouth, only a bolus of IV diltiazem used, no conversion to oral rate controlling agent following discontinuation of IV diltiazem, and if pregnant. Infusions lasting >24 hours and <24 hours were compared. Primary objective was to evaluate duration in goal heart rate for the first 48 hours after conversion to PO diltiazem. Secondary outcomes included length of hospitalization, ICU transfer, 30-day readmission, and development of cardiovascular events including stroke, myocardial infarction, or cardiovascular death.
Results:
146 out of 251 patients met inclusion criteria. 75.3% of patients maintained a goal heart rate (less than 110bpm) for at least 80% of the 48 hours after conversion to oral diltiazem in < 24 hours group compared to only 59% (p =0.037). The <24 hours group had more patients in heart rate goal for >85% of 48 hours after conversion to oral diltiazem compared to the >24 hours group (p=0.03). Diltiazem drips used for >24 hours had a higher percentage of ICU transfers (p = 0.035) and longer hospitalization (p = 0.001). There were no differences regarding major adverse cardiovascular events and readmission rates.
Conclusions:
Diltiazem drip use for <24 hours was associated with greater time spent in goal heart rate as well as a lower rate of ICU transfers and shorter hospitalization when compared to drips used > 24 hours.
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