Given the variable response to treatment, it remains unclear whether inhaled epoprostenol is beneficial in H1N1-associated ARDS. Identification of patients for whom this therapy is most appropriate remains a clinical challenge.
Mechanical ventilation is a well-established and commonly employed modality of treatment for critically ill patients in the ICU. Pneumonia is a frequent complication in mechanically ventilated patients. Patients who develop ventilator-associated pneumonia (VAP) incur higher medical costs, have prolonged ICU and hospital stays, and have increased mortality risk. There is growing interest in finding new treatment modalities for this condition because the success rate for treating VAP with systemic antibiotics continues to be < 70%. Accordingly, clinicians are reevaluating the role of aerosolized antibiotics, either as a sole therapy or as adjuncts to systemic antibiotics, in an attempt to improve clinical outcomes in patients with VAP. There are several clinical settings in which aerosolized antibiotics could be used for treating pneumonia, including their use for prevention, as monotherapy, as adjunctive therapy with systemic antibiotics, and for treatment of extensively drug-resistant or pan drug-resistant pathogens. However, aerosolized antibiotics have not been uniformly effective for improving clinical outcomes of patients with VAP, and local and systemic side effects could complicate their use. Moreover, many questions about aerosolized antibiotics, such as optimal formulations and dosage and treatment regimens, remain unanswered and warrant future investigations.
INTRODUCTION: Swyer James syndrome (SJS) is a unilateral acquired hypoplastic lung disease due to childhood infectious obliterative bronchiolitis which can remain undiagnosed until adulthood and may mimic pulmonary embolism. We report a case of SJS fasely diagnosed as pulmonary embolism.CASE PRESENTATION: A 61-year old female with past history of hypogammaglobinemia, recurrent bronchitis, obstructive sleep apnea and unprovoked left lower lobe pulmonary embolism five prior to admission. She presented to Emergency Department with acute onset chest pain. Work up for acute coronary syndrome was negative. Subsequently she underwent ventilation perfusion lung scan which revealed left lower lobe mismatched perfusion defect suggestive of acute pulmonary embolism. Due to lack of risk factors and negative hypercoagulable work up, patient underwent CT angiogram of chest which showed no evidence of pulmonary arterial filling defects but a diminutive left lower lobe pulmonary artery with decreased overall size of left hemithorax, peripheral scarring, atelectasis consistent with SJS. Further history revealed that patient had history of recurrent respiratory tract infection as childhood. We hypothesized that her history of left lower lobe pulmonary embolism was mostly likely due to underlying hypoplastic left pulmonary artery and not true pulmonary thromboembolic disease. She was treated symptomatically for musculoskeletal pain and discharged to follow up with pulmonary clinic.
INTRODUCTION: Pulmonary fibrosis is among the triad of conditions in patients affected by telomere diseases, along with pancytopenia and hepatic cirrhosis. Danazol, a synthetic androgen, has been studied as treatment for these diseases [Townsley et al.]. We report a case of a patient with pulmonary fibrosis secondary to telomere disease who had participated in the 2-year NIH trial of danazol. CASE PRESENTATION:A 33-year-old male with pulmonary fibrosis presented with 6 months of progressive dyspnea and dry cough that acutely worsened with productive cough, fever, and chills. He was diagnosed 7 years prior with telomere disease associated with aplastic anemia and liver fibrosis. His enrollment in the NIH trial ended nearly 3 years before presentation. On admission he was febrile with an oxygen saturation of 92% on room air and bibasilar crackles on chest auscultation. CBC showed pancytopenia with neutropenia, and procalcitonin was elevated. CT Chest angiogram showed extensive peripheral reticulation and fibrosis, with upper lobe predominance, associated with traction bronchiectasis. BAL was bland with negative fungal and AFB stains, and cultures. He improved on antibiotics for community-acquired pneumonia. During the 2-year NIH trial, his FVC and DLCO remained relatively stable; however, for the 3 years following danazol treatment, both FVC and DLCO declined [Figure 1]. DISCUSSION: Telomere diseases result from defective maintenance of telomeres, leading to shortened telomere length, early cellular senescence, and organ impairment including bone marrow failure, hepatic cirrhosis, and pulmonary fibrosis. Shortened telomeres, arising from genetic mutations in telomerases, have been identified in sporadic and familial pulmonary fibrosis. In the study by Townsley et al., treatment with danazol resulted in a significant reduction of telomere attrition. The secondary endpoint of lung function, DLCO, remained stable during the 2 year treatment period. Similarly, FVC remained stable during treatment, but declined in enrollment prior to, and the year following discontinuation of therapy. In our patient, FVC and DLCO continued to decline for the 3 years following the trial. While our patient is only a single experience, and the NIH study did not primarily address lung function, significant slowing of the rate of decline in lung function may occur in patients with pulmonary fibrosis associated with telomere diseases treated with danazol.CONCLUSIONS: Clinicians should be careful to evaluate all patients with pulmonary fibrosis for other conditions indicative of telomere diseases, as future treatments to stabilize lung function may differ from those for other forms of pulmonary fibrosis.
Background A radiological finding of a cavitary pulmonary lesion in a patient acutely infected with severe acute respiratory syndrome coronavirus-2 early during the coronavirus disease 2019 pandemic created a diagnostic and treatment dilemma, as invasive procedures with bronchoscopy and percutaneous needle lung biopsy posed an infection hazard to healthcare workers due to the associated risk of viral aerosolization. Available guidelines recommended delay of non-emergent procedures, but timely proceeding with those deemed urgent provided appropriate personal protective equipment and negative pressure isolation were available and exposure risk was not excessive. Thoughtful consideration by clinicians was required to avoid delay in diagnosis of a potential new malignancy and prevent unnecessary healthcare worker exposure to the virus. Additionally, acute severe acute respiratory syndrome coronavirus-2 infection in patients with malignancy complicated timing of oncologic treatment. Case presentation A 26-year-old otherwise healthy Caucasian male initially presented with an enlarging right upper lobe cavitary pulmonary lesion despite antimicrobial therapy. During his hospitalization and evaluation, the patient was found to be acutely infected with severe acute respiratory syndrome coronavirus-2 without hypoxia or viral pneumonia. Bronchoscopy was deemed too high risk for viral aerosolization and healthcare worker infection. He underwent computed-tomography-guided percutaneous needle biopsy of the lesion by interventional radiology while on mechanical ventilation after elective intubation by anesthesiology. Biopsy revealed classic Hodgkin lymphoma consistent with primary pulmonary Hodgkin lymphoma. After collaboration with oncology, his treatment with combined chemotherapy and immunotherapy was delayed for 3Â weeks following diagnosis to allow for viral clearance. Conclusion A careful multidisciplinary strategy is required to expeditiously diagnose and treat aggressive cancers of the respiratory tract in patients acutely infected with severe acute respiratory syndrome coronavirus-2 while observing practices to prevent healthcare worker infection during the ongoing coronavirus disease 2019 pandemic.
Boron neutron capture therapy is a brachyradiotherapy utilizing the (10)B(n,alpha)(7)Li reaction that has been used to treat glioblastoma multiforme (GBM), melanoma and colon carcinoma liver metastases. GBM clinical trials resulted in modestly improved life expectancies compared with conventional therapies. Early results trials focused on malignant melanoma and colon carcinoma provide dramatically better results. Macrodosimetry cannot explain these apparent differences. The dichotomy can only be understood using microdosimetry techniques. A computer program has been created to provide an improved tissue model. This model permits the dose in each cell's cytoplasm, nucleus, and the interstitium to be calculated for ellipsoidal cells placed in either random or ordered locations. The nuclei can be centered or eccentric. The new model provides insight into the micro level for differences in the trials. The differences arise from the tissue's cellular geometry and the effects of neighboring cells. These results help to explain the observed clinical outcomes.
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