Norwalk Hospital is a not-for-profit, acute care community teaching hospital in the Hospital Hill section of Norwalk, Connecticut. The hospital serves a population of 250,000 in lower Fairfield County, Connecticut. The 366-bed hospital has more than 500 physicians on its active medical staff, and 2,000 health professionals and support personnel. The hospital was part of the Western Connecticut Health Network, which included two other hospitals - Danbury Hospital and New Milford Hospital - up until April 2019, when WCHN merged with Health Quest to form Nuvance Health.
Abstract Introduction Allergic bronchopulmonary aspergillosis (ABPA) is an immunologically mediated lung disease which primarily affects patients with asthma or cystic fibrosis. It results from repeated inhalation of Aspergillus spores, predominantly Aspergillus fumigatus, which elicits a Type I, Type III or Type IV hypersensitivity response, eventually leading to local inflammation which further causes increased mucus production, airway hyperreactivity, and bronchiectasis. Current diagnostic criteria require a diagnosis of asthma with total immunoglobulin (Ig)E levels of > 1000 ng/ml, elevated serum IgE and/or IgG to Aspergillus, immediate cutaneous hyperreactivity, and central bronchiectasis. However, cases of ABPA without asthma have been reported, mainly in case reports. Due to its rarity, diagnosis is clinically challenging and can potentially lead to misdiagnosis and inappropriate treatment. Here we describe a patient without prior history of asthma who presented with chronic cough, ultimately diagnosed with ABPA. Case Report A 67-year-old female never smoker without significant past medical history or prior pulmonary disease, although with a history of atopy without asthma, presented with a chronic cough of 6 months. Her cough was incessant, productive of copious amounts of clear to yellowish phlegm. She denied fevers, night sweats, dyspnea, heartburn or postnasal drip. There was no reported history of environmental exposures or sick contacts. She was treated with four cycles of different antibiotics in the interim without any significant relief. Chest x-ray done for ongoing cough showed a 3.8 cm right perihilar mass. The subsequent CT chest showed prominent mucoid impaction and tree-in-bud opacification in anterior right upper lobe with lesser areas of similar findings in the right middle lobe and lingula. This led to pulmonary consultation, and subsequent blood work revealed WBC of 5.7 with absolute eosinophil count of 1120 and markedly elevated total IgE level of 4248. Aspergillus IgE was also elevated along with multiple other aeroallergens. ANCA testing was negative. Patient was treated with high-dose prednisone taper over 3 months with complete resolution of her symptoms. Repeat CT was dramatically improved with some residual bronchiectasis without mucoid impaction. Repeat IgE and absolute eosinophil count at end of treatment were 615 and 150 respectively. She has had sustained clinical remission over 18 months with most recent IgE 510. Conclusion ABPA without asthma is an elusive diagnosis because of existing criteria for diagnosis, typically requiring known asthma. Pulmonologists should maintain a high index of clinical suspicion for this condition, especially in patients presenting with peripheral eosinophilia and characteristic radiological features. This abstract is funded by: N/A
BACKGROUND:Whether adding a bilateral superficial cervical plexus block to a thyroidectomy enhanced recovery pathway improves postoperative quality of recovery remains uncertain. METHODS:In a single-center prospective, randomized, double-blind, placebo-controlled trial in adults undergoing thyroidectomy with general anesthesia, participants were randomized to bilateral superficial cervical plexus blocks with 0.25% bupivacaine or saline. All participants received multimodal analgesia with dexamethasone, acetaminophen, nonsteroidal anti-inflammatory drugs, and incisional local anesthetic. The primary outcome was quality of recovery, measured by the QoR-40 survey, on postoperative day 1. Secondary outcomes included the need for rescue opioid, total opioid consumption, nausea, vomiting, antiemetic administration, length of stay in the postanesthesia care unit (PACU), and opioid use on postoperative day 1. RESULTS:A total of 160 participants were randomized to receive a superficial cervical plexus block with bupivacaine 0.25% (n = 78) or saline (n = 82). On postoperative day 1, mean QoR-40 scores were 174 (95% CI, 170 to 178) for bupivacaine and 173 (95% CI, 169 to 177) for saline. The adjusted mean difference between bupivacaine versus saline was 0.91 (95% CI, -3.57 to 5.40; P = 0.688). There were no significant between-group differences in the need for opioids in the PACU or on postoperative day 1, nausea, vomiting, or PACU length of stay. However, the total amount of opioid administered in the PACU was lower in the bupivacaine group (median [interquartile range], 0 [0 to 8]) compared with the saline group (2 [0 to 20]; Hodges-Lehmann location shift, 0 morphine milligram equivalents; 95% CI, -4 to 0; P = 0.017), and fewer participants in the bupivacaine group received rescue antiemetics (3 [3.8%] vs . 13 [16%]; difference, -12%; 95% CI, -22% to -1.8%; P = 0.011). CONCLUSIONS:Bilateral superficial cervical plexus blocks did not improve quality of recovery after thyroidectomy when added to a multimodal analgesic regimen including dexamethasone, acetaminophen, nonsteroidal anti-inflammatory drugs, and incisional local anesthetic but were associated with lower total PACU opioid consumption.
Abstract Rationale Intensive care unit (ICU) patients face a high risk of morbidity and mortality, often requiring patients and their families to navigate complex decisions regarding treatment options and goals of care. Effective end-of-life (EOL) communication skills and showing empathy during difficult conversations are essential for delivering patient- and family-centered care around EOL. In this study, we implemented a dedicated EOL communication skills training program and evaluated its impact on participants’ perceived skills and attitudes toward EOL conversations. Methods This prospective, qualitative educational intervention study was conducted from March to October 2025 at Norwalk Hospital, a community-based teaching hospital in Norwalk, CT. Internal medicine residents and medical students completing ICU rotations were enrolled. The intervention was a single 1-hour EOL communication training session adapted from a curriculum developed by the Beth Israel Deaconess Medical Center Shapiro Institute for Education and Research. The session was facilitated by pulmonary/critical care fellows and emphasized four core competencies: agenda-setting, the ask-tell-ask framework, clear information delivery, and recognition and response to emotion. Participants completed pre- and post-session surveys evaluating communication skills, perceived comfort, and attitudes toward EOL conversations using a 5-point Likert scale. Survey administration time points illustrated in Figure 1. Statistical significance was set at α = 0.01 (two tailed). Effect sizes were calculated as mean change divided by retrospective pre-intervention standard deviation with ≥0.8 considered a large effect. Results Eighteen participants completed the EOL communication training session and surveys. The cohort included 3 fourth-year medical students and 15 internal medicine residents (PGY-1 n = 5, PGY-2 n = 7, PGY-3 n = 3). Pre-intervention, most participants rated their communication skills and comfort with EOL discussions as poor or fair. Post-intervention responses demonstrated significant improvements in perceived confidence across all domains. Overall confidence in skills increased from 17% pre-intervention to 62% post-intervention with the greatest relative improvement observed among medical students and first-year residents. The domains seeing highest impact were knowledge of language to avoid during difficult conversations (effect size 1.89; p < 0.01) and confidence in delivering bad or distressing news to families (effect size 1.27; p < 0.01). Conclusion Findings suggest that even brief, structured communication training can meaningfully enhance trainee preparedness for and confidence in EOL communication in the ICU. Given the importance of EOL discussions in critical care, broader implementation and longitudinal reinforcement of core competencies may further enhance confidence, reduce decisional conflict, and support higher-quality patient-centered care. Our future research will examine durability of initial intervention and role for repeat training. This abstract is funded by: None
Abstract Rationale Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) plays an integral role in the evaluation and diagnosis of benign or malignant lung disease. Appropriate training in technique and anatomy is imperative to its optimal utilization. Yield varies depending on technique, experience/case volume, patient factors/complications, number of passes, pathology support, and rapid on-site evaluation (ROSE). This quality improvement (QI) initiative aims to evaluate EBUS procedures performed at Norwalk and Danbury Hospitals (Nuvance East), two community-based academic medical centers without subspecialty interventional pulmonologists. Systematic review of EBUS for quality metrics has been difficult with limitations in IT systems creating the need for manual data pull. We aim to identify areas for improvement, and to implement institutional level changes for the improvement in quality of care. Methods This retrospective study analyzed EBUS-TBNA procedures performed in Nuvance East between January 1, 2024, and December 31, 2024. Data was collected from electronic medical records including patient demographics, procedural details, pathologic diagnosis (including malignant or nonmalignant), staging, and complications (defined as unexpected hospital admission post-procedure, significant hemoptysis, respiratory failure, aspiration, death, or other). We also examined whether clinical diagnosis matched the final pathologic diagnosis, and if sampling was adequate. Results A total of 59 procedures were reviewed with only 1 terminated for inability to get adequate tissue. There were no recorded complications in any of the patients. Of the 59 patients, 36 (61%) had a malignant diagnosis. Of those, 22 (61%) were adenocarcinoma, 5 (14%) squamous cell lung, 3 (8%) carcinoid, 2 (5.5%) lymphoma, and 1 each (2.8%) of mesothelioma, melanoma, and a preliminary NSCLC still awaiting differentiation. Of the remaining 23 patients, 5 (22%) had no definitive diagnosis, 2 (9%) were granulomatous, 2 had “other” benign etiologies, and there was 1 case each of chronic aspiration, ILD, and organizing pneumonia. ROSE was used in 42% of cases. Sampling was adequate in 85% with pathology matching clinical diagnosis in 64% of cases. However, 11 patients (19%) required a subsequent procedure for definitive diagnosis. When ROSE was used, clinical and pathological diagnoses matched in 76% vs 56% when ROSE was not used. Conclusion This ongoing EBUS-TBNA QI project aims to assess the current performance of EBUS-TBNA procedures within Nuvance East. By identifying procedural and logistic pitfalls and variability in current practices, we intend to use ongoing prospective data to guide institutional changes to improve diagnostic accuracy, procedural safety, and overall patient care. This abstract is funded by: None
Abstract Introduction Chylothorax is a rare cause of pleural effusion and has a 90-day mortality rate up to 82%. In children, congenital abnormalities represent the most common etiology of chylothorax. Chylothorax is treated by thoracic duct ligation or thoracic duct embolization, which is favored due to its minimally invasive approach and more favorable success rates. Recurrence of chylothorax after treatment is uncommon and often challenging to manage. We report a case of recurrent bilateral chylothoraces in a healthy young male who had thoracic duct embolization in childhood. Case A 23-year-old man presented with three days of progressive dyspnea, pleuritic chest discomfort and pink-tinged sputum. The patient reported having a pericardial effusion requiring a pericardial window and lymphangiography at age 11, but he was unable to report the cause of the pericardial effusion or indication for lymphangiography. Review of patients prior imaging showed metallic mediastinal coils, consistent with previous thoracic duct embolization. On admission, vital signs were normal. Laboratory evaluation was notable for an elevated D-dimer (8,040 ng/mL). Chest radiograph showed moderate bilateral effusions, and CT angiography revealed large bilateral pleural effusions without pulmonary embolism and a small pericardial effusion (Figure 1a). Right-sided thoracentesis drained 2L of milky fluid (Figure 1b). Pleural studies revealed lymphocyte-predominant fluid (WBC 2,515/mm3; 81% lymphocytes), protein 3.8 g/dL, LDH 122 U/L, normal glucose and pH, and triglycerides 2,015 mg/dL, confirming chylothorax. Subsequent left sided thoracentesis removed an additional 2L of fluid. Cultures returned with no growth of organisms, and cytology was negative for malignant cells. Patient underwent robotic-assisted thoracic duct ligation with bilateral chest tube placement and talc pleurodesis. He had no recurrence of chylothorax and was discharged to home. Patient continues to take octreotide and interval imaging shows no recurrent effusions. Discussion Chylothorax may recur even years following thoracic duct embolization. Therefore, patients with treated chylothorax should be monitored longitudinally, although the best method for surveillance is undetermined. Prompt recognition of recurrent chylothorax is essential to avoid complications from prolonged chyle loss. Definitive management of recurrent chylothorax requires multidisciplinary review and may include thoracic duct ligation in cases of embolization failure. This abstract is funded by: None
