Butt, Ifrah; Shaikh, Umair; Fernandez, Marlena; Shaharyar, Sameer; Heller, Daniel Author Information

Intravenous sedation during colonoscopy has become the standard practice in the United States given its higher patient satisfaction and procedural quality. This practice is not free of side effects as a significant proportion of patients undergoing this procedure tend to have respiratory depression and desaturation events. Obesity, as it relates to higher levels of body mass index (BMI) has a positive correlation with the incidence of hypoxemia. During colonoscopy High flow nasal cannula (HFNC) may potentially improve oxygen performance in patients receiving colonoscopy under intravenous sedation. Here we present 3 cases of patients undergoing adjunctive oxygen therapy with HFNC during colonoscopy with intravenous sedation. We found patients to have lower number of desaturation events and were satisfied with their experience.

Lee, Chi Chan; Perez, Osman; Farooqi, Faryal; Akella, Trupti; Danckers, Mauricio; Shaharyar, Sameer Author Information

Elena Cervantes, Carmen; Lee, Chi Chan; Wulff, Luis; Shaharyar, Sameer; Iguina, Michelle Author Information

Background: Flexible bronchoscopy (FB) is commonly performed to assess, diagnose, and treat patients with respiratory disease, and is typically performed via transnasal or transoral approaches. FB can be performed via tracheal tubes in patients with tracheostomies; however, the safety and technical feasibility has not been established. The present study evaluates the safety and feasibility of performing FB via tracheal tubes. Materials and Methods: A total of 45 patients underwent 56 procedures involving FB via tracheal tubes at a single institution from November 2013 to November 2014 and were included in this retrospective case series. Results: Patients had a median age of 68 years (interquartile range, 56 to 82.5), and 51% were female. Most patients had 2 comorbidities (interquartile range, 1 to 3), with the most common being hypertension, diabetes mellitus, and chronic kidney disease. Upper airway obstruction was the primary indication for bronchoscopy in 40% of patients. Fifty-three percent of patients had a Shiley tube #6, [internal cannula diameter (ICD) of 6.5 mm]; tracheal tubes in the remaining patients ranged from Shiley #4 (ICD, 5.5 mm) to Shiley #8 (ICD, 8.5 mm). One patient did not complete the procedure due to severe hypertension (intraprocedural systolic blood pressure >180 mm Hg). During FB, no patients experienced cardiorespiratory arrest, arrhythmia, bleeding, or desaturation that required resuscitation. Eleven patients had a mucus plug leading to atelectasis during bronchoscopy, and 8 of these had a postprocedural chest x-ray finding of lung reexpansion. Conclusion: FB via tracheal tubes is a technically feasible and safe procedure that does not compromise patient oxygenation.

Acute esophageal necrosis (AEN) also known as "black esophagus" or necrotizing esophagitis is a rare syndrome characterized by a striking diffuse patchy or circumferential black appearance of the esophageal mucosa that preferentially affects the distal esophagus and terminates at the gastroesophageal junction. Only 88 patients over a span of 40 years have received this diagnosis, and the prevalence of this disease ranges from 0.001 to 0.2% of cases in literature. It more commonly affects men (4 : 1 ratio) in the sixth decade of life. It is associated with a high mortality rate, approaching 32%. We report a case of AEN presenting in the setting of diabetic ketoacidosis (DKA), affecting both the proximal and distal esophagus.

Multiple myelomas (MM) of the immunoglobulin D (IgD) subtype is rare amongst plasma cell malignancies. It can present a diagnostic challenge because of the low amount of immunoglobulin in the serum. The amount of monoclonal (M)-protein is often undetectable on electrophoresis. Historically, survival in these patients was typically shorter compared to the immunoglobulin A (IgA) and immunoglobulin G (IgG) subtypes due to advanced disease upon presentation. With the advent of better diagnostic techniques, the prognosis of this disease is changing. We describe a case of an extramedullary testicular plasmacytoma (EMP) of the IgD subtype as the primary feature of MM, which responded well to novel therapy. A 72-year-old White male presented to the emergency room with a right testicular mass for three months. He subsequently underwent right radical orchiectomy. Pathology of the specimen revealed plasmacytoid cells positive for cluster of differentiation (CD79a), lambda free light chain, IgD, and BCL-1 (Cyclin D1) on immunochemical stains. Urine and serum immunofixation were positive for monoclonal IgD with lambda light chain specificity and Bence Jones proteinuria. Bone marrow biopsy showed large sheets of plasma cells with greater than 90% cellularity. Flow cytometry displayed atypical plasma cells expressing cluster of differentiation (CD38, CD20, and CD56) with cytoplasm and lambda light chain, approximately 20%, consistent with a plasma cell dyscrasia. Stage 3 IgD lambda multiple myeloma was diagnosed. He received novel treatment with Bortezomib and dexamethasone for three months, followed by Lenalidomide. His performance status and lab data improved significantly. He had progression-free survival (PFS) of approximately three years and remained in complete remission low-dose dose of Lenalidomide daily. IgD myeloma was considered a diagnostic challenge due to undetectable M-protein levels on serum protein electrophoresis (SPEP). With the advent of serum free light chain assay and serum and cytologic examinations, diagnostic accuracy has significantly improved. The IgD subtype is commonly associated with poor clinical outcomes. However, the use of novel agents and autologous transplant has changed the prognosis of this disease.

Background: Cardiovascular disease (CVD) accounts for a significant portion of deaths in patients with COPD; however, evidence for early detection strategies for CVD in this population remain limited. Our paper aims to summarize existing data regarding subclinical CVD in patients with COPD with a view to identifying screening strategies in these patients.Methods: A systematic review of published literature was conducted for studies examining the relationship of COPD and markers of subclinical disease such as coronary artery calcification (CAC), carotid intima media thickness (cIMT), endothelial dysfunction, arterial stiffness as measured by pulse wave velocity (PWV) and augmentation indices (AIx). Both MEDLINE and EMBASE databases were searched till October 2015.Results: A total of 22 studies were included in the review. Compared with control subjects, patients with COPD had significantly higher cIMT (SMD 0.53, 95% CI 0.16-0.90), PWV (SMD 0.91, 95% CI 0.67-1.16) and AIx (SMD 0.86, 95% CI 0.52-1.19). Additionally, an overall higher prevalence of subclinical CVD as assessed by CAC, ABI and FMD was noted in our review.Conclusion: Although our findings need further evaluation in prospective studies, our review presents significant evidence in support of increased subclinical CVD burden in COPD patients independent of smoking status. Further large-scale case-control studies are required to highlight the significance of subclinical CVD screening in COPD patients.

Pulmonary alveolar microlithiasis (PAM) is a rare infiltrative lung disease characterized by deposition of spherical calcium phosphate microliths called calcospherites within the alveoli. PAM was first described by Friedrich in 1856 and then by Harbitz in 1918. The disease pathogenesis is based on mutations in the SLC34A2 gene that encodes for the Type IIb sodium-phosphate cotransporter. The majority of the patients are diagnosed at an early age, usually between the ages of 20 and 40 years. The hallmark of this disease is a striking dissociation between the radiological findings and the mild clinical symptoms.We report a case of 35-year-old woman who presented post-motor vehicle accident with back pain and with minimal dyspnea on exertion. The final diagnosis was made after computed tomography and lung biopsy. The present case exhibits the remarkable clinico-radiological dissociation with complete calcification of the lungs on radiographic images with a relatively mild clinical presentation.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) and remained unchanged (p=0.4295). MoH rates among IMV with & without PTX/H were 40.3% & 28.0%, respectively (p=0.0977). Conclusions: In this first population-based study of adults with CF-ICU, IMV was consistently required in 1 in 5 ICU admissions, with IMV events involving diagnoses of PTX/H only in a small minority. CF-ICU with IMV was associated with high, though unchanged use of hospital resources. Short-term survival was unchanged during study period despite progressive rise in risk of death, possibly reflecting in part improved care over time. A diagnosis of PTX/H tended to be associated with better short-term survival. The present findings support consideration of IMV among adults with CF, though additional studies are warranted in other healthcare settings to corroborate these results and identify sources of the observed trends.

BACKGROUND:Handgrip strength (HGS) and gait speed (GS) are objective components of the frailty syndrome in the elderly, and are associated with increased all-cause mortality. However, their association with cardiovascular (CVD) mortality is less lucid. The present systematic review aims to summarize the available literature assessing HGS, GS and their association with CVD Mortality. METHODS:Medline and Embase databases were searched systematically using controlled vocabulary and free text terms. A total of 344 results were obtained and scanned for inclusion. Articles were included if they presented results of original research and provided information on HGS or GS and CVD mortality. RESULTS:A total of 19 studies (N=63,396) were included for review. Twelve studies examined hand grip strength with CVD mortality and 7 studies assessed gait speed. Almost all included studies demonstrated an association of HGS/GS with CVD mortality on univariate analyses. Decreased HGS or GS were associated with increased mortality in most studies (8/12 for HGS and 6/7 for GS). In most positive studies, the association of HGS/GS was usually found to be independent of traditional CVD risk factors. CONCLUSION:The present review demonstrates that decreased HGS and GS are associated with CVD mortality, with the association found to be more consistent for GS as compared to HGS. Both of these measures provide valuable prognostic information above and beyond traditional scoring methods and should be considered for implementation in clinical practice.

Cardiovascular disease (CVD) accounts for a significant portion of deaths in patients with COPD; however, evidence for early detection strategies for CVD in this population remain limited. Our paper aims to summarize existing data regarding subclinical CVD in patients with COPD with a view to identifying screening strategies in these patients.A systematic review of published literature was conducted for studies examining the relationship of COPD and markers of subclinical disease such as coronary artery calcification (CAC), carotid intima media thickness (cIMT), endothelial dysfunction, arterial stiffness as measured by pulse wave velocity (PWV) and augmentation indices (AIx). Both MEDLINE and EMBASE databases were searched till October 2015.A total of 22 studies were included in the review. Compared with control subjects, patients with COPD had significantly higher cIMT (SMD 0.53, 95% CI 0.16-0.90), PWV (SMD 0.91, 95% CI 0.67-1.16) and AIx (SMD 0.86, 95% CI 0.52-1.19). Additionally, an overall higher prevalence of subclinical CVD as assessed by CAC, ABI and FMD was noted in our review.Although our findings need further evaluation in prospective studies, our review presents significant evidence in support of increased subclinical CVD burden in COPD patients independent of smoking status. Further large-scale case-control studies are required to highlight the significance of subclinical CVD screening in COPD patients.

This is a single-arm, pre and post effectiveness study that evaluated the impact of a comprehensive workplace lifestyle program on severe obesity among high cardiovascular disease risk individuals in a large, diverse employee population. Employees of Baptist Health South Florida were considered eligible to participate if they had 2 or more of the following cardiometabolic risk factors: total cholesterol ≥200 mg/dL, systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg, hemoglobin A1c ≥6.5%, body mass index ≥30kg/m(2). Participants received a personalized diet plan and physical activity intervention, and were followed for 1 year. Data on anthropometric measurements, blood pressure, blood glucose, and other biochemical measures were collected. Participants' body mass index was calculated and their eligibility for bariatric surgery (BS) also assessed. A total of 297 persons participated in the program; 160 participants completed all procedures through 12 months of follow-up. At baseline, 34% (n = 100) of all participants were eligible for BS. In an intention-to-treat analysis, 27% (n = 27) of BS eligible participants at baseline became ineligible after 12 months. Considering program completers only, 46% of BS eligible participants at baseline became ineligible. Irrespective of BS eligibility at 12 months, mean values of cardiometabolic risk factors among program completers improved after the follow-up period. Workplace wellness programs provide an important option for weight loss that can obviate the need for BS, reduce cardiovascular disease risk, and potentially reduce costs. However, in designing future worksite lifestyle interventions, measures should be taken to improve participation and retention rates in such programs.

IntroductionHumidified oxygen via a high flow nasal cannula (HFNC) is a form of supplemental oxygen therapy that has significant theoretical advantages over conventional oxygen therapy (COT). However, the clinical role of HFNC in acute hypoxemic respiratory failure (AHRF) has not been well established. This review compares the efficacy of HFNC with COT and non-invasive ventilation (NIV) in patients with AHRF.MethodsStudies reviewed were selected based on relevance from a systematic literature search conducted in Medline and EMBASE to include all published original research through May 2016. Twelve studies matched the inclusion criteria.ResultsIn the majority of the studies, HFNC was associated with superior comfort and patient tolerance as compared to NIV or COT. HFNC was associated with reduced work of breathing in comparison with COT in some, but not all, studies in the review. COT and NIV were associated with a higher 90-day mortality rate compared to HFNC in only one multicenter randomized trial versus no mortality difference reported by others. Three out of four studies demonstrated a decreased need for escalation of oxygen therapy with HFNC. Six out of eight studies demonstrated improved oxygenation with HFNC as compared to COT. Two of three studies revealed worse oxygenation with HFNC as compared to NIV.ConclusionThis review suggests that HFNC may be superior to COT in AHRF patients in terms of oxygenation, patient comfort, and work of breathing. It may be reasonable to consider HFNC as an intermediate level of oxygen therapy between COT and NIV.