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Cureus Aug 2023Hiatal hernias and Bochdalek hernias are two types of diaphragmatic hernias that present with similar symptoms. However, they differ in their etiology and anatomical...
Hiatal hernias and Bochdalek hernias are two types of diaphragmatic hernias that present with similar symptoms. However, they differ in their etiology and anatomical location. In this case study, we present the clinical features and management of a patient who presented with symptoms suggestive of a hiatal hernia but was later diagnosed with a Bochdalek hernia. Our case has a 64-year-old female patient who presented with chronic obstructive pulmonary disease, hypertension, and gastroesophageal reflux disease. During her pulmonologist-ordered imaging, which included a CT scan, the report showed a large 8 cm hiatal hernia. Due to her condition, she was scheduled for a hiatal hernia repair, along with a transoral incisionless fundoplication (TIF) procedure. During the operation, a large defect was seen in the left hemidiaphragm with herniation of bowel loops into the chest cavity. It was confirmed to be a Bochdalek hernia. The surgeon proceeded to continue the laparoscopic repair, pulling the bowel back into the abdomen, and using the falciform ligament of the liver to buttress the diaphragm. The surgery was a success, and the patient had no postoperative complications. This case serves as a reminder that a high degree of suspicion is required for the diagnosis of Bochdalek hernias, especially in patients with atypical presentations or imaging findings suggestive of an alternative diagnosis, such as a hiatal hernia. The patient had chronic symptoms of various gastrointestinal and respiratory comorbidities, which should serve as a caution for clinicians to carefully consider the possibility of a Bochdalek hernia when evaluating patients with similar symptoms. This case study also illustrates the success of a minimally invasive surgical approach for repairing a Bochdalek hernia, with the use of laparoscopic techniques and using falciform ligament to support the diaphragm.
PubMed: 37736470
DOI: 10.7759/cureus.43859 -
Pulmonology Dec 2023In this review, we present the effects of lung hyperinflation on the cardiovascular system (CVS) and the beneficial outcomes of different deflation treatment modalities.... (Review)
Review
In this review, we present the effects of lung hyperinflation on the cardiovascular system (CVS) and the beneficial outcomes of different deflation treatment modalities. We discuss the effects of long-acting bronchodilator drugs, medical and surgical lung volume reduction on the performance of the CVS. Although there is a small number of studies investigating lung deflation and the CVS, the short-term improvement in heart function was clearly demonstrated. However, more studies, with longer duration, are needed to verify these significant beneficial effects of deflation of the lungs on the CVS. Dynamic hyperinflation during exercise could be a research model to investigate further the effects of lung hyperinflation and/or deflation on the CVS.
Topics: Humans; Pulmonary Disease, Chronic Obstructive; Cardiologists; Pulmonologists; Lung; Bronchodilator Agents
PubMed: 37031001
DOI: 10.1016/j.pulmoe.2023.02.011 -
Medicina (Kaunas, Lithuania) Sep 2023: Treatment of advanced lung cancer (LC) has become increasingly personalized over the past decade due to an improved understanding of tumor molecular biology and... (Review)
Review
: Treatment of advanced lung cancer (LC) has become increasingly personalized over the past decade due to an improved understanding of tumor molecular biology and antitumor immunity. The main task of a pulmonologist oncologist is to establish a tumor diagnosis and, ideally, to confirm the stage of the disease with the least invasive technique possible. : The paper will summarize published reviews and original papers, as well as published clinical studies and case reports, which studied the role and compared the methods of invasive pulmonology diagnostics to obtain adequate tumor tissue samples for molecular analysis, thereby determining the most effective molecular treatments. : Bronchoscopy is often recommended as the initial diagnostic procedure for LC. If the tumor is endoscopically visible, the biopsy sample is susceptible to molecular testing, the same as tumor tissue samples obtained from surgical resection and mediastinoscopy. The use of new sampling methods, such as cryobiopsy for peripheral tumor lesions or cytoblock obtained by ultrasound-guided transbronchial needle aspiration (TBNA), enables obtaining adequate small biopsies and cytological samples for molecular testing, which have until recently been considered unsuitable for this type of analysis. During LC patients' treatment, resistance occurs due to changes in the mutational tumor status or pathohistological tumor type. Therefore, the repeated taking of liquid biopsies for molecular analysis or rebiopsy of tumor tissue for new pathohistological and molecular profiling has recently been mandated. : In thoracic oncology, preference should be given to the least invasive diagnostic procedure providing a sample for histology rather than for cytology. However, there is increasing evidence that, when properly processed, cytology samples can be sufficient for both the cancer diagnosis and molecular analyses. A good knowledge of diagnostic procedures is essential for LC diagnosing and treatment in the personalized therapy era.
Topics: Humans; Carcinoma, Non-Small-Cell Lung; Lung Neoplasms; Bronchoscopy; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Molecular Diagnostic Techniques
PubMed: 37893442
DOI: 10.3390/medicina59101723 -
Thyroid Research Aug 2023The discovery of driver oncogenes for thyroid carcinomas and the identification of genomically targeted therapies to inhibit those oncogenes have altered the treatment...
BACKGROUND
The discovery of driver oncogenes for thyroid carcinomas and the identification of genomically targeted therapies to inhibit those oncogenes have altered the treatment algorithm in thyroid cancer (TC), while germline testing for RET mutations has become indicated for patients with a family history of RET gene mutations or hereditary medullary TC (MTC). In the context of an increasing number of selective RET inhibitors approved for use, this paper aims to describe challenges and barriers affecting providers' ability to deliver optimal care for patients with RET-altered TC across the patient healthcare journey.
METHODS
A mixed-method educational and behavioral needs assessment was conducted in Germany (GER), Japan (JPN), the United Kingdom (UK), and the United States (US) prior to RET-selective inhibitor approval. Participants included medical oncologists (MO), endocrinologists (EN) and clinical pathologists (CP) caring for patients affected with TC. Data collection tools were implemented in three languages (English, German, Japanese). Qualitative data were coded and thematically analyzed in NVivo. Quantitative data were analyzed via frequency and crosstabulations in SPSS. The findings presented here were part of a broader study that also investigated lung cancer challenges and included pulmonologists.
RESULTS
A total of 44 interviews and 378 surveys were completed. Suboptimal knowledge and skills were self-identified among providers, affecting (1) assessment of genetic risk factors (56%, 159/285 of MOs and ENs), (2) selection of appropriate genetic biomarkers (59%, 53/90 of CPs), (3) treatment plan initiation (65%, 173/275 of MOs and ENs), (4) management of side effects associated with multitargeted tyrosine kinase inhibitors (78%, 116/149 of MOs and ENs), and (5) transfer of patients into palliative care services (58%, 160/274 of MOs and ENs). Interviews underscored the presence of systemic barriers affecting the use of RET molecular tests and selective inhibitors, in addition to suboptimal knowledge and skills necessary to manage the safety and efficacy of targeted therapies.
CONCLUSION
This study describes concrete educational needs for providers involved in the care of patients with RET-altered thyroid carcinomas. Findings can be used to inform the design of evidence-based education and performance improvement interventions in the field and support integration into practice of newly approved RET-selective inhibitors.
PubMed: 37574538
DOI: 10.1186/s13044-023-00166-4 -
Pulmonology Dec 2023Interstitial lung disease (ILD) contributes significantly to morbidity and mortality in connective tissue disease (CTD). Early detection and accurate diagnosis are...
Early detection of interstitial lung disease in rheumatic diseases: A joint statement from the Portuguese Pulmonology Society, the Portuguese Rheumatology Society, and the Portuguese Radiology and Nuclear Medicine Society.
INTRODUCTION
Interstitial lung disease (ILD) contributes significantly to morbidity and mortality in connective tissue disease (CTD). Early detection and accurate diagnosis are essential for informing treatment decisions and prognosis in this setting. Clear guidance on CTD-ILD screening, however, is lacking.
OBJECTIVE
To establish recommendations for CTD-ILD screening based on the current evidence.
METHOD
Following an extensive literature research and evaluation of articles selected for their recency and relevance to the characterization, screening, and management of CTD-ILD, an expert panel formed by six pulmonologists from the Portuguese Society of Pulmonology, six rheumatologists from the Portuguese Society of Rheumatology, and six radiologists from the Portuguese Society of Radiology and Nuclear Medicine participated in a multidisciplinary discussion to produce a joint statement on screening recommendations for ILD in CTD.
RESULTS
The expert panel achieved consensus on when and how to screen for ILD in patients with systemic sclerosis, rheumatoid arthritis, mixed connective tissue disease, Sjögren syndrome, idiopathic inflammatory myopathies and systemic lupus erythematous.
CONCLUSIONS
Despite the lack of data on screening for CTD-ILD, an expert panel of pulmonologists, rheumatologists and radiologists agreed on a series of screening recommendations to support decision-making and enable early diagnosis of ILD to ultimately improve outcomes and prognosis in patients with CTD.
PubMed: 38148269
DOI: 10.1016/j.pulmoe.2023.11.007 -
Cureus Dec 2023This comprehensive review delves into the intricate relationship between asthma and pregnancy, specifically focusing on the challenges encountered in the first trimester... (Review)
Review
This comprehensive review delves into the intricate relationship between asthma and pregnancy, specifically focusing on the challenges encountered in the first trimester and the ensuing impact on maternal and fetal health. Examining physiological changes during pregnancy reveals the dynamic interplay influencing respiratory function and immune responses. Key findings underscore the vulnerability to asthma exacerbations in the critical first trimester, emphasizing the potential risks to both maternal and fetal well-being. Maternal and fetal outcomes are discussed, emphasizing the associations between poorly controlled asthma and adverse perinatal outcomes. Implications for clinical practice highlight the importance of preconception care, continuous monitoring, and collaborative efforts between obstetricians and pulmonologists. Patient education emerges as a fundamental aspect to empower pregnant women in managing their condition. The conclusion emphasizes the imperative for comprehensive care, advocating for individualized treatment plans, multidisciplinary collaboration, and public health initiatives. By adopting this holistic approach, healthcare providers can navigate the complexities of asthma during pregnancy, ultimately ensuring the optimal health of both the expectant mother and her developing fetus.
PubMed: 38169705
DOI: 10.7759/cureus.49849 -
Europace : European Pacing,... Jul 2023Chronic obstructive pulmonary disease (COPD) negatively impacts the efficacy of heart rhythm control treatments in patients with atrial fibrillation (AF). Although COPD...
AIMS
Chronic obstructive pulmonary disease (COPD) negatively impacts the efficacy of heart rhythm control treatments in patients with atrial fibrillation (AF). Although COPD is recognized as a risk factor for AF, practical guidance about how and when to screen for COPD is not available. Herein, we describe the implementation of an integrated screening and management pathway for COPD into the existing pre-ablation work-up in an AF outpatient clinic infrastructure.
METHODS AND RESULTS
Consecutive unselected patients accepted for AF catheter ablation in the Maastricht University Medical Center+ were prospectively screened for airflow limitation using handheld (micro)spirometry at the pre-ablation outpatient clinic supervised by an AF nurse. Patients with results suggestive of airflow limitation were offered referral to the pulmonologist. Handheld (micro)spirometry was performed in 232 AF patients, which provided interpretable results in 206 (88.8%) patients. Airflow limitation was observed in 47 patients (20.3%). Out of these 47 patients, 29 (62%) opted for referral to the pulmonologist. The primary reason for non-referral was low perceived symptom burden. Using this screening strategy 17 (out of 232; 7.3%) ultimately received a diagnosis of chronic respiratory disease, either COPD or asthma.
CONCLUSION
A COPD care pathway can successfully be embedded in an existing AF outpatient clinic infrastructure, using (micro)spirometry and remote analysis of results. Although one out of five patients had results suggestive of an underlying chronic respiratory disease, only 62% of these patients opted for a referral. Pre-selection of patients as well as patient education might increase the diagnostic yield and requires further research.
Topics: Humans; Atrial Fibrillation; Pulmonary Disease, Chronic Obstructive; Lung; Risk Factors
PubMed: 37421318
DOI: 10.1093/europace/euad193 -
JCO Global Oncology Mar 2024To characterize treatment patterns and real-world clinical outcomes of patients with metastatic non-small cell lung cancer (mNSCLC) who developed progression on an...
Real-World Treatment Patterns and Clinical Outcomes After Platinum-Doublet Chemotherapy and Immunotherapy in Metastatic Non-Small Cell Lung Cancer: A Multiregional Chart Review in the United States, Europe, and Japan.
PURPOSE
To characterize treatment patterns and real-world clinical outcomes of patients with metastatic non-small cell lung cancer (mNSCLC) who developed progression on an anti-PD-1/anti-PD-L1, herein referred to as anti-PD-(L)1, and platinum-doublet chemotherapy.
METHODS
Eligible oncologists/pulmonologists in the United States, Europe (France, Germany, and United Kingdom), and Japan completed electronic case report forms for patients with mNSCLC (no evidence of alterations). Eligible patients had disease progression on/after an anti-PD-(L)1 and platinum-doublet chemotherapy (received concurrently or sequentially), initiated a subsequent line of therapy (LOT) between 2017 and 2021, and had an Eastern Cooperative Oncology Group (ECOG) performance status 0-2 at this subsequent LOT initiation (index date). Overall survival (OS), time to treatment discontinuation (TTD), and real-world progression-free survival (rwPFS) after index were assessed using Kaplan-Meier analysis.
RESULTS
Overall, 160 physicians (academic, 54.4%; community, 45.6%) provided deidentified data from 487 patient charts (United States, 141; Europe, 218; Japan, 128; at mNSCLC diagnosis: median age 66 years, 64.7% male, 81.3% nonsquamous, 86.2% de novo mNSCLC; at line of interest initiation: 86.0% ECOG 0-1, 39.6% liver metastases, 18.9% brain metastases, 79.1% smoking history). The most common treatment regimens upon progression after anti-PD-(L)1/platinum-doublet chemotherapy were nonplatinum chemotherapy (50.5%), nonplatinum chemotherapy plus vascular endothelial growth factor receptor inhibitor (12.9%), and platinum-doublet chemotherapy (6.6%). Median OS was 8.8 months (squamous, 7.8 months; nonsquamous, 9.5 months). Median TTD was 4.3 months (squamous, 4.1 months; nonsquamous, 4.3 months). Median rwPFS was 5.1 months (squamous, 4.6 months; nonsquamous, 5.4 months).
CONCLUSION
In this multiregional, real-world analysis of pooled patient chart data, patients with mNSCLC who had disease progression after anti-PD-(L)1/platinum-doublet chemotherapy had poor clinical outcomes with various treatment regimens, demonstrating an unmet clinical need for effective options after failure on anti-PD-(L)1 and platinum-doublet chemotherapy treatments.
Topics: Humans; Male; United States; Aged; Female; Carcinoma, Non-Small-Cell Lung; Lung Neoplasms; Platinum; Japan; Protein-Tyrosine Kinases; Vascular Endothelial Growth Factor A; Antineoplastic Combined Chemotherapy Protocols; Proto-Oncogene Proteins; Immunotherapy; Disease Progression; Carcinoma, Squamous Cell
PubMed: 38484195
DOI: 10.1200/GO.23.00483 -
Patient Preference and Adherence 2023Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, and ultimately fatal lung disease that, while rare, has seen incidence rise over time. There is no cure...
I-PreFer Study: A Discrete Choice Experiment to Explore Patient, Caregiver and Pulmonologist Preferences of Idiopathic Pulmonary Fibrosis Pharmacological Treatment Options.
PURPOSE
Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, and ultimately fatal lung disease that, while rare, has seen incidence rise over time. There is no cure for IPF other than a lung transplant, though two antifibrotic (AF) drugs do exist to slow disease progression. While these drugs are efficacious, they are both associated with differing profiles of adverse events. This study aimed to elicit patient, caregiver and pulmonologist preferences on the treatment profiles of AFs via a discrete choice experiment (DCE).
PATIENTS AND METHODS
The DCE and associated survey were distributed across 7 European countries, and bespoke DCEs were developed for patients/caregivers and pulmonologists. After collaboration with European Pulmonary Fibrosis & Related Disorders Federation (EU-PFF) and expert pulmonologists, respectively, a patient/caregiver DCE with 5 attributes and a pulmonologist DCE with 6 attributes were finalized. The DCEs had a blocked approach to reduce participant burden and were distributed on an online survey platform. Preferences were estimated through conditional multinomial logit regression analysis.
RESULTS
Ninety-five patients, 22 caregivers and 115 pulmonologists fully completed their respective DCEs. Overall, patients and caregivers preferred management of treatment-related adverse events over both survival benefits and disease progression. Nearly all preference levels were found to be significantly different from their reference level. In contrast, pulmonologists showed a greater preference for control of lung function and exacerbations over adverse events. Although there were relative differences between the univariate subgroups in terms of the preference weights, most of these were not statistically significant.
CONCLUSION
The outcomes from this study suggest that while patients and caregivers had similar preferences for characteristics of IPF treatments, pulmonologists did not share those same preferences. Patients and caregivers preferred safety, while pulmonologists preferred efficacy. These differences should be considered by clinicians to better involve the patient in treatment decision-making for IPF.
PubMed: 37560147
DOI: 10.2147/PPA.S409767 -
Emergency Medicine Journal : EMJ Oct 2023Serial point-of-care ultrasound (PoCUS) can potentially improve acute patient care through treatment adjusted to the dynamic ultrasound findings. The objective was to... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Serial point-of-care ultrasound (PoCUS) can potentially improve acute patient care through treatment adjusted to the dynamic ultrasound findings. The objective was to investigate if treatment guided by monitoring patients with acute dyspnoea with serial cardiopulmonary PoCUS and usual care could reduce the severity of dyspnoea compared with usual care alone.
METHODS
This was a randomised, controlled, blinded-outcome trial conducted in three EDs in Denmark between 9 October 2019 and 26 May 2021. Patients aged ≥18 years admitted with a primary complaint of dyspnoea were allocated 1:1 with block randomisation to usual care, which included a single cardiopulmonary PoCUS within 1 hour of arrival (control group) or usual care (including a PoCUS within 1 hour of arrival) plus two additional PoCUS performed at 2 hours interval from the initial PoCUS (serial ultrasound group). The primary outcome was a reduction of dyspnoea measured on a verbal dyspnoea scale (VDS) from 0 to 10 recorded at inclusion and after 2, 4 and 5 hours.
RESULTS
There were 206 patients recruited, 102 in the serial ultrasound group and 104 in the control group, all of whom had complete follow-up. The mean difference in VDS between patients in the serial ultrasound and the control group was -1.09 (95% CI -1.51 to -0.66) and -1.66 (95% CI -2.09 to -1.23) after 4 and 5 hours, respectively. The effect was more pronounced in patients with a presumptive diagnosis of acute heart failure (AHF). A larger proportion of patients received diuretics in the serial ultrasound group.
CONCLUSION
Therapy guided by serial cardiopulmonary PoCUS may, together with usual care, facilitate greater improvement in the severity of dyspnoea, especially in patients with AHF compared with usual care with a single PoCUS in the ED. Serial PoCUS should therefore be considered for routine use to aid the physician in stabilising the patient faster.
TRIAL REGISTRATION NUMBER
NCT04091334.
Topics: Humans; Adolescent; Adult; Point-of-Care Systems; Point-of-Care Testing; Heart; Dyspnea; Heart Failure; Ultrasonography; Emergency Service, Hospital
PubMed: 37595984
DOI: 10.1136/emermed-2022-212694