Kaiser Permanente Castle Medical Center

Three cases of Dial and Liebow's intravascular bronchioloalveolar tumour are described, with emphasis on ultrastructure and histogenesis. The tumour cells are quite different from adjacent reactive alveolar cells and electron microscopy does not support the suggested alveolar cell origin. The tumour cells contain abundant microfilaments, moderate amounts of rough endoplasmic reticulum and varying numbers of Weibel-Palade bodies. With features of smooth muscle, myofibroblast and endothelial cell differentiation, a vascular origin from precursor mesenchymal cells such as the vasoformative reserve cells is suggested.

PURPOSE: The role of vitamin K in the prevention and treatment of osteoporosis and arterial calcification is examined. SUMMARY: Vitamin K is essential for the activation of vitamin K-dependent proteins, which are involved not only in blood coagulation but in bone metabolism and the inhibition of arterial calcification. In humans, vitamin K is primarily a cofactor in the enzymatic reaction that converts glutamate residues into gamma-carboxyglutamate residues in vitamin K-dependent proteins. Numerous studies have demonstrated the importance of vitamin K in bone health. The results of recent studies have suggested that concurrent use of menaquinone and vitamin D may substantially reduce bone loss. Menaquinone was also found to have a synergistic effect when administered with hormone therapy. Several epidemiologic and intervention studies have found that vitamin K deficiency causes reductions in bone mineral density and increases the risk of fractures. Arterial calcification is an active, cell-controlled process that shares many similarities with bone metabolism. Concurrent arterial calcification and osteoporosis have been called the "calcification paradox" and occur frequently in postmenopausal women. The results of two dose-response studies have indicated that the amount of vitamin K needed for optimal gamma-carboxylation of osteocalcin is significantly higher than what is provided through diet alone and that current dosage recommendations should be increased to optimize bone mineralization. Few adverse effects have been reported from oral vitamin K. CONCLUSION: Phytonadione and menaquinone may be effective for the prevention and treatment of osteoporosis and arterial calcification.

OBJECTIVES: The Hawaii Child Asthma Research to Elevate Standards (CARES) Program implemented an emergency department (ED)-based education and management program to facilitate National Asthma Education and Prevention Program (NAEPP) guideline understanding among asthmatic children and their families, ED staff, and health care providers. METHODS: The multipronged approach used: (1) 2-phased prospective tracking system of ED asthma patients; (2) ED-based educational intervention for patients/families; and (3) asthma education for ED staff and community-based health care providers. Data were collected across 4 EDs during phase I (October 8, 2002, to October 1, 2003) and phase II (October 1, 2003, to July 8, 2004). Follow-up data were collected by telephone 3 weeks (phase I), and 3 weeks and 3 months (phase II) after the ED encounter. The patient/family intervention was delivered throughout phase II. During phase I, ED and community-based health care professionals developed strategies for building an integrated asthma care system. ED staff training was delivered before phase II. Continuing medical education for health care providers was delivered before and during the first month of phase II. RESULTS: Tracking data on 706 phase I and 353 phase II patient encounters revealed that the majority of patients with persistent asthma did not use long-term controller medications and did not possess a written asthma action plan. From preintervention to postintervention, the number of patients possessing a written asthma action plan increased from 48 to 322. Of 186 persistent asthmatics, 34 were using controller medications daily, 34 as needed, and 118 not at all. Daily use increased to 80 3 weeks postintervention and to 68 3 months postintervention. CONCLUSION: An ED-based childhood asthma tracking system can serve as a basis for designing and implementing an ED-based educational intervention. ED staff, primary care providers, and others can work together to promote asthma care.

BACKGROUND: The objective of the study was to quantitatively compare school- and community-based dental clinics in New York City that provide dental services to children in need. It was hypothesized that the school-based clinics would perform better in terms of several measures. METHODS: We reviewed billing and visit data derived from encounter forms and expense reports from 4 school- and 3 community-based clinics during 12 months in 2004-2005. The health clinics, administered by the Children's Aid Society, provided dental services to children regardless of ability to pay. The assessments were based on 8 performance indicators, including some based on relative value units, and profile of service indicators was used for assessment. Descriptive statistics and results from hypothesis tests are reported. RESULTS: Based on significant and large differences on the indicators, the school-based health clinics appear to have definite advantages over community-based dental clinics. Results were consistent across many indicators. CONCLUSIONS: The results support increasing the number of school-based dental clinics in urban areas that serve children in need. Being based in schools, factors such as transportation issues, parent availability, and missed appointments are greatly reduced. This has great public dental health implications for children in underserved areas. Schools provide a natural location to provide preventive and responsive dental care. Similar advantages could be expected in rural areas and other areas of need.

The objective of this study was to identify the predictors of outcome of distal rectus femoris transfer in cerebral palsy. Preoperative and postoperative gait data for 81 patients were examined, focusing on knee flexion/extension range. Outcome was 'good' for 46 patients and 'poor' for 35. The poor outcome group had no improvement in knee range because of increased crouch postoperatively. Outcome was unrelated to quadriceps strength, crouch, velocity, or type of cerebral palsy. Gross Motor Function Classification System was predictive of outcome, with poor results in all level IV patients (P< or =0.008). In conclusion, Gross Motor Function Classification System IV patients may not benefit from distal rectus femoris transfer because of increased postoperative crouch.

This chapter contains sections titled: Life history and biology Broodstock husbandry Larviculture Growout Diseases Marketing Hatchery economics Production economics Summary: industry constraints and future expectations Conclusions Literature cited

Background: The American Heart Association (AHA) has implemented several programs to educate the public about cardiopulmonary resuscitation (CPR). A common issue in bystander CPR is the fear of hurting the victim. As a result, the victim may not receive CPR in time. The purpose of this study was to measure the emotional impact of CPR training on high school students using two approved AHA courses. Methods: A total of 60 students participated in this study. These students had a mean age of 15.4±1.2 years old and were selected from a high school in Southern California. Subjects were divided into two groups, Basic Life Support (BLS) (n1=31) and Hands-Only CPR (n2=29). Emotional impacts were assessed by having each subject answer a questionnaire based on given scenarios before and after their training session. Results: There was a significant difference in both groups when comparing positive-emotion scores before and after the training (BLS: 30.3± 6.0 vs. 34.5±6.7, p < 0.001; Hands-only 27.9±5.0 vs. 32.1±6.5, p<0.001). In addition, both groups showed significant reductions in negative-emotion scores (BLS:29.2±6.7 vs. 23.7±6.5, p< 0.001 and Hands-Only:26.8±6.1vs. 24.8±7.7, p=0.05). Conclusion: Our results indicate that the AHA programs have positive effects on students’ emotional response. We recommend that future studies include an in-depth study design that probes the complexity of students’ emotions after completing an AHA session.

This is a case of Acute Respiratory Distress Syndrome managed using esophageal balloon catheter to adjust inspiratory pressure and positive end expiratory pressure according to the inspiratory and expiratory transpulmonary pressures. There are no studies that examine the transpulmonary pressures in airway pressure release ventilation (APRV). We aimed to test the feasibility of using the esophageal balloon in the nonconventional mode of APRV. All pressures were observed when switching the mode from a pressure-controlled mode to APRV using the same inspiratory pressure and using various incremental release times (T Low )to calculate the expiratory transpulmonary pressure. At all T Low levels the transpulmonary pressure at end exhalation was in the negative value indicating alveolar collapse. A larger study is needed to confirm our findings and to help guide setting APRV.

There have been a recent shortage of both critical care physicians and respiratory therapists with training in mechanical ventilation that is accentuated by the recent COVID-19 crisis. Hospitalists and primary care physicians find themselves more often dealing with and treating critically ill patients on mechanical ventilation without specific training. This two part review will try to explain and simplify some of the physiologic concepts of mechanical ventilation, strategies for managements of different diseases, monitoring, brief review of some of the common modes used for support and weaning during mechanical ventilation and to address some of the adverse effects associated with mechanical ventilation. We understand the complexity of the subject and this review would not be a substitute of seeking appropriate counselling, further training, and medical knowledge about mechanical ventilation. Further free resources are available to help clinicians who feel uncomfortable making decisions with such technology Keywords: Mechanical ventilation, Driving pressure, Compliance, Resistance, Capnometry, Dead space, ARDS, PEEP, auto-PEEP, Plateau pressure, esophageal balloon

Abstract: Background There has been an exponential increase in modes of mechanical ventilation over the last couple decades. With this increase, there have been paucity of evidence of which mode is superior to others or much guidance to use a mode in different disease status causing respiratory failure. Methods: An international survey of six questions was posted on the “society of mechanical ventilation” website and advertised on social media over the period of four months. This is a descriptive study, results are presented in two different ways. First as the total modes used and secondly, per the geographical areas as the preferred mode, mode used mostly in ARDS, COPD, and Spontaneous weaning trials. Results: Conventional older modes, Volume-controlled and Pressure-controlled ventilation were used significantly more in general and in different disease states irrespective of geographical location. Four other modes were used almost equally in all disease states irrespective of geographical location. Pressure support ventilation was the most common mode used during the spontaneous breathing trial. Conclusion: There was large heterogenicity of modes used between clinicians in general, in different disease states and in between different international geographical locations. Mechanical ventilation modes utilization varies widely and remains a personal preference with no consensus between clinicians globally. Keywords: Modes of mechanical ventilation, ARDS, COPD, SBT, survey

Background: Airway pressure release ventilation has been available to clinicians for the last four decades. Unfortunately, its clinical value continues to be debatable. One of the many reasons responsible is the lack of consistency between its settings in clinical practice and research. We hypothesized that clinicians disagree on specific methods when establishing these parameters. Materials and Methods: A questionnaire-based survey was developed and sent to clinicians (critical care attending physician, critical care fellows in training and respiratory therapists) in about one hundred different academic hospitals with critical care training program. The survey consisted of ten questions including each of the four major APRV settings: T-High, T-Low, P-High, and P-Low. The survey was anonymous. Main results: Amongst the 187 respondents, there were significant disagreements between different categories of clinicians regarding methodology for establishing initial settings of APRV. However, when the responses were analyzed after sub-grouping based on categories of clinicians (Critical care attending physician vs critical care fellows vs respiratory therapists), no significant differences could be found. Conclusions: There is no agreement between different categories of clinicians when it comes to the methodology for establishing initial APRV settings. Our study highlights the need for larger clinical trials comparing different approaches to the same which could then be used for establishing scientific guidelines based on best evidence. Keywords: APRV, survey, T-High, T-Low, P-High, P-Low

1Adventist Health Castle Medical Center, KAILUA, HI 2Adventist Health Castle Medical Center, Kailua, HI

Introduction: Aspergillus is a ubiquitous fungus causing various pulmonary diseases depending on the host's immune status. Aspergillus tracheobronchitis, a rare form of invasive aspergillosis, primarily affects severely immunocompromised or critically ill patients. We present the first known case of Aspergillus tracheobronchitis complicated by tracheal perforation and subcutaneous emphysema successfully treated with conservative endotracheal tube manipulation. Case description: A 64-year-old male with type 2 diabetes mellitus presented with generalized weakness and abdominal discomfort, later diagnosed with a perforated cecum requiring right colectomy. His postoperative course in the intensive care unit was complicated by septic shock, acute kidney injury, and failed extubation due to airway compromise. Seven days after the failed extubation, he developed subcutaneous emphysema in the neck. Chest computed tomography scan showed neck, left chest wall, and mediastinal emphysema. Bronchoscopy identified a focal black necrotic lesion on the left proximal tracheal wall and multiple small mucosal ulcerations throughout the proximal to distal trachea. The endotracheal tube was advanced beyond proximal tracheal necrotic lesion. Subcutaneous emphysema reduced overnight, suggesting that the lesion was the source of the air leak. Bronchial washings confirmed Aspergillus fumigatus, establishing a diagnosis of invasive Aspergillus tracheobronchitis. Treatment with voriconazole prevented further expansion of emphysema, which gradually resolved. Conclusion: Subcutaneous emphysema in ventilated patients with tracheobronchitis is a rare and challenging complication. This case demonstrates successful management through endotracheal tube manipulation to tamponade the lesion, highlighting subcutaneous emphysema as a potential manifestation of Aspergillus tracheobronchitis and offering a minimally invasive treatment approach. LEARNING POINTS: Subcutaneous emphysema may present as a manifestation of Aspergillus/fungal tracheobronchitis.Aspergillus tracheobronchitis should be considered in patients with predisposing factors such as lung transplantation, acquired immunodeficiency syndrome (AIDS), diabetes mellitus, chronic obstructive pulmonary disease, and malignancies.Tracheal perforation caused by Aspergillus tracheobronchitis can be managed through endotracheal tube manipulation.

Yellow curve: Pressure (cmH2O) on X-axis and Time (seconds) on Y-axis Pink curve: Flow (L/sec) on X-axis and Time (seconds) on Y-axis Green curve: Tidal volume (ml) on X-axis and Time (seconds) on Y-axis Orange curve: Esophageal pressure (cmH2O) on X-axis and Time (seconds) on Y-axis The blue arrows point to the inspiratory effort on flow and esophageal curves that is not followed by a breath

Non-invasive ventilation use in acute COPD exacerbation and acute respiratory failure is very strong, however the evidence beyond home non-invasive ventilation for COPD patients is less clear. In this review we summarize the literature on the effectiveness of home non-invasive ventilation on mortality, hospital admission rates, quality of life, lung functions, gas exchange, exercise tolerance as well as mood and anxiety. Published guidelines from multiple societies mostly give weak and conditional guidelines on the use of home non-invasive ventilation. High intensity home non-invasive ventilation was recently introduced and may further improve the outcomes. New research regarding high intensity home non-invasive ventilation and new technology are needed to define the role and the benefits of home non-invasive ventilation in patients with COPD. Keywords: Home non-invasive ventilation, COPD, GOLD

Pneumothorax is a collapsed lung due to presence of air in the pleural cavity. In the absence of trauma, it is categorized as either primary or secondary spontaneous type. Primary spontaneous pneumothorax has no association with any pulmonary disease; secondary spontaneous pneumothorax (SSP) is caused by underlying lung disease. Catamenial pneumothorax is a SSP that occurs during perimenstruation thought to be associated with thoracic endometriosis. Less than 300 cases have been reported to date. No formal registry or guide for proper diagnosis and treatment algorithm is available. We are reporting a case of catamenial pneumothorax with recurrent symptomatology who suffered for 10 years due to the lack of association between timing of menstruation and spontaneous pneumothorax.A 29-year-old African American woman presented with one day history of persistent left-sided chest pain, accompanied by nonproductive cough, and increased shortness of breath at rest; she finished her menses three days prior. She had a chest tube inserted for spontaneous pneumothorax 10 years ago. Preliminary report of chest x-ray did not suggest evidence of pneumothorax; however, due to previous history of spontaneous pneumothorax, chest computerized tomography (CT) scan was pursued revealing a moderate size left pneumothorax. It also showed multiple bilateral pulmonary cysts and two small separate foci of pleural based tissue mass lesions adjacent to the diaphragm. Patient stated that she developed left upper back pain 4-5 separate incidences within the 10-year span of her first diagnosed pneumothorax. Chest x-rays were done during those occurrences but did not reveal any pneumothorax. At one point, patient was even sent for physical therapy with suspected muscle strain. She then recalled experiencing these symptoms toward the end of her menstruation. A thoracostomy tube was inserted; patient did well without supplemental oxygen. After two days, chest tube was removed, and patient was discharged home but did not follow up as outpatient. Six months later, she experienced another pneumothorax, and was then treated with pleurodesis. As far as we know, patient did not have any other episodes since that procedure.We present a case of catamenial pneumothorax with recurrent suffering that was misdiagnosed for 10 years. Despite appropriate menstrual history during medical interview, it is paramount to associate the possibility of this rare pneumothorax to menstruation to avoid this missed diagnosis. Formalizing a worldwide registry will standardize the way to enhance research into the true cause(s) and proper treatment algorithm for this rare, but possibly life-threatening, disorder.

Left figure: Passive patient esophageal pressure (Pes) in cmH2O on x-axis versus tidal volume in ml on y-axis. Green dashed line represents the chest wall compliance Right figure: same patient actively breathing on pressure support ventilation. (Pes) in cmH2O on x-axis versus tidal volume in ml on y-axis. Green dashed line represents the chest wall compliance. Red shaded area is the Campbell diagram representing the inspiratory work of breathing

How to calculate total respiratory system, chest wall and lung compliance and resistance. Picture Quiz

The authors declare no conflicts of interest.