Gilda Diaz-Fuentes - Academia.edu (original) (raw)

Papers by Gilda Diaz-Fuentes

Research paper thumbnail of Case Report Ciprofloxacin-Induced Thrombotic Thrombocytopenic Purpura: A Case of Successful Treatment and Review of the Literature

Attribution License, which permits unrestricted use, distribution, and reproduction in any medium... more Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. A 49-year-old African American woman was admitted to our hospital with abdominal pain, nausea, vomiting, lethargy, and confusion. She was receiving ciprofloxacin for a urinary-tract infection prior to admission. Laboratory examination revealed anemia, thrombocytopenia, elevated lactate dehydrogenase, and serumcreatinine. Peripheral smear showednumerous schistocytes, and the patient was diagnosed with thrombotic thrombocytopenic purpura (TTP). Ciprofloxacin was identified as the offending agent. The patient received treatment with steroids and plasmapheresis, which led to rapid clinical recovery. This is the first case to our knowledge of successfully treated ciprofloxacin-induced TTP; previously reported cases had fulminant outcomes. Quinolones are an important part of the antibiotic armamentarium, and this case can raise awareness of the a...

Research paper thumbnail of Family-Centered Care Project to Improve Experience of Families Who Lost Their Loved Ones in the Icu at an Inner-City Hospital in New York City: A Performance Improvement Initiative

Chest, 2020

To assess the impact of a multidisciplinary team approach on family satisfaction with end of life... more To assess the impact of a multidisciplinary team approach on family satisfaction with end of life care in intensive care unit (ICU). METHODS: A multidisciplinary Family-Centered Care (FCC) team was created at BronxCare Hospital Center. Our institution cares for an underserved inner-city community. Team members included nurses, physicians, social workers and spiritual advisors. The goal of FCC initiative was to address families' needs before, during and after patient's death. All ICU staff was educated about the new project. FCC protocol began with identification of a dying patient. The process was coordinated by designated nursing staff using a checklist. Hospital policy was changed to allow families to be present during resuscitation efforts and a moment of silence was held after each patient's demise. Spiritual services were offered. Kit with beverages and snacks, as well as bereavement booklets were provided. Families also received a follow-up phone call and condolences cards. ICU staff adherence with the project was monitored regularly.

Research paper thumbnail of Unilateral pulmonary artery agenesis: An unusual cause of unilateral ARDS

Respiratory Medicine Case Reports, 2018

Unilateral pulmonary artery agenesis (UPAA) is a rare malformation that can present as an isolate... more Unilateral pulmonary artery agenesis (UPAA) is a rare malformation that can present as an isolated anomaly or may be associated with certain congenital cardiac anomalies, such as tetralogy of Fallot, atrial septal defect, coarctation of aorta, right aortic arch, truncus arteriosus and pulmonary atresia. Clinical presentation is nonspecific which makes the diagnosis elusive; chronic dyspnea, hemoptysis or recurrent infections are the most common manifestations. Patients may remain asymptomatic until adulthood. There is no definitive treatment for patients with UPAA. Acute respiratory distress syndrome (ARDS) is usually a bilateral disease, unilateral ARDS has been described after lung resection or trauma. We present a case of a 39 year-old woman who developed unilateral ARDS and was later diagnosed with isolated UPAA.

Research paper thumbnail of Acute Colonic Pseudo-Obstruction Caused by Dexmedetomidine: A Case Report and Literature Review

American Journal of Case Reports, 2019

Rare co-existance of disease or pathology Background: Acute colonic pseudo-obstruction (ACPO) is ... more Rare co-existance of disease or pathology Background: Acute colonic pseudo-obstruction (ACPO) is an infrequent entity characterized by non-toxic, non-mechanical, abrupt, functional dilation of the colon. Clinically patients present with abdominal distention, anxiety, severe abdominal pain, nausea, and vomiting. This rare entity can lead to a fatal outcome if not recognized early. A high level of suspicions is paramount for early diagnosis and prompt intervention. Case Report: A 50-year-old male was admitted to the intensive unit care due to acute hypoxic respiratory failure, pneumonia, and septic shock requiring mechanical ventilation and intravenous vasopressors. Two weeks after admission, his clinical course deteriorated and was complicated with acute abdominal distension, pain, and ileus. Imaging confirmed acute onset of ileus and after ruling out metabolic and infectious causes, the diagnosis of ACPO was made. Aggressive medical and surgical management resulted in a favorable outcome. Conclusions: Critically ill patients on ventilator are commonly sedated; therefore, usual symptoms of ACPO can be missed or misinterpreted leading to late diagnosis with increased morbidity and mortality. Clinicians must be aware of potential harm and side effects from common sedatives used in the intensive care unit and should be current on medical literature. Alpha-2 agonists, i.e., dexmedetomidine, is increasingly been used in critical care setting and there are few reports of a possible association with ACPO. We present here a case of a patient with dexmedetomidine-induced ACPO, and we provide a review of the existing literature and pathophysiology of the condition.

Research paper thumbnail of Hepatic Rupture Complicating Postpartum HELLP Syndrome

D55. FROM THE WHITE ELEPHANT TO THE COMMON CANARY: PRESENTATION AND OUTCOMES OF COMMON AND NOT-SO-COMMON CRITICAL ILLNESSES, 2012

Research paper thumbnail of Upper Airway Obstruction Due to Factor VIII Inhibitor Deficiency

Journal of Bronchology, 2008

ABSTRACT

Research paper thumbnail of Diffuse Alveolar Hemorrhage and Acute Respiratory Distress Syndrome During Treatment of Rheumatoid Arthritis With Etanercept

Journal of Bronchology & Interventional Pulmonology, 2012

Etanercept (Enbrel) is a drug targeted against tumor necrosis factor-α, which is increasingly bei... more Etanercept (Enbrel) is a drug targeted against tumor necrosis factor-α, which is increasingly being used in treatment of a variety of autoimmune disorders. It has been reported to have a relatively safe profile; reported reactions have been of minor to moderate severity and range from hypersensitivity reactions, serious infections, fulminant pneumonias, and lung nodules. We report a case of diffuse alveolar hemorrhage and acute lung injury probably related to its use in a patient with rheumatoid arthritis. A high index of suspicion for noninfectious pulmonary diseases should also be considered when a patient with autoimmune disease treated with etanercept presents with pulmonary infiltrates and hypoxia refractory to antibiotics. Flexible bronchoscopy with sequential lavage should be attempted to detect and confirm the diagnosis of diffuse alveolar hemorrhage even if the patient does not have hemoptysis.

Research paper thumbnail of Role of Transbronchial Lung Biopsy in HIV Positive Patients Suspected to Have Pneumocystis jirovecii Pneumonia

Journal of Bronchology, 2007

Objectives: Despite several reports on the results of flexible bronchoscopy (FB) in patients susp... more Objectives: Despite several reports on the results of flexible bronchoscopy (FB) in patients suspected to have Pneumocystis jirovecii pneumonia (PCP), controversy still exists regarding the role of transbronchial biopsy (TBBx) in addition to bronchoalveolar lavage (BAL) routinely in these patients. The goal of the study was to evaluate the role of performing TBBx routinely during FB in patients suspected to have infection due to P. jirovecii. A retrospective chart review of all the HIV positive patients, who were sputum negative and who underwent FB in 2002 and 2003 for suspicion of PCP was carried out.

Research paper thumbnail of Cost Containment in the Intensive Care Unit (Icu)

Critical Care Medicine, 1998

Research paper thumbnail of Adult Respiratory Distress Syndrome (Ards): Comparison Between Hiv Positive and Hiv Negative/Unknown Patients–Determinants of Outcome in an Inner City Hospital

CHEST Journal, 2007

PURPOSE: Implementation of lung protective strategies and fluid restriction has been shown to imp... more PURPOSE: Implementation of lung protective strategies and fluid restriction has been shown to improve outcome in ARDS. Reported predictors of mortality include age, etiology of ARDS and HIV status among others.The objective of the study is to compare etiology and determinants of outcome for ARDS in HIV positive and HIV negative/unknown patients. METHODS: Retrospective review of hospitalized patients with ARDS from 2005 to 2007.P value less than 0.05 was considered significant. RESULTS: We identified 53 patients, mean age 51 years, 30 and 23 in the HIV positive and negative/unknown groups respectively. The 30 HIV patients had AIDS as per CDC definition. Out of the other 23 patients, 6 were HIV negative, 4 had normal CD4 counts and the remaining 13 patients had no HIV test or CD4 cells available-they had no risk factor for HIV infection. There were no statistically significant differences between the two groups for demographics, co-morbid conditions other than HIV status,mortality,severity of illness and lung Injury scores. Plateau pressures were <35cmH2O in both groups.There was statistically significant difference in the tidal volume (TV) used between the groups, mean TV in the HIV negative was 6cc/kg versus 7.4cc/kg in the HIV positive. Exclusion of the HIV unknown patients did not change the results of the analysis. Table 1-Multivariate comparison analysis of determinants of outcome between survivors and non survivors showed that weight gain(positive fluid balance) was the only statistically significant variable associated with poor outcome, p 0.01 Table 2. CONCLUSION: We did not find HIV status to be a determinant of outcome in our ARDS patients.Low TV ventilatory strategy was seen more often in the HIV negative/unknown group. Our study support the data that weight gain(positive fluid balance)is a predictive factor for mortality in ARDS patients. CLINICAL IMPLICATIONS: HIV status should not be a consideration when treating and implementing lung protecting strategies in ARDS patients.Fluid balance should be monitored and maintained in ARDS.

Research paper thumbnail of Isolated Abnormalities of Diffusion Capacity (Dlco) in Pulmonary Function Tests Among Inner City Patients

CHEST Journal, 2008

PURPOSE: Isolated abnormalities in DLCO are often seen during pulmonary function testing (PFT). T... more PURPOSE: Isolated abnormalities in DLCO are often seen during pulmonary function testing (PFT). There are very few studies evaluating the significance of these abnormalities. METHODS: All pfts done from January 2006 to March 2008 were analyzed retrospectively. ...

Research paper thumbnail of Reviewer ' s report Title : Unsuspected Pulmonary Alveolar Proteinosis in a person with AIDS : A case report

Research paper thumbnail of Impact of Group Asthma Education on Asthma Control and Emergency Room Visits in an Underserved New York Community

Canadian Respiratory Journal, 2019

Objective. Asthma education programs have been shown to be effective in decreasing health care ut... more Objective. Asthma education programs have been shown to be effective in decreasing health care utilization and improving disease control and management. However, there are few studies evaluating the outcomes of group asthma education. The aim of this study was to assess the impact of an outpatient adult group asthma education program in an inner-city-based hospital caring for an underserved population. Methods. We conducted a pre- and poststudy of all patients with asthma who participated in two structured group asthma education sessions led by a respiratory therapist, clinical pharmacist, and pulmonologist. The study period (January 2016 to April 2018) included the year before group education and the year after education. The primary outcomes were the number of patients requiring emergency room visits and hospital admission. The secondary outcomes included asthma control as assessed by Asthma Control Test scores, use of systemic corticosteroids, and change in test scores postinterv...

Research paper thumbnail of Influenza A Pneumonia Associated with Diffuse Alveolar Hemorrhage. A Case Report and Literature Review

American Journal of Case Reports, 2019

Rare co-existance of disease or pathology Background: Diffuse alveolar hemorrhage (DAH) represent... more Rare co-existance of disease or pathology Background: Diffuse alveolar hemorrhage (DAH) represents a life-threatening complication for many respiratory infections. We present a case of a patient with influenza A pneumonia associated with DAH. Case Report: An 80-year-old female patient was admitted with lethargy, dyspnea, and chest pain. On examination, she was afebrile with bilateral basal inspiratory crackles. Her chest x-ray revealed retro-cardiac infiltrate. Her hospital course was complicated by respiratory failure and septic shock requiring intubation. Nasopharyngeal swabs, rapid testing was positive for influenza A. Bronchoscopy showed diffuse bleeding and bronchoalveolar lavage (BAL) of the left lower lobe showed progressively bloody returns, consistent with DAH. Methylprednisolone 250 mg daily was started, with improvement in oxygenation. Repeat bronchoscopy 2 days later revealed normal mucosa and no further bleeding. The patient's respiratory status and infiltrates improved, but her overall status continued to deteriorate, and she died 2 weeks after admission. Conclusions: High fatality rates have been reported in patients with influenza A viral pneumonia complicated by DAH. Advanced age and the presence of significant co-morbidities might predispose a patient to the development of a more aggressive clinical manifestation of influenza A and also increases the risk of developing DAH. Therefore, clinicians managing patients with influenza A viral pneumonia with this predisposing history should also maintain a high suspicion for DAH. We suggest early BAL for diagnosis and for the evaluation of other infections etiologies. Aggressive supportive care and the use of antiviral agents is recommended. The role of steroids is unclear and can be considered in patients with fulminant disease but might have no outcome benefit.

Research paper thumbnail of Comparative outcomes of inpatients with lung collapse managed by bronchoscopic or conservative means

BMJ Open Respiratory Research, 2019

BackgroundAlthough the incidence and prevalence of atelectatic lung collapse is unknown, such eve... more BackgroundAlthough the incidence and prevalence of atelectatic lung collapse is unknown, such events are common among inpatients, and there are no guidelines for optimally instituting bronchoscopic techniques. The aim of this study was to evaluate the outcomes of patients with complete or near-complete lung collapse managed via interventional flexible fibreoptic bronchoscopy or a conservative approach.MethodsRetrospective analysis of all adult patients admitted to BronxCare Health System between January 2011 and October 2017 with a diagnosis of lung collapse/atelectasis. The primary outcome was radiological resolution. Timing of bronchoscopy relative to radiological resolution and mortality served as secondary outcomes.ResultsOf the 177 patients meeting inclusion criteria, 149 (84%) underwent bronchoscopy and 28 (16%) were managed through conservative measures only. A significantly greater number of patients in the bronchoscopy group achieved complete or near-complete resolution on ...

Research paper thumbnail of Impact of a Certified Asthma Educator Pharmacist on Medication Adherence in Patients with Persistent Asthma in an Inner-City Hospital

Journal of Pharmaceutics and Therapeutics, 2018

Background: The medication management for people with asthma (MMA) Healthcare Effectiveness Data ... more Background: The medication management for people with asthma (MMA) Healthcare Effectiveness Data and Information Set (HEDIS) measure assesses adherence to controller therapy >75% of the calendar year. A new “Action List” feature recently incorporated into Allscripts, the hospital electronic health record (EHR), is used by a certified asthma educator (AE-C) pharmacist to track both the progress of and to improve patients’ MMA measures.Objective: To evaluate the impact of an AE-C pharmacist using an EHR Action List on improving the number of patients with a MMA…

Research paper thumbnail of Significance of NT-pro-BNP in acute exacerbation of COPD patients without underlying left ventricular dysfunction

International Journal of Chronic Obstructive Pulmonary Disease, 2017

Background: B-type natriuretic peptide (BNP) and the N-terminal fragment of pro-BNP (NT-pro-BNP) ... more Background: B-type natriuretic peptide (BNP) and the N-terminal fragment of pro-BNP (NT-pro-BNP) are established biomarkers of heart failure. Increased levels of natriuretic peptide (NP) have been associated with poor outcomes in acute exacerbation of COPD (AECOPD); however, most studies did not address the conditions that can also increase NT-pro-BNP levels. We aimed to determine if NT-pro-BNP levels correlate with outcomes of AECOPD in patients without heart failure and other conditions that can affect NT-pro-BNP levels. Methods: We conducted a retrospective study in patients hospitalized for AECOPD with available NT-pro-BNP levels and normal left ventricular ejection fraction. We compared patients with normal and elevated NT-pro-BNP levels and analyzed the clinical and outcome data. Results: A total of 167 of 1,420 (11.7%) patients met the study criteria. A total of 77% of male patients and 53% of female patients had elevated NT-pro-BNP levels (P=0.0031). NT-pro-BNP levels were not associated with COPD severity and comorbid illnesses. Log-transformed NTpro-BNP levels were positively associated with echocardiographically estimated right ventricular systolic pressure (r=0.3658; 95% confidence interval [CI]: 0.2060-0.5067; P,0.0001). Patients with elevated NT-pro-BNP levels were more likely to require intensive care (63% vs 43%; P=0.0207) and had a longer hospital length of stay (P=0.0052). There were no differences in the need for noninvasive positive pressure ventilation (P=0.1245) or mechanical ventilation (P=0.9824) or in regard to in-hospital mortality (P=0.5273). Conclusion: Patients with AECOPD and elevated NT-pro-BNP levels had increased hospital length of stay and need for intensive care. Based on our study, serum NT-pro-BNP levels cannot be used as a biomarker for increased mortality or requirement for invasive or noninvasive ventilation in this group of patients.

Research paper thumbnail of Dexamethasone for Severe Acute Chest Syndrome Complicating Sickle Cell Disease

Critical Care Medicine, 2004

Research paper thumbnail of Ciprofloxacin-Induced Thrombotic Thrombocytopenic Purpura: A Case of Successful Treatment and Review of the Literature

Case Reports in Critical Care, 2015

A 49-year-old African American woman was admitted to our hospital with abdominal pain, nausea, vo... more A 49-year-old African American woman was admitted to our hospital with abdominal pain, nausea, vomiting, lethargy, and confusion. She was receiving ciprofloxacin for a urinary-tract infection prior to admission. Laboratory examination revealed anemia, thrombocytopenia, elevated lactate dehydrogenase, and serum creatinine. Peripheral smear showed numerous schistocytes, and the patient was diagnosed with thrombotic thrombocytopenic purpura (TTP). Ciprofloxacin was identified as the offending agent. The patient received treatment with steroids and plasmapheresis, which led to rapid clinical recovery. This is the first case to our knowledge of successfully treated ciprofloxacin-induced TTP; previously reported cases had fulminant outcomes. Quinolones are an important part of the antibiotic armamentarium, and this case can raise awareness of the association between quinolones and TTP. A high index of suspicion for detection and early and aggressive management are vitally important for a ...

Research paper thumbnail of Comparison of the Yield of Transthoracic Needle Aspiration and Core Needle Biopsy Between Pulmonologist and Radiologist in a Community Based Practice

Journal of Bronchology, 2008

Background: Transthoracic needle aspiration (TTNA) and core needle biopsy (CNB) are performed by ... more Background: Transthoracic needle aspiration (TTNA) and core needle biopsy (CNB) are performed by a pulmonologist or an interventional radiologist (IR). Very few pulmonary fellowship programs offer training in TTNA/CBN. We compared the yield and complications of TTNA/CNB when performed by pulmonologist versus IR. Method: This was a retrospective analysis of patients that underwent TTNA/CNB from 2003 to 2007 at our institution. Procedures were performed by either, any of 5 pulmonary fellows under the supervision of any of 4 pulmonologists or by a single IR. Results: Thirty-five patients were included, 19 in the pulmonary and 16 in the IR group. There were no differences in yield (P = 0.28) or complications (P = 0.31) between the groups. The overall diagnostic yield was 63% for pulmonary versus 69% for IR. Malignancy was the most common diagnosis (70%). CNB was used by pulmonary in 21% compared with 50% of IR cases. The yield was higher when TTNA was combined with CBN (75% vs. 61% for TTNA alone). An on-site pathologist was present only during the pulmonary cases. Conclusions: The overall yield and complications were similar in both groups. Combining TTNA and CBN provides higher yield than TTNA alone. Obtaining expertise in CNB is of the outmost importance to maximize yield and decrease need for more invasive procedures. Pulmonary fellowship programs should continue to offer training in TTNA/CNB with an onsite pathologist where available, to achieve diagnostic yield comparable with the interventional radiologist. Those programs should develop a system to maintain proficiency for the faculty.

Research paper thumbnail of Case Report Ciprofloxacin-Induced Thrombotic Thrombocytopenic Purpura: A Case of Successful Treatment and Review of the Literature

Attribution License, which permits unrestricted use, distribution, and reproduction in any medium... more Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. A 49-year-old African American woman was admitted to our hospital with abdominal pain, nausea, vomiting, lethargy, and confusion. She was receiving ciprofloxacin for a urinary-tract infection prior to admission. Laboratory examination revealed anemia, thrombocytopenia, elevated lactate dehydrogenase, and serumcreatinine. Peripheral smear showednumerous schistocytes, and the patient was diagnosed with thrombotic thrombocytopenic purpura (TTP). Ciprofloxacin was identified as the offending agent. The patient received treatment with steroids and plasmapheresis, which led to rapid clinical recovery. This is the first case to our knowledge of successfully treated ciprofloxacin-induced TTP; previously reported cases had fulminant outcomes. Quinolones are an important part of the antibiotic armamentarium, and this case can raise awareness of the a...

Research paper thumbnail of Family-Centered Care Project to Improve Experience of Families Who Lost Their Loved Ones in the Icu at an Inner-City Hospital in New York City: A Performance Improvement Initiative

Chest, 2020

To assess the impact of a multidisciplinary team approach on family satisfaction with end of life... more To assess the impact of a multidisciplinary team approach on family satisfaction with end of life care in intensive care unit (ICU). METHODS: A multidisciplinary Family-Centered Care (FCC) team was created at BronxCare Hospital Center. Our institution cares for an underserved inner-city community. Team members included nurses, physicians, social workers and spiritual advisors. The goal of FCC initiative was to address families' needs before, during and after patient's death. All ICU staff was educated about the new project. FCC protocol began with identification of a dying patient. The process was coordinated by designated nursing staff using a checklist. Hospital policy was changed to allow families to be present during resuscitation efforts and a moment of silence was held after each patient's demise. Spiritual services were offered. Kit with beverages and snacks, as well as bereavement booklets were provided. Families also received a follow-up phone call and condolences cards. ICU staff adherence with the project was monitored regularly.

Research paper thumbnail of Unilateral pulmonary artery agenesis: An unusual cause of unilateral ARDS

Respiratory Medicine Case Reports, 2018

Unilateral pulmonary artery agenesis (UPAA) is a rare malformation that can present as an isolate... more Unilateral pulmonary artery agenesis (UPAA) is a rare malformation that can present as an isolated anomaly or may be associated with certain congenital cardiac anomalies, such as tetralogy of Fallot, atrial septal defect, coarctation of aorta, right aortic arch, truncus arteriosus and pulmonary atresia. Clinical presentation is nonspecific which makes the diagnosis elusive; chronic dyspnea, hemoptysis or recurrent infections are the most common manifestations. Patients may remain asymptomatic until adulthood. There is no definitive treatment for patients with UPAA. Acute respiratory distress syndrome (ARDS) is usually a bilateral disease, unilateral ARDS has been described after lung resection or trauma. We present a case of a 39 year-old woman who developed unilateral ARDS and was later diagnosed with isolated UPAA.

Research paper thumbnail of Acute Colonic Pseudo-Obstruction Caused by Dexmedetomidine: A Case Report and Literature Review

American Journal of Case Reports, 2019

Rare co-existance of disease or pathology Background: Acute colonic pseudo-obstruction (ACPO) is ... more Rare co-existance of disease or pathology Background: Acute colonic pseudo-obstruction (ACPO) is an infrequent entity characterized by non-toxic, non-mechanical, abrupt, functional dilation of the colon. Clinically patients present with abdominal distention, anxiety, severe abdominal pain, nausea, and vomiting. This rare entity can lead to a fatal outcome if not recognized early. A high level of suspicions is paramount for early diagnosis and prompt intervention. Case Report: A 50-year-old male was admitted to the intensive unit care due to acute hypoxic respiratory failure, pneumonia, and septic shock requiring mechanical ventilation and intravenous vasopressors. Two weeks after admission, his clinical course deteriorated and was complicated with acute abdominal distension, pain, and ileus. Imaging confirmed acute onset of ileus and after ruling out metabolic and infectious causes, the diagnosis of ACPO was made. Aggressive medical and surgical management resulted in a favorable outcome. Conclusions: Critically ill patients on ventilator are commonly sedated; therefore, usual symptoms of ACPO can be missed or misinterpreted leading to late diagnosis with increased morbidity and mortality. Clinicians must be aware of potential harm and side effects from common sedatives used in the intensive care unit and should be current on medical literature. Alpha-2 agonists, i.e., dexmedetomidine, is increasingly been used in critical care setting and there are few reports of a possible association with ACPO. We present here a case of a patient with dexmedetomidine-induced ACPO, and we provide a review of the existing literature and pathophysiology of the condition.

Research paper thumbnail of Hepatic Rupture Complicating Postpartum HELLP Syndrome

D55. FROM THE WHITE ELEPHANT TO THE COMMON CANARY: PRESENTATION AND OUTCOMES OF COMMON AND NOT-SO-COMMON CRITICAL ILLNESSES, 2012

Research paper thumbnail of Upper Airway Obstruction Due to Factor VIII Inhibitor Deficiency

Journal of Bronchology, 2008

ABSTRACT

Research paper thumbnail of Diffuse Alveolar Hemorrhage and Acute Respiratory Distress Syndrome During Treatment of Rheumatoid Arthritis With Etanercept

Journal of Bronchology & Interventional Pulmonology, 2012

Etanercept (Enbrel) is a drug targeted against tumor necrosis factor-α, which is increasingly bei... more Etanercept (Enbrel) is a drug targeted against tumor necrosis factor-α, which is increasingly being used in treatment of a variety of autoimmune disorders. It has been reported to have a relatively safe profile; reported reactions have been of minor to moderate severity and range from hypersensitivity reactions, serious infections, fulminant pneumonias, and lung nodules. We report a case of diffuse alveolar hemorrhage and acute lung injury probably related to its use in a patient with rheumatoid arthritis. A high index of suspicion for noninfectious pulmonary diseases should also be considered when a patient with autoimmune disease treated with etanercept presents with pulmonary infiltrates and hypoxia refractory to antibiotics. Flexible bronchoscopy with sequential lavage should be attempted to detect and confirm the diagnosis of diffuse alveolar hemorrhage even if the patient does not have hemoptysis.

Research paper thumbnail of Role of Transbronchial Lung Biopsy in HIV Positive Patients Suspected to Have Pneumocystis jirovecii Pneumonia

Journal of Bronchology, 2007

Objectives: Despite several reports on the results of flexible bronchoscopy (FB) in patients susp... more Objectives: Despite several reports on the results of flexible bronchoscopy (FB) in patients suspected to have Pneumocystis jirovecii pneumonia (PCP), controversy still exists regarding the role of transbronchial biopsy (TBBx) in addition to bronchoalveolar lavage (BAL) routinely in these patients. The goal of the study was to evaluate the role of performing TBBx routinely during FB in patients suspected to have infection due to P. jirovecii. A retrospective chart review of all the HIV positive patients, who were sputum negative and who underwent FB in 2002 and 2003 for suspicion of PCP was carried out.

Research paper thumbnail of Cost Containment in the Intensive Care Unit (Icu)

Critical Care Medicine, 1998

Research paper thumbnail of Adult Respiratory Distress Syndrome (Ards): Comparison Between Hiv Positive and Hiv Negative/Unknown Patients–Determinants of Outcome in an Inner City Hospital

CHEST Journal, 2007

PURPOSE: Implementation of lung protective strategies and fluid restriction has been shown to imp... more PURPOSE: Implementation of lung protective strategies and fluid restriction has been shown to improve outcome in ARDS. Reported predictors of mortality include age, etiology of ARDS and HIV status among others.The objective of the study is to compare etiology and determinants of outcome for ARDS in HIV positive and HIV negative/unknown patients. METHODS: Retrospective review of hospitalized patients with ARDS from 2005 to 2007.P value less than 0.05 was considered significant. RESULTS: We identified 53 patients, mean age 51 years, 30 and 23 in the HIV positive and negative/unknown groups respectively. The 30 HIV patients had AIDS as per CDC definition. Out of the other 23 patients, 6 were HIV negative, 4 had normal CD4 counts and the remaining 13 patients had no HIV test or CD4 cells available-they had no risk factor for HIV infection. There were no statistically significant differences between the two groups for demographics, co-morbid conditions other than HIV status,mortality,severity of illness and lung Injury scores. Plateau pressures were <35cmH2O in both groups.There was statistically significant difference in the tidal volume (TV) used between the groups, mean TV in the HIV negative was 6cc/kg versus 7.4cc/kg in the HIV positive. Exclusion of the HIV unknown patients did not change the results of the analysis. Table 1-Multivariate comparison analysis of determinants of outcome between survivors and non survivors showed that weight gain(positive fluid balance) was the only statistically significant variable associated with poor outcome, p 0.01 Table 2. CONCLUSION: We did not find HIV status to be a determinant of outcome in our ARDS patients.Low TV ventilatory strategy was seen more often in the HIV negative/unknown group. Our study support the data that weight gain(positive fluid balance)is a predictive factor for mortality in ARDS patients. CLINICAL IMPLICATIONS: HIV status should not be a consideration when treating and implementing lung protecting strategies in ARDS patients.Fluid balance should be monitored and maintained in ARDS.

Research paper thumbnail of Isolated Abnormalities of Diffusion Capacity (Dlco) in Pulmonary Function Tests Among Inner City Patients

CHEST Journal, 2008

PURPOSE: Isolated abnormalities in DLCO are often seen during pulmonary function testing (PFT). T... more PURPOSE: Isolated abnormalities in DLCO are often seen during pulmonary function testing (PFT). There are very few studies evaluating the significance of these abnormalities. METHODS: All pfts done from January 2006 to March 2008 were analyzed retrospectively. ...

Research paper thumbnail of Reviewer ' s report Title : Unsuspected Pulmonary Alveolar Proteinosis in a person with AIDS : A case report

Research paper thumbnail of Impact of Group Asthma Education on Asthma Control and Emergency Room Visits in an Underserved New York Community

Canadian Respiratory Journal, 2019

Objective. Asthma education programs have been shown to be effective in decreasing health care ut... more Objective. Asthma education programs have been shown to be effective in decreasing health care utilization and improving disease control and management. However, there are few studies evaluating the outcomes of group asthma education. The aim of this study was to assess the impact of an outpatient adult group asthma education program in an inner-city-based hospital caring for an underserved population. Methods. We conducted a pre- and poststudy of all patients with asthma who participated in two structured group asthma education sessions led by a respiratory therapist, clinical pharmacist, and pulmonologist. The study period (January 2016 to April 2018) included the year before group education and the year after education. The primary outcomes were the number of patients requiring emergency room visits and hospital admission. The secondary outcomes included asthma control as assessed by Asthma Control Test scores, use of systemic corticosteroids, and change in test scores postinterv...

Research paper thumbnail of Influenza A Pneumonia Associated with Diffuse Alveolar Hemorrhage. A Case Report and Literature Review

American Journal of Case Reports, 2019

Rare co-existance of disease or pathology Background: Diffuse alveolar hemorrhage (DAH) represent... more Rare co-existance of disease or pathology Background: Diffuse alveolar hemorrhage (DAH) represents a life-threatening complication for many respiratory infections. We present a case of a patient with influenza A pneumonia associated with DAH. Case Report: An 80-year-old female patient was admitted with lethargy, dyspnea, and chest pain. On examination, she was afebrile with bilateral basal inspiratory crackles. Her chest x-ray revealed retro-cardiac infiltrate. Her hospital course was complicated by respiratory failure and septic shock requiring intubation. Nasopharyngeal swabs, rapid testing was positive for influenza A. Bronchoscopy showed diffuse bleeding and bronchoalveolar lavage (BAL) of the left lower lobe showed progressively bloody returns, consistent with DAH. Methylprednisolone 250 mg daily was started, with improvement in oxygenation. Repeat bronchoscopy 2 days later revealed normal mucosa and no further bleeding. The patient's respiratory status and infiltrates improved, but her overall status continued to deteriorate, and she died 2 weeks after admission. Conclusions: High fatality rates have been reported in patients with influenza A viral pneumonia complicated by DAH. Advanced age and the presence of significant co-morbidities might predispose a patient to the development of a more aggressive clinical manifestation of influenza A and also increases the risk of developing DAH. Therefore, clinicians managing patients with influenza A viral pneumonia with this predisposing history should also maintain a high suspicion for DAH. We suggest early BAL for diagnosis and for the evaluation of other infections etiologies. Aggressive supportive care and the use of antiviral agents is recommended. The role of steroids is unclear and can be considered in patients with fulminant disease but might have no outcome benefit.

Research paper thumbnail of Comparative outcomes of inpatients with lung collapse managed by bronchoscopic or conservative means

BMJ Open Respiratory Research, 2019

BackgroundAlthough the incidence and prevalence of atelectatic lung collapse is unknown, such eve... more BackgroundAlthough the incidence and prevalence of atelectatic lung collapse is unknown, such events are common among inpatients, and there are no guidelines for optimally instituting bronchoscopic techniques. The aim of this study was to evaluate the outcomes of patients with complete or near-complete lung collapse managed via interventional flexible fibreoptic bronchoscopy or a conservative approach.MethodsRetrospective analysis of all adult patients admitted to BronxCare Health System between January 2011 and October 2017 with a diagnosis of lung collapse/atelectasis. The primary outcome was radiological resolution. Timing of bronchoscopy relative to radiological resolution and mortality served as secondary outcomes.ResultsOf the 177 patients meeting inclusion criteria, 149 (84%) underwent bronchoscopy and 28 (16%) were managed through conservative measures only. A significantly greater number of patients in the bronchoscopy group achieved complete or near-complete resolution on ...

Research paper thumbnail of Impact of a Certified Asthma Educator Pharmacist on Medication Adherence in Patients with Persistent Asthma in an Inner-City Hospital

Journal of Pharmaceutics and Therapeutics, 2018

Background: The medication management for people with asthma (MMA) Healthcare Effectiveness Data ... more Background: The medication management for people with asthma (MMA) Healthcare Effectiveness Data and Information Set (HEDIS) measure assesses adherence to controller therapy >75% of the calendar year. A new “Action List” feature recently incorporated into Allscripts, the hospital electronic health record (EHR), is used by a certified asthma educator (AE-C) pharmacist to track both the progress of and to improve patients’ MMA measures.Objective: To evaluate the impact of an AE-C pharmacist using an EHR Action List on improving the number of patients with a MMA…

Research paper thumbnail of Significance of NT-pro-BNP in acute exacerbation of COPD patients without underlying left ventricular dysfunction

International Journal of Chronic Obstructive Pulmonary Disease, 2017

Background: B-type natriuretic peptide (BNP) and the N-terminal fragment of pro-BNP (NT-pro-BNP) ... more Background: B-type natriuretic peptide (BNP) and the N-terminal fragment of pro-BNP (NT-pro-BNP) are established biomarkers of heart failure. Increased levels of natriuretic peptide (NP) have been associated with poor outcomes in acute exacerbation of COPD (AECOPD); however, most studies did not address the conditions that can also increase NT-pro-BNP levels. We aimed to determine if NT-pro-BNP levels correlate with outcomes of AECOPD in patients without heart failure and other conditions that can affect NT-pro-BNP levels. Methods: We conducted a retrospective study in patients hospitalized for AECOPD with available NT-pro-BNP levels and normal left ventricular ejection fraction. We compared patients with normal and elevated NT-pro-BNP levels and analyzed the clinical and outcome data. Results: A total of 167 of 1,420 (11.7%) patients met the study criteria. A total of 77% of male patients and 53% of female patients had elevated NT-pro-BNP levels (P=0.0031). NT-pro-BNP levels were not associated with COPD severity and comorbid illnesses. Log-transformed NTpro-BNP levels were positively associated with echocardiographically estimated right ventricular systolic pressure (r=0.3658; 95% confidence interval [CI]: 0.2060-0.5067; P,0.0001). Patients with elevated NT-pro-BNP levels were more likely to require intensive care (63% vs 43%; P=0.0207) and had a longer hospital length of stay (P=0.0052). There were no differences in the need for noninvasive positive pressure ventilation (P=0.1245) or mechanical ventilation (P=0.9824) or in regard to in-hospital mortality (P=0.5273). Conclusion: Patients with AECOPD and elevated NT-pro-BNP levels had increased hospital length of stay and need for intensive care. Based on our study, serum NT-pro-BNP levels cannot be used as a biomarker for increased mortality or requirement for invasive or noninvasive ventilation in this group of patients.

Research paper thumbnail of Dexamethasone for Severe Acute Chest Syndrome Complicating Sickle Cell Disease

Critical Care Medicine, 2004

Research paper thumbnail of Ciprofloxacin-Induced Thrombotic Thrombocytopenic Purpura: A Case of Successful Treatment and Review of the Literature

Case Reports in Critical Care, 2015

A 49-year-old African American woman was admitted to our hospital with abdominal pain, nausea, vo... more A 49-year-old African American woman was admitted to our hospital with abdominal pain, nausea, vomiting, lethargy, and confusion. She was receiving ciprofloxacin for a urinary-tract infection prior to admission. Laboratory examination revealed anemia, thrombocytopenia, elevated lactate dehydrogenase, and serum creatinine. Peripheral smear showed numerous schistocytes, and the patient was diagnosed with thrombotic thrombocytopenic purpura (TTP). Ciprofloxacin was identified as the offending agent. The patient received treatment with steroids and plasmapheresis, which led to rapid clinical recovery. This is the first case to our knowledge of successfully treated ciprofloxacin-induced TTP; previously reported cases had fulminant outcomes. Quinolones are an important part of the antibiotic armamentarium, and this case can raise awareness of the association between quinolones and TTP. A high index of suspicion for detection and early and aggressive management are vitally important for a ...

Research paper thumbnail of Comparison of the Yield of Transthoracic Needle Aspiration and Core Needle Biopsy Between Pulmonologist and Radiologist in a Community Based Practice

Journal of Bronchology, 2008

Background: Transthoracic needle aspiration (TTNA) and core needle biopsy (CNB) are performed by ... more Background: Transthoracic needle aspiration (TTNA) and core needle biopsy (CNB) are performed by a pulmonologist or an interventional radiologist (IR). Very few pulmonary fellowship programs offer training in TTNA/CBN. We compared the yield and complications of TTNA/CNB when performed by pulmonologist versus IR. Method: This was a retrospective analysis of patients that underwent TTNA/CNB from 2003 to 2007 at our institution. Procedures were performed by either, any of 5 pulmonary fellows under the supervision of any of 4 pulmonologists or by a single IR. Results: Thirty-five patients were included, 19 in the pulmonary and 16 in the IR group. There were no differences in yield (P = 0.28) or complications (P = 0.31) between the groups. The overall diagnostic yield was 63% for pulmonary versus 69% for IR. Malignancy was the most common diagnosis (70%). CNB was used by pulmonary in 21% compared with 50% of IR cases. The yield was higher when TTNA was combined with CBN (75% vs. 61% for TTNA alone). An on-site pathologist was present only during the pulmonary cases. Conclusions: The overall yield and complications were similar in both groups. Combining TTNA and CBN provides higher yield than TTNA alone. Obtaining expertise in CNB is of the outmost importance to maximize yield and decrease need for more invasive procedures. Pulmonary fellowship programs should continue to offer training in TTNA/CNB with an onsite pathologist where available, to achieve diagnostic yield comparable with the interventional radiologist. Those programs should develop a system to maintain proficiency for the faculty.