Hemorrhagic Bullous Dermatosis

Introduction The patient is a 64 year old man with active primary central nervous system B-cell lymphoma who was hospitalized for management of a right lower extremity traumatic injury complicated by a calf hematoma. During the hospital stay, the patient was diagnosed with a provoked left lower extremity deep vein thrombosis (DVT) and treated initially with therapeutic dosing of enoxaparin. Five days after low molecular weight heparin (LMWH) initiation, gradual development of tense, well-circumscribed bullae were noted to appear on his arms and hands bilaterally, ranging from 0.5 cm to 1.5 cm in diameter. These lesions were both nonpruritic and nontender with no significant surrounding erythema (Figure 1). Bullae were located distal to the site of enoxaparin injections. Aside from a normocytic normochromic anemia related to chronic medical conditions, results of platelet counts, creatinine levels, and coagulation profiles remained unremarkable. A shave biopsy of one of the lesions revealed an intraepidermal collection of red blood cells without evidence of thrombotic or vasculitic changes (Figures 2 & 3). enoxaparin dose was reduced several days after lesion onset due to increasing calf hematoma size, in an effort to balance anticoagulation benefit for the DVT with risk of continued bleeding into the hematoma. The bullae started to regress approximately two weeks after onset, eventually crusting over. The patient was eventually discharged home

Editorial: Assessment of pain in the older population

For many years now we have proposed that pain is regularly assessed and fundamental to the management process. To date, there has been a great deal of research exploring the most appropriate pain assessment tools and great strides have been made in their implementation. Assessment of pain in the older population has presented challenges, especially when there are communication difficulties, as seen in adults with dementia or other communication issues. Pain is not a natural part of the ageing process and people should not be expected to live with it. In recent years, there has been recognition that stoicism does not mean there is no pain and a number of behavioural pain assessment tools have been developed, evaluated, and introduced widely, with widespread implementation of validated pain assessment. The papers in this collection examine the issues of pain assessment in older adults and those with dementia, moving forward thinking on these subjects and presenting innovative ways of implementing pain management using technology. The COVID 19 pandemic resulted in many older adults being isolated at home, so they consequently became more isolated. Furthermore, many services were disbanded in the UK and staff were reallocated to COVID areas which resulted in a reduced number of pain services and therefore increased waiting times

Transbronchial lung cryobiopsy guided by endobronchial ultrasound radial miniprobe in interstitial lung diseases : preliminary results of a prospective study

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Tension pneumothorax as a severe complication of endobronchial ultrasound-guided transbronchial fine needle aspiration of mediastinal lymph nodes

This article presents a case report of a patient suffering from bullous emphysema and chronic obstructive pulmonary disease, who was diagnosed with tension pneumothorax after undergoing endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Tension pneumothorax is a severe but rare complication of EBUS-TBNA. It can result from lung injury caused by the biopsy needle or, in patients suffering from bullous emphysema, from spontaneous rupture of an emphysematous bulla resulting from increased pressure in the chest cavity during cough caused by bronchofiberoscope insertion. The authors emphasize that patients should be carefully monitored after the biopsy, and, in the case of complications, provided with treatment immediately in proper hospital conditions. Patients burdened with a high risk of complications should be identified before the procedure and monitored with extreme care after its completion

The assessment of pain in older people: UK National Guidelines

We are facing a huge increase in the older population over the next 30 years. This brings an anticipated increase in the prevalence of chronic pain and with this comes the challenge of assessment of pain in many varied settings. Our first iteration of this document was published in 2007. But there has been a proliferation of literature and research since then, so we have developed a new set of guidelines. Different patterns and sites of pain were seen in men and women. Age differences suggest that pain prevalence increased with age up to 85 years and then decreased. The available studies on barriers and attitudes to pain management point towards an adherence to bio-medically orientated beliefs about pain, concern amongst clinicians in relation to activity recommendations, and a negative orientation in general towards patients with chronic painful conditions. A multidisciplinary approach to the assessment and treatment of pain is essential, but the assessment is a complex process which is hampered by many communication issues, including cognitive ability and socio-cultural factors. Such issues are part of the UK ageing population. Structured pain education should be implemented that provides all health professionals (whether professionally or non-professionally trained) with standardised education and training in the assessment and management of pain according to level of experience. Although subjective, patient self-report is the most valid and reliable indicator of pain and it may be necessary to ask questions about pain in different ways in order to elicit a response. A number of valid and reliable self-report measures are available and can be used even when moderate dementia exists. The Numerical Rating Scale or verbal descriptors can be used with people who have mild to moderate cognitive impairment. For people with severe cognitive impairment Pain in Advanced Dementia (PAINAD) and Doloplus-2 are recommended. PAINAD and Doloplus-2 scales continue to show positive results in terms of reliability and validity. There has been no recent evaluation of the Abbey pain scale although it is widely used throughout the UK. There is a need for more research into pain assessment using the collaborative role of the multidisciplinary team in all care settings. Self-report questionnaires of function are limited in their ability to capture the fluctuations in capacity and ability. The concentration on items of relevance to the population of interest means that issues of personal relevance can be obscured. Strong associations were seen between pain and depressed mood with each being a risk factor for the other. Additionally, loneliness and social isolation were associated with an increased risk of pain. Clinicians should be cognisant that social isolation and or depressive signs and symptoms may be indicators of pre-existing pain or a predictor of future pain onset. There are a number of evidence based guidelines on pain assessment in older people with or without cognitive impairment from around the world, including Australia and Europe

The influence of lung volume reduction with intrabronchial valves on the quality of life of patients with heterogeneous emphysema — a prospective study

Introduction: A heterogeneous emphysema is one of the most severe forms of chronic obstructive pulmonary disease (COPD). In some cases, besides the standard pharmacotherapy, a new treatment option of emphysema can be used — bronchoscopic lung volume reduction (BLVR) with the use of intrabronchial valves. Objectives: To examine the health-related quality of life (HRQoL) of patients with severe emphysema after intrabronchial valve (IBV) implantation for the treatment of one lung. Material and methods: From 2011 to 2013 a single center prospective observational study was performed. The study assessed the effect of the therapeutic BLVR intervention, measured by St. George Respiratory Questionnaire (SGRQ). A statistical analysis by use of Wilcoxon test for dependent variables was performed. Results: Twenty patients were enrolled to the study (mean age 63 ± 10 years old), all ex-smokers with tobacco exposure 38 ± 11.3 packyears. After 3 months of IBV treatment the average SGRQ score improved significantly in total (–12.8; p < 0.001) and in domains and differences were for: “symptoms” (–8.5; p < 0.001), “activity” (–13.9; p < 0.001) and “influence on life”(–13.5; p < 0.002). Conclusions: The presented study revealed the significant improvement of the quality of life measured by SGRQ after the IBV treatment for heterogeneous emphysema. For the first time our study showed the significant improvement of all three domains of SGRQ after IBV treatment.Introduction: A heterogeneous emphysema is one of the most severe forms of chronic obstructive pulmonary disease (COPD). In some cases, besides the standard pharmacotherapy, a new treatment option of emphysema can be used — bronchoscopic lung volume reduction (BLVR) with the use of intrabronchial valves. Objectives: To examine the health-related quality of life (HRQoL) of patients with severe emphysema after intrabronchial valve (IBV) implantation for the treatment of one lung. Material and methods: From 2011 to 2013 a single centre prospective observational study was performed. The study assessed the effect of the therapeutic BLVR intervention, measured by St. George Respiratory Questionnaire (SGRQ). A statistical analysis by use of Wilcoxon test for dependent variables was performed. Results: Twenty patients were enrolled to the study (mean age 63 ± 10 years), all ex-smokers with tobacco exposure 38 ± 11.3 packyears. After 3 months of IBV treatment the average SGRQ score improved significantly in total (–12.8; p < 0.001) and in domains and the differences were for: “symptoms” (–8.5; p < 0.001), “activity” (–13.9; p < 0.001) and “influence on life”(–13.5; p < 0.002). Conclusions: The presented study revealed a significant improvement of the quality in the life measured by SGRQ after IBV treatment for heterogeneous emphysema. For the first time our study showed the significant improvement of all three domains of SGRQ after IBV treatment

Initial Polish experience of Flexible 19 gauge Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration

  INTRODUCTION: EBUS is a well established minimally invasive diagnostic tool for mediastinal and hilar lymphadenopathy. The novel ViziShot Flex 19G needle (Olympus Respiratory America, Redmond, WA, USA) was introduced in 2015 in order to improve loaded scope flexion and to obtain larger tissue samples for analysis. The aims of this study were to assess diagnostic yield of Flex 19G needles and to present endoscopist’s feedback about the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). MATERIAL AND METHODS: The Flex 19G needles were used in patients with hilar and/or mediastinal adenopathy in two Polish pulmonology centers. Cytology smears and cell blocks (CB) were prepared. The prospective analysis was performed due to collected data. RESULTS: Twenty two selected patients with confirmed adenopathy on chest-CT (mean age 58 ± 12) underwent EBUS-TBNA with use of Flex 19G needles. All procedures occurred to be diagnostic for smears (yield 100%). The malignancy was found in 15 cases (68.2%), and benign adenopathy in 7 (31.8%). In 12 of 14 cases of lung cancer (yield 85.7%) CB were diagnostic for immunohistochemical and molecular staining. After puncturing nodes, especially in hilar position not extensive bleeding was observed. Comparing to standard 21/22G EBUS-TBNA endoscopists underlined better flexion of loaded scope and sample adequacy and found non-significant differences in another biopsy details. CONCLUSIONS: The first Polish experience with use of Flex 19G EBUS-TBNA needle occurs to be similar in performance with standard technique with use of 22/21G needles and presents high diagnostic yield for lung cancer diagnostics, especially when preparing CB. A safety profile of the biopsy is acceptable.