Hi can someone please help with this case of repeated pneumothoraces in a 20-year-old male patient? He initially presented with intense chest pain, and dyspnea, on a history of dysphagia, and regurgitation after meals and persistent fatigue with physical exertion. Chest X ray was done, which resulted in the  diagnosis of spontaneous pneumothorax with 40% collapse of the left lung. The patient fit the profile for a tall, slim male. He was treated, observed and discharged. 6 months later, he then experienced similar symptoms caused by 80% collapse of the previously affected left lung. 

After a CT scan, a partial lung resection was performed to remove blebs that could have become the cause for additional pneumothoraces. Genetic testing was done with the suspicion for Marfan syndrome, but did not yield significant findings. Gastrointestinal investigations  confirmed the diagnosis of GERD with associated Barrett's esophagitis. He was prescribed proton pump inhibitors (PPIs) for 8 weeks. 

What could be the underlying cause of these symptoms?

©

A 70-year-old woman presented with acute chest pain and shortness of breath. Of note, 72 hours earlier, she had undergone vertebroplasty for an osteoporotic compression fracture from L1 to L2. The patient had a medical history of end-stage renal failure, type 2 diabetes, hypertension and bronchogenic cancer. Physical examination was normal, vital signs on admission were: blood pressure 166/85 mm Hg, heart rate 70 bpm. Laboratory tests showed elevated levels of cardiac markers and D-dimer (3.09 mg/L). ECG showed normal sinus rhythm without significant ST segment deviation. Chest X-ray showed 2 needle-shaped fragments in the central shadow of the mediastinum. Symptoms improved with antianginal agents and a coronary computed tomography angiography showed no coronary artery lesions. 

To what do you think the images shown on the chest x-ray are due? 

Should we delay or reject surgery in patients who is smoking?

Addiction to tobacco and tobacco products (cigarettes, pipes, cigars, hookahs) is a very common and deadly social phenomenon all over the world. The harmful effects of tobacco cause problems both during surgery and postoperative period. Numerous studies were conducted on how and why smokers face higher levels of risk during surgery. Smokers are at significantly higher risk for post-surgical complications including impaired heart and lung functions, infections and impaired wound healing. In addition, they have an increased risk of bleeding during surgery and prolonged hospital stay postoperatively. 

Studies showed that smokers have nearly twice the risk of developing pneumonia, heart attack and a stroke postoperatively. The nicotine and carbon monoxide can decrease oxygen levels, increase heart rate and blood pressure, and greatly increase the risk of heart-related complications after surgery. Carbon monoxide depletes the oxygene levels in the blood and it accumulates ten times more in the blood of smokers which causes body to need more oxygene. Furthermore, it rises the amount of mucus secretion and causes narrowing of the small airways which makes them prone to collapse. At the end, the lungs become more susceptible to infection and other complications. Since smoking causes the death of many cells in the body, diminishes the patients’ lung capacity and decreases the air flow due to the loss of alveoli, which in turn, increases the risk of post-surgical complications of the lungs. There is also a higher likelihood of bronchospasm and other life threatening complications during anaesthesia. During general anaesthesia more anesthetic drugs and gases are required in these patients, keeping the blood pressure under control is became troublesome, and the increasing probability of experiencing problems during awakening from anesthesia is usual. Chemicals in the cigarette interfere with the rate of certain drugs break down in the body which will result in more needs of anaesthesia and pain-relieving drugs after surgery. 

Smoking distorts a patient’s immune system and can delay healing, increasing the risk of infection at the wound site. Nicotine inhibits normal platelet function that increases the risk of bleeding. Since lung secretions will increase after anesthesia, these patients have frequently reflex coughing, which in turn, may result severe chest pain and the risk of postoperative bleeding. Patients who quit smoking are less likely to experience all complications with anesthesia when compared to regular smokers. 

The effects of smoking on the success of surgical and medical treatment of otolaryngological diseases have been evaluated in many studies and it has been reported that smoking doubles the recovery time after surgery, reduces the success rate of surgery by half, and increases the likelihood of revision surgery by three times. According to these results, it should not be difficult to predict that smokers will benefit less from surgery than non-smokers. There are advantages to postponing minor or non-emergency surgery to give patients the opportunity to lay off smoking. Smokers who quit one month or more before surgery have a lower risk of complication. Many companies around the globe impose a smoking ban on their employees, and some insurance companies do not cover the health expenses of the patients who smoke. Moreover, some surgeons refuse to perform a procedure on smokers since smoking increases the risks that the patient faces during surgery and lowers the success rate. In some countries, cessation of smoking at least one month before all surgeries was made compulsory. 

All kind of physicians, surgeons, nurses and families should support the patient to give up smoking addiction at every stage of care, especially before an operation. It is more difficult to lay off smoking by reducing, while the rate of those who decide to quit suddenly is 80%, the rate of those who quit by reducing is 5%. Do yourself a big favor and get rid of this addiction as soon as possible and live a long and healthy life with your loved ones. 

Prof. Dr. Mustafa KAZKAYASI

THURSDAY, July 20, 2023 (HealthDay News) -- History of present illness (HPI) writeups are of similar quality whether written by a chatbot or senior internal medicine residents, according to a study published online July 17 in JAMA Internal Medicine.

Ashwin Nayak, M.D., from Stanford University in California, and colleagues evaluated the ability of a chatbot to generate an HPI compared with senior internal medicine residents. The analysis included HPIs generated by ChatGPT and those written by four residents based on three patient interview scripts portraying different types of chest pain.

The researchers found that the acceptance rate for chatbot-generated HPIs improved from 10.0 to 43.3 percent by the final round of prompt engineering. Based on the 15-point composite scale, grades of resident and chatbot-generated HPIs differed by less than 1 point (resident mean, 12.18, versus chatbot mean, 11.23). Resident HPIs scored higher on level of detail scale (resident mean, 4.13, versus chatbot mean, 3.57). HPIs were correctly characterized as written by residents or the chatbot by attending physicians 61 percent of the time.

"These findings underscore the potential of chatbots to aid clinicians with medical documentation," the authors write.

Abstract/Full Text (subscription or payment may be required)

Editorial (subscription or payment may be required)

Copyright © 2020 HealthDay. All rights reserved.

STAT News

I’ve heard “WebMD said it could be cancer” countless times in my 15 years working as an emergency medicine physician. I get it: When someone is feeling unwell or hoping a worrying symptom will go away, it makes sense for them to turn to easily accessible resources. As people become increasingly familiar with artificial intelligence platforms like ChatGPT, it’s only a matter of time before patients turn to these tools in search of a diagnosis or second opinion.Change is already on the horizon. ChatGPT passed the United States Medical Licensing Exams, And recently the New England Journal of Medicine announced NEJM AI, a whole new journal devoted fully to artificial intelligence in clinical practice. These and many other developments have left many wondering (and sometimes worrying) what role AI will have in the future of health care. It’s already predicting how long patients will stay in the hospital, denying insurance claims, and supporting pandemic preparedness efforts.

While there are areas within medicine ripe for the assistance of AI, any assertion that it will replace health care providers or make our roles less important is pure hyperbole. Even with all its promise, it’s hard to imagine how AI will ever replicate that gut feeling honed by sitting at the bedside and placing our hands on thousands of patients. Recently, I had an encounter that revealed one of the limitations for AI at the patient’s bedside, now and perhaps even in the future. While working in the emergency room, I saw a woman with chest pain. Based on nearly every algorithm and clinical decision rule that providers like me use to determine next steps in care of cases like this, my patient was safe for discharge. But something didn’t feel right. It’s hard to say exactly what tipped me off that day. But my gut instinct compelled me to do more instead of just discharging her. When I repeated her blood tests and electrocardiogram a short while later, the results were unequivocal — my patient was having a heart attack.

We have algorithms to guide us, but we still need to select the right one and navigate the sequence correctly despite sometimes conflicting information. Even then, they aren’t flawless. It’s these intricacies of our jobs that likely cause many providers to cast a suspicious eye at the looming overlap of artificial intelligence and the practice of medicine...Read more

Will AI diminish physicians'' ability to trust there gut?

A comprehensive systematic review and meta-analysis was conducted to assess the diagnostic accuracy and prognostic value of stress cardiovascular magnetic resonance imaging (CMR) in stable chest pain. The study aimed to provide contemporary quantitative data on the topic and shed light on the low-risk period for adverse cardiovascular (CV) events after a negative stress CMR result. A total of 64 studies involving 74,470 patients were included in the analysis, with data obtained from PubMed, Embase, Cochrane Database of Systematic Reviews, PROSPERO, and ClinicalTrials.gov.

The findings revealed that stress CMR exhibited high diagnostic accuracy, with a sensitivity of 81% and specificity of 86% for detecting functionally obstructive coronary artery disease. The presence of stress-inducible ischemia and late gadolinium enhancement (LGE) were associated with higher all-cause mortality, CV mortality, and major adverse cardiovascular events (MACEs). Subgroup analysis indicated that stress CMR had even higher diagnostic accuracy when suspected coronary artery disease was present or when 3-T imaging was used. Importantly, patients with normal stress CMR results had a lower risk of MACEs for at least 3.5 years after the test...Read more

Could this be a feasible routine investigation for stable chest pain?