Diseases Commons^™

Off-Label Use Of Direct Oral Anticoagulants In Patients Receiving Surgical Mechanical And Bioprosthetic Heart Valves, Ankur Kalra, Sajjad Raza, Baqir Hasan Jafry, Harley E. King, Joseph A. Lahorra, Lars G. Svensson, Samir R. Kapadia

Medical College Documents

This cohort study assesses direct oral anticoagulant use in patients with surgical prosthetic heart valves in the United States and evaluates differences in preoperative and postoperative profiles in patients discharged while receiving direct oral anticoagulant vs warfarin.

Impact Of Social Isolation On Mortality And Morbidity In 20 High-Income, Middle-Income And Low-Income Countries In Five Continents, Ryo Naito, Darryl P. Leong, Shrikant Ishve Bangdiwala, Martin Mckee, S V. Subramanian, Sumathy Rangarajan, Shofiqul Islam, Alvaro Avezum, Karen E. Yeates, Syed Iqbal Azam

Community Health Sciences

Objective: To examine the association between social isolation and mortality and incident diseases in middle-aged adults in urban and rural communities from high-income, middle-income and low-income countries.
Design: Population-based prospective observational study.
Setting: Urban and rural communities in 20 high income, middle income and low income.
Participants: 119 894 community-dwelling middle-aged adults.
Main outcome measures: Associations of social isolation with mortality, cardiovascular death, non-cardiovascular death and incident diseases.
Results: Social isolation was more common in middle-income and high-income countries compared with low-income countries, in urban areas than rural areas, in older individuals and among women, those with less education and …

Racial And Geographic Disparities In Influenza Vaccination In The U.S. Among Individuals With Atherosclerotic Cardiovascular Disease: Renewed Importance In The Setting Of Covid-19, Mahmoud Al Rifai, Umair Khalid, Arunima Misra, Jing Liu, Khurram Nasir, Miguel Cainzos-Achirica, Dhruv Mahtta, Christie M. Ballantyne, Laura A. Petersen, Salim S. Virani

Office of the Provost

Introduction: The importance of receiving an annual influenza vaccine among patients with atherosclerotic cardiovascular disease (ASCVD) is well established. With the rapid community spread and the possibility of another wave of COVID-19 infections in the fall, receiving an influenza vaccine is of particular importance to mitigate the risk associated with overlapping influenza and COVID-19 infections.
Methods: We utilized cross-sectional data from the 2016 to 2019 Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative U.S. telephone-based survey of adults 18 years or older. Race/ethnicity was our exposure of interest. We assessed the relative difference in influenza vaccination by race/ethnicity for …

Occupational Therapy’S Role In Addressing Sexuality And Intimacy For Individuals With Progressive Neuromuscular Disorders, Lindsay N. Richards

Student Capstone Papers

Individuals with progressive neuromuscular disorders (PND); specifically, Parkinson’s disease (PD), Multiple Sclerosis (MS), Huntington’s Disease (HD), and Amyotrophic Lateral Sclerosis (ALS) often face physical, psychological, and social challenges related to sex and intimacy. Occupational therapy (OT) practitioners are experts in activity analysis and are equipped with unique knowledge of performance skills and client factors to address deficits in occupational performance.

Though there is literature presenting the effects of PND on sexual occupations, a gap exists as it relates to qualitative data from the perspective of the individual and their partners. A mixed-methods survey was conducted examining the lived experience of …

Starting Antihypertensive Drug Treatment With Combination Therapy: Controversies In Hypertension - Con Side Of The Argument, Zhen-Yu Zhang, Yu-Ling Yu, Kei Asayama, Tine W. Hansen, Gladys E. Maestre, Jan A. Staessen

School of Medicine Publications

The 2018 European Society of Cardiology/European Society of Hypertension1 and the 2020 International Society of Hypertension2 guidelines for the management of hypertension proposed that initial combination therapy with 2 antihypertensive agents in a single-pill combination (SPC) is preferred in most patients in need of blood pressure (BP) lowering treatment and should replace the long-standing concept of starting treatment with a single agent, rotating through antihypertensive drug classes, and next moving towards combining drug classes. By moving SPCs forward as the initial BP-lowering strategy, the European1 and International2 Societies of Hypertension Guideline Committees overlooked several principles in …

Predictive Modeling And Estimation Of The Doubling Time Of Confirmed Cases Of Covid-19 In Niger, Ibrahim Sidi Zakari, Hadiza Galadima

Community & Environmental Health Faculty Publications

Modeling is increasingly used to assess scenarios and make projections on the future course of new coronavirus disease. This allows for better planning of care as well as a relaxation or tightening of the restrictive measures decreed by the government and the health authorities. The data analyzed in this study covers the period from March 19 to June 05, 2020 and allowed predictions of new cases of COVID-19 based on a growth model with a growth rate that changes linearly over time. In addition, we calculated and predicted the doubling time of the number of positive cases in each region …

Telemedicine: A New Frontier In Clinical Practice, Munazza Asad, Nooresahar, Saniya Sabzwari

Department of Family Medicine

The COVID-19 pandemic has highlighted the important role of telemedicine as a tool for safe healthcare delivery across the world. While its use was more common in the developed world, the developing world has also adopted this strategy. It is important to develop a clear process and contextual guidance for effective use of this strategy for better patient-doctor interaction and its role in teaching/learning of trainees.

Association Of Vitamin D Deficiency And Disease Activity In Systemic Lupus Erythematosus Patients: Two-Year Follow-Up Study, Ainan Arshad, Saad Bin Zafar Mahmood, Ahmed Ayaz, Adil A. Manji, Akash Kumar Ahuja

Section of Internal Medicine

Objectives: This study aims to determine the prevalence of vitamin D deficiency in Pakistani systemic lupus erythematosus (SLE) patients and the effect of vitamin D deficiency on the severity and outcomes of SLE.
Patients and methods: This retrospective study evaluated SLE patients presenting to our hospital between January 2009 and December 2018. A total of 98 patients (13 males, 85 females; mean age 39.8±14.9 years; range, 16 to 73 years) with vitamin D levels available at the time of diagnosis were included in the study. Disease activity was measured using SLE disease activity score at the time of diagnosis and …

“It Really Proves To Us That We Are Still Valuable”: Qualitative Research To Inform A Safer Conception Intervention For Men Living With Hiv In South Africa, Lynn T. Matthews, Letitia Greener, Hazar Khidir, Christina Psaros, Abigail Harrison, F. Nzwakie Mosery, Mxolisi Mathenjwa, Kasey O'Neil, Cecilia Milford, Steven A. Safren, David R. Bangsberg, Jennifer A. Smit

OHSU-PSU School of Public Health Faculty Publications and Presentations

Objective: Many men living with HIV want to have children. Opportunities to reduce periconception HIV transmission include antiretroviral therapy as prevention, pre-exposure prophylaxis, limiting condomless sex to peak fertility, and sperm processing. Whether men have knowledge of or want to adopt these strategies remains unknown.

Methods: We conducted focus group discussions (FGDs) with men accessing HIV care in South Africa in 2014 to inform a safer conception intervention for men. Eligible men were 25–45 years old, living with HIV, not yet accessing treatment, and wanting to have a child with an HIV-negative or unknown serostatus female partner (referred …

Evaluation Of Serum Ferritin For Prediction Of Severity And Mortality In Covid-19- A Cross Sectional Study, Sibtain Ahmed, Zeeshan Ansar Ahmed, Imran Siddiqui, Naveed Haroon Rashid, Maheen Mansoor, Lena Jafri

Department of Pathology and Laboratory Medicine

Background: Ferritin even though widely recognized as a representative of total body iron stores, its prognostic utility is linked with COVID-19. This study was aimed at evaluation of the association of ferritin with severity in Coronavirus disease 2019 (COVID-19), hospitalized patients and to test the hypothesis that it is an independent predictor of mortality.
Material and methods: This study was conducted at Chemical Pathology, Department of Pathology and Laboratory Medicine, Aga Khan University (AKU), Karachi. Medical records of all in-patients including both genders, and all age groups with documented COVID-19 from 1st March to 10^th August 2020 were reviewed. …

Female Genital Tuberculosis In Pakistan - A Retrospective Review Of 10-Year Laboratory Data And Analysis Of 32 Cases, Tazeen Fatima, Rumina Hasan, Faisal Malik, Imran Ahmed, Linda Alice Bartlett, Michael G. Gravett, Sadia Shakoor

Department of Pathology and Laboratory Medicine

Background: Female genital tuberculosis (FGTB) is an underobserved clinical entity owing to diagnostic challenges stemming from difficulty of obtaining diagnostic specimens and paucibacillary nature of the disease. Yet, FGTB is a cause of infertility, pelvic pain, or menstrual irregularities in high-burden countries. To assess laboratory and microbiology diagnostic utilization for FGTB in Pakistan, we have collected data from 2007 to 2016 to inform the need for improved laboratory diagnostics. The objectives of this study were to determine the proportion of FGTB as culture-confirmed extrapulmonary tuberculosis (EPTB) and to describe the characteristics of women with culture-confirmed FGTB in a nationwide laboratory …

Scientometric Analysis And Visualization Of Astrovirus Based On R-Packages, Sivankalai S, Virumandi A, Sivasekaran K, Bala Sankar B, Balamurugan B, Sharmila M, Kaladevi P

Library Philosophy and Practice (e-journal)

We examined scientific production of the astroviruses study community done the past two decades in the worldwide. Scientometric methods, particularly the literature development models, Document types, Most Global Cited Documents, Most Frequent Words, Authors collaboration, Author Impact (h-index, g-index, m-index), Most Local Cited Authors, Relevant Countries by Corresponding Author, Most Cited Countries, Most Relevant Affiliations are identified. The results of this study confess that the scientific literature on astroviruses in worldwide had grown-up exponentially with an annual growth rate of about 8.86% during the above declared period. Journal of medical virology were the most productive journals contributing 71 articles of …

Early Identification Of Sepsis: A Nurse Driven Protocol To Reduce Morbidity, Mortality And Hospital Costs, Ruth Biju

Student Scholarly Projects

Practice Problem: About 270,000 people die from sepsis every year, which is one person every 2 minutes, more than prostate cancer, breast cancer, and AIDS combined. It was identified that the organization had a good process in place for the treatment of severe sepsis but no process for early assessment of worsening symptoms of sepsis.

PICOT: The PICOT question that guided this project was: In adult inpatients (P), does the use of a nurse-driven sepsis screening tool (I) compared to not using a screening tool (C) affect early identification and treatment of sepsis (O) within an 8-week period (T)?

Evidence: …

Hypoglossal Nerve Paraganglioma Depicting As Glomus Tumor Of Neck, Zaid Ahmed Shamsi, Fareed Ahmed Shaikh, Muhammad Wasif, Mustafa Belal Hafeez Chaudhry, Nadeem Ahmed Siddiqui, Ziad Sophie

Department of Surgery Docs

Introduction: Paraganglioma are infrequent neuroendocrine tumors that are most commonly found in the carotid body, ganglia of the vagus, jugular and tympanic nerve. Very rarely they can involve other cranial nerves outside the cranial cavity, we present one such case of hypoglossal nerve paraganglioma in neck.
Case report: A 48 years old male presented with 1-month history of right sided stroke and aphasia. Ultrasonography of neck revealed a highly vascular mass on the right side of the neck. CT angiogram confirmed a highly vascular mass arising above the carotid bifurcation. With the working diagnosis of Glomus tumor, he underwent right …

Proximal Subclavian Artery Injury Managed Without Performing Median Sternotomy: A Case Report, Zia Ur Rehman

Department of Surgery Docs

No abstract provided.

Role Of Contrast Enhanced Computed Tomography In Assessing Cervical Lymph Node Metastases In Oral Cavity Squamous Cell Carcinoma, Talha Ahmed Qureshi, Muhammad Wasif, Mohammad Sohail Awan, Adnan Yar Muhammad, Ainulakbar Mughal, Abdullah Ameen

Section of Otolaryngology, Head & Neck Surgery

Objective: To evaluate the diagnostic accuracy of contrast-enhanced computed tomography scan in detecting cervical nodal metastasis in oral cavity squamous cell carcinoma.
Methods: The retrospective cross-sectional study was conducted at Aga Khan University Hospital, Karachi, Pakistan. and comprised records from January 1, 2015, to October 31, 2016, of patients diagnosed with oral cavity squamous cell carcinoma and who underwent surgical resection of primary tumour along with neck dissection after having a contrast-enhanced computed tomography scan of head and neck. Diagnostic accuracy of the scans was calculated using final histopathology as the gold standard. All scans were reviewed by a consultant …

Are The Current Animal Trypanosomiasis Management Methods In Kenya Complementary Or Substitutes? Evidence From Kwale County, Arnold Lumumbah Musungu, David Jakinda Otieno, Beatrice Wambui Muriithi, Rose Nyikal, Daniel Masiga, Michael Nyanganga Okal

All Peer-Reviewed Publications

African animal trypanosomiasis (AAT) and its vectors, mainly tsetse, are a major constraint to livestock production in sub-Saharan Africa (SSA). Control efforts have been ongoing for decades, but finding a sustainable solution remains a major concern. This paper assessed the complementarity and substitutability of existing AAT management methods to inform policies toward an integrated approach. A multivariate probit (MVP) analytical technique was used to model interrelationships in the control methods from 308 randomly selected livestock keepers. The results show that the current AAT control methods are complementary and not substitutes. Furthermore, the number of years of formal education, household size, …

Is Covid-19 Pushing Us To The Fifth Industrial Revolution (Society 5.0)?, Zouina Sarfraz, Azza Sarfraz, Hamza M. Iftikar, Ramsha Akhund

Department of Paediatrics and Child Health

The coronavirus disease 2019 (COVID-19) pandemic may further promote the development of Industry 4.0 leading to the fifth industrial revolution (Society 5.0). Industry 4.0 technology such as Big Data (BD) and Artificial Intelligence (AI) may lead to a personalized system of healthcare in Pakistan. The final bridge between humans and machines is Society 5.0, also known as the super-smart society that employs AI in healthcare manufacturing and logistics. In this communication, we review various Industry 4.0 and Society 5.0 technologies including robotics and AI being inspected to control the rate of transmission of COVID-19 globally. We demonstrate the applicability of …

Evaluating The Revised American Society For Gastrointestinal Endoscopy Guidelines For Common Bile Duct Stone Diagnosis, Jake S Jacob, Michelle E Lee, Erin Y Chew, Aaron P Thrift, Robert J Sealock

Faculty, Staff and Students Publications

BACKGROUND/AIMS: The American Society for Gastrointestinal Endoscopy (ASGE) revised its guidelines for risk stratification of patients with suspected choledocholithiasis. This study aimed to assess the diagnostic performance of the revision and to compare it to the previous guidelines.

METHODS: We conducted a retrospective cohort study of 267 patients with suspected choledocholithiasis. We identified high-risk patients according to the original and revised guidelines and examined the diagnostic accuracy of both guidelines. We measured the association between individual criteria and choledocholithiasis.

RESULTS: Under the original guidelines, 165 (62%) patients met the criteria for high risk, of whom 79% had confirmed choledocholithiasis. The …

Deficiency Of Stat1 In Cd11c+ Cells Alters Adipose Tissue Inflammation And Improves Metabolic Dysfunctions In Mice Fed A High-Fat Diet, Antu Antony, Zeqin Lian, Xiaoyuan Dai Perrard, Jerry Perrard, Hua Liu, Aaron R Cox, Pradip Saha, Lothar Hennighausen, Sean M Hartig, Christie M Ballantyne, Huaizhu Wu

Faculty, Staff and Students Publications

CD11c+ macrophages/dendritic cells (MDCs) are increased and display the classically activated M1-like phenotype in obese adipose tissue (AT) and may contribute to AT inflammation and insulin resistance. Stat1 is a key transcription factor for MDC polarization into the M1-like phenotype. Here, we examined the role of Stat1 in obesity-induced AT MDC polarization and inflammation and insulin resistance using mice with specific knockout of Stat1 in MDCs (cKO). Stat1 was upregulated and phosphorylated, indicating activation, early and persistently in AT and AT MDCs of wild-type mice fed a high-fat diet (HFD). Compared with littermate controls, cKO mice fed an HFD (16 …

Pegylated Arginine Deiminase Depletes Plasma Arginine But Maintains Tissue Arginine Availability In Young Pigs, Mahmoud A Mohammad, Inka C Didelija, Barbara Stoll, Trung C Nguyen, Juan C Marini

Faculty, Staff and Students Publications

Pegylated arginine deiminase (ADI-PEG20) results in the depletion of arginine with the production of isomolar amounts of citrulline. This citrulline has the potential to be utilized by the citrulline recycling pathway regenerating arginine and sustaining tissue arginine availability. The goal of this research was to test the hypothesis that ADI-PEG20 depletes circulating arginine in pigs but maintains tissue arginine concentration and function, and to characterize the kinetics of citrulline and arginine. Two multitracer approaches (bolus dose and primed-continuous infusion) were used to investigate the metabolism of arginine and citrulline in Control (

Tbx5-Encoded T-Box Transcription Factor 5 Variant T223m Is Associated With Long Qt Syndrome And Pediatric Sudden Cardiac Death, Alexandra M Markunas, Perathu K R Manivannan, Jordan E Ezekian, Agnim Agarwal, William Eisner, Katherina Alsina, Hugh D Allen, Gregory A Wray, Jeffrey J Kim, Xander H T Wehrens, Andrew P Landstrom

Faculty, Staff and Students Publications

Long QT syndrome (LQTS) is a genetic disease resulting in a prolonged QT interval on a resting electrocardiogram, predisposing affected individuals to polymorphic ventricular tachycardia and sudden death. Although a number of genes have been implicated in this disease, nearly one in four individuals exhibiting the LQTS phenotype are genotype-negative. Whole-exome sequencing identified a missense T223M variant in TBX5 that cosegregates with prolonged QT interval in a family with otherwise genotype-negative LQTS and sudden death. The TBX5-T223M variant was absent among large ostensibly healthy populations (gnomAD) and predicted to be pathogenic by in silico modeling based on Panther, PolyPhen-2, Provean, …

On The Application, Reporting, And Sharing Of In Silico Simulations For Genetic Studies, Kaleigh Riggs, Huann-Sheng Chen, Melissa Rotunno, Bing Li, Naoko I Simonds, Leah E Mechanic, Bo Peng

Faculty, Staff and Students Publications

In silico simulations play an indispensable role in the development and application of statistical models and methods for genetic studies. Simulation tools allow for the evaluation of methods and investigation of models in a controlled manner. With the growing popularity of evolutionary models and simulation-based statistical methods, genetic simulations have been applied to a wide variety of research disciplines such as population genetics, evolutionary genetics, genetic epidemiology, ecology, and conservation biology. In this review, we surveyed 1409 articles from five journals that publish on major application areas of genetic simulations. We identified 432 papers in which genetic simulations were used …

Mental Health Disorders Among Patients With Acute Myocardial Infarction In The United States, Jayakumar Sreenivasan, Muhammad Shahzeb Khan, Safi U Khan, Urvashi Hooda, Wilbert S Aronow, Julio A Panza, Glenn N Levine, Yvonne Commodore-Mensah, Roger S Blumenthal, Erin D Michos

Faculty, Staff and Students Publications

OBJECTIVE: To assess the prevalence, temporal trends and sex- and racial/ethnic differences in the burden of mental health disorders (MHD) and outcomes among patients with myocardial infarction (MI) in the United States.

METHODS: Using the National Inpatient Sample Database, we evaluated a contemporary cohort of patients hospitalized for acute MI in the United States over 10 years period from 2008 to 2017. We used multivariable logistic regression analysis for in-hospital outcomes, yearly trends and estimated annual percent change (APC) in odds of MHD among MI patients.

RESULTS: We included a total sample of 6,117,804 hospitalizations for MI (ST elevation MI …

Is Covid-19-Induced Platelet Activation A Cause Of Concern For Patients With Cancer?, Lenard M Lichtenberger, K Vinod Vijayan

Faculty, Staff and Students Publications

Patients with cancer are more susceptible to be infected by SARS-CoV-2 and develop severe outcomes including ICU admittance, mechanical ventilator support, and a high rate of mortality. Like mid-to late-stage cancer, SARS-CoV-2 infection is associated with platelet hyperactivity, systemic inflammation, thrombotic complications, and coagulopathy. Platelets also promote cancer cell growth, survival in circulation, and angiogenesis at sites of metastases. In this article, we will discuss the potential for platelets in the development of systemic inflammation and thrombosis in SARS-CoV-2-infected patients with cancer, with the concern that the platelet-induced pathogenic events are likely magnified in cancer patients with COVID-19.

Fusobacteriumnucleatum Adheres To Clostridioides Difficile Via The Radd Adhesin To Enhance Biofilm Formation In Intestinal Mucus, Melinda A Engevik, Heather A Danhof, Jennifer Auchtung, Bradley T Endres, Wenly Ruan, Eugénie Bassères, Amy C Engevik, Qinglong Wu, Maribeth Nicholson, Ruth Ann Luna, Kevin W Garey, Sue E Crawford, Mary K Estes, Renate Lux, Mary Beth Yacyshyn, Bruce Yacyshyn, Tor Savidge, Robert A Britton, James Versalovic

Faculty, Staff and Students Publications

Background:

Although Clostridioides difficile infection (CDI) is known to involve the disruption of the gut microbiota, little is understood regarding how mucus-associated microbes interact with C. difficile. We hypothesized that select mucus-associated bacteria would promote C. difficile colonization and biofilm formation.

Methods/Results:

To create a model of the human intestinal mucus layer and gut microbiota, we used bioreactors inoculated with healthy human feces, treated with clindamycin and infected with C. difficile with the addition of human MUC2-coated coverslips. C. difficile was found to colonize and form biofilms on MUC2-coated coverslips and 16S rRNA sequencing revealed a unique biofilm profile …

Testosterone Therapy And Bone Quality In Men With Diabetes And Hypogonadism: Study Design And Protocol, Vittoria Russo, Georgia Colleluori, Rui Chen, Sanjay Mediwala, Clifford Qualls, Michael Liebschner, Dennis T Villareal, Reina Armamento-Villareal

Faculty, Staff and Students Publications

CONTEXT: Type 2 diabetes mellitus (T2D) is often accompanied by male hypogonadism and both conditions are associated with increased risk for fractures. Testosterone (T) has been shown to improve the bone health of hypogonadal men but has not been tested in patients who also have T2D in addition to low T. To date, there is no treatment that is specifically recommended for bone disease among patients with T2D. This study will evaluate the effect of T therapy on the bone health of male veterans with low T who also have T2D.

METHODS: This is a randomized double-blind placebo-controlled trial of …

The Crosstalk Between Cardiomyocyte Calcium And Inflammasome Signaling Pathways In Atrial Fibrillation, Xiaolei Wang, Xiaohui Chen, Dobromir Dobrev, Na Li

Faculty, Staff and Students Publications

Atrial fibrillation (AF) is the most frequent arrhythmia in adults. The prevalence and incidence of AF is going to increase substantially over the next a few decades. Because AF increases the risk of stroke, heart failure, dementia, and others, it severely impacts the quality of life, morbidity and mortality. Although the pathogenesis of AF is multifaceted and complex, focal ectopic activity and reentry are considered as the fundamental proarrhythmic mechanisms underlying AF development. Over the past 2 decades, large amount of evidence points to the key role of intracellular Ca2+ dysregulation in both initiation and maintenance of AF. More recently, …

Dnp Final Report: Breaking The Cycle: Care Coordination Interventions And Sickle Cell Readmissions, Naphtali Edge

DNP Final Reports

Background

Approximately 100,000 people in the United States are affected by Sickle Cell Disease (SCD). Sickle Cell Disease represents the second highest readmitting diagnosis at Houston Methodist Hospital. The purpose of this study is to determine the impact of implementing care coordination interventions to reduce hospital readmissions of patients with SCD.

PICOT

In adult patients with SCD in the acute care hospital setting, how does care coordination intervention compared to no care coordination intervention affect the readmission rate for patients with SCD over a 3 – 6-month period?

Body of Evidence

Eleven studies were critical appraised and included in the …

Pancoast Syndrome Due To High Grade Anaplastic Tumor, Christian Almanzar, Seth Maxwell, Mauricio Gomez, Omar Ansari, Luis Silva

HCA Healthcare Journal of Medicine

The Pancoast tumor is an uncommon type of lung cancer that arises from within the superior sulcus. With most clinical manifestations occurring due to mass effect, Pancoast syndrome is a known complication that includes shoulder and arm musculoskeletal pain, Horner’s syndrome and neurological complications of the upper extremities, including weakness and atrophy. Even though adenocarcinoma is the most common cause of Pancoast syndrome among lung cancers, other malignancies can be responsible as well. Treatment is similar to that of other standard NSCLC treatments that include chemotherapy, radiation, immunotherapy and surgery. Here we report a patient with Pancoast syndrome secondary to …