Critical Illness Due to Covid-19: A Description of the Surge in a Single Center in Sioux Falls

BACKGROUND

We aim to describe the basic demographics, clinical course and outcomes of critically ill patients with Covid-19 admitted to Avera McKennan Hospital and University Health Center Intensive Care Unit (ICU) between March 20 and May 4, 2020.

METHODS

In this single centered, retrospective, observational study, we enrolled 37 critically ill adults with COVID-19 pneumonia admitted to the (ICU) between March 20 and May 4, 2020. Demographic data, admitting symptoms, laboratory values, co-morbidities, treatments and clinical outcomes were collected. Data was compared between survivors and non-survivors. We aim to describe our data and report the 28-day mortality as of June 1, 2020.

RESULTS

Of 154 patients admitted with COVID-19 pneumonia during our study period, 37 (24 percent) were critically ill and required an ICU stay. The mean age was 58 years and 76 percent were men. Of these 37 patients, 28 (78 percent) had a chronic illness (diabetes in 43 percent, hypertension in 47 percent). In addition, 54 percent were associated with a local meat packing plant. Most common presenting symptoms were dyspnea (92 percent), cough (70 percent) and fever (68 percent). The mean PaO2/ FiO2 ratio was 143 (67-362). Significant lab findings include the following: 54 percent of patients had lymphocytopenia, the mean ferritin was 850 ng/mL (10-3528), the mean D-Dimer was 4.09 FEU ug/mL and the mean IL-6 was 96.5 pg/mL. At 28 days, 24 percent (nine) had died. Twenty-five (68 percent) patients required mechanical ventilation, with 10 (27 percent) of those patients requiring initiation of neuromuscular blocking agents for ventilator compliance. Of those four (40 percent) did not survive. In addition, 20 patients (54 percent) were proned. Pneumomediastinum or pneumothorax occurred in five of the 37 (14 percent). Renal replacement therapy was required in 6 of the 37 patients, 4 of whom (66 percent) died. Steroids were used in 70 percent of patients, tocilizumab in 59 percent, and hydroxychloroquine in 27 percent. All patients received antibiotics. Convalescent plasma became available for our 5th patient. A total of 29 (78 percent) received convalescent plasma, (86 percent of survivors and 56 percent non-survivors). Median ICU length of stay was 11 days for both survivors (1-49) and non-survivors (1-21). There were no differences in age, body mass index (BMI), or initial PaO2/FiO2 (P/F) among those two groups. Non-survivors (nine) included the two immune compromised patients in our cohort, two patients with pre-existing DNR/DNI status, and one death within two hours of admit. Compared with survivors, more of the non-survivors received vasopressors (78 percent vs 46 percent), dialysis (44 percent vs 7 percent) and hydroxychloroquine (44 percent vs 21 percent). The first 5 patients treated in the ICU did not survive. One month after the initial case was reported in South Dakota, our ICU experienced a six-week surge. At its highest, COVID-19-related census reached 63 percent of the ICU capacity (15/24).

CONCLUSION

Mortality of critically ill patients with COVID-19 is high. Multi-organ, advanced and prolonged critical care resources are needed. Interpretation of our data is limited by a higher mortality of the earlier members of the cohort, a change in therapeutic practice over time and institution of social distancing.

[Medical biostatistics with GMRC Shiny Stats - learning by doing]

Biostatistics are omnipresent in the scientific and medical literature and are an essential skill for any health student. We have developed a practical training tool - GMRC Shiny stats - an interactive application specifically dedicated to medical data statistical analysis. The application has been designed to provide an analysis workflow corresponding to the usual progression of an experienced statistician during data analysis. The most common statistical analyses can be performed (descriptive statistics, inferences according to frequentist methods, survival analyses, correlation, agreement measurements, etc.). GMRC Shiny stats is intuitive and user-friendly and assists students in choosing the most appropriate statistical tests. With all these functionalities, students can learn statistical analysis by doing. Getting involved in the statistical analysis and processing of their own data is likely to improve their biostatistics skills.

[The role of new molecular tests in the diagnosis of melanoma in a setting of congenital nævus in an infant]

INTRODUCTION

Congenital and infantile melanomas are extremely rare. We report a case of a child presenting at birth with a giant congenital nevus complicated by melanoma and on long-term follow-up with exploration using new immunohistochemistry and molecular biology tools.

OBSERVATION

A new-born girl presented at birth with a large congenital cervico-mandibular tumour with para-pharyngeal extension and underlying osteolysis. At 7 months, histology and immunohistochemistry of the operative specimen revealed nodules with atypical features (mitotic figures, necrosis and positive expression of KI67 and P53 in approximatively 50 % of the melanocytic nuclei). A diagnosis was made of infantile melanoma associated with congenital nevi. Repeated surgery and monitoring (clinical and imaging) were performed. At the age of 7 years, as there was no evidence of metastatic lesions, further analyses were performed on the initial operative specimen. Investigation of transcription factor expression using immunohistochemistry, comparative genomic hybridization and histology-guided mass spectrometry, although suspect, did not in itself support a diagnosis of melanoma. Finally, at the age of 7 years, hepatic and pulmonary metastases were reported. Despite combined immunotherapy with ipilimumab and nivolumab, the child died 5 months later.

CONCLUSION

This case illustrates the complexity of diagnosis of infantile melanoma and the risk of metastatic involvement long after the initial diagnosis. Diagnosis may be difficult and necessitates expert advice and the application of several recent methods to reach a conclusion and initiate appropriate treatment.

Viscosity of liquid Na-K alloys from molecular dynamics simulations

The shear viscosity of liquid Na-K alloys is computed from molecular dynamics simulations using the Green-Kubo formalism. Interatomic interactions are described using effective pair potentials obtained from Fiolhais pseudo-potential and self-consistent screening. The composition dependence of the viscosity is first investigated at 373 K, then its temperature dependence at three different compositions, namely Na₁₀-K₉₀, Na₅₀-K₅₀, and Na₉₀-K₁₀. Simulation results are first compared with available experimental data. The evolution of the viscosity of the alloys versus temperature is similar to that of a pure one component fluid. This is discussed in connection with the chemical order of the mixtures.

Dialkylcarbamoyl chloride-coated versus alginate dressings after pilonidal sinus excision: a randomized clinical trial (SORKYSA study)

Background

Disease of the pilonidal sinus is a common condition that affects mainly young adults. Options for management include excision of the sinus tracts, leaving the wound open to heal by secondary intention. The aim of this study was to compare wound healing with dialkylcarbamoyl chloride (DACC)‐coated dressings versus alginate dressings.

Methods

This multicentre trial randomized consecutive patients undergoing surgery for pilonidal disease to postoperative wound care with either DACC‐coated or alginate dressings. The primary outcome was the proportion of wounds healed after 75 days. Secondary outcomes were the local status of wounds during the healing process, the quality assessment of the dressings by the patient, and the time needed to return to usual activities.

Results

A total of 246 patients were included: 120 in the DACC‐coated group and 126 in the alginate group. In per‐protocol analysis, there were significantly more patients with completely healed wounds after 75 days in the DACC group than in the alginate group: 78 of 103 (75·7 per cent) versus 58 of 97 (60 per cent) respectively (odds ratio 2·55, 95 per cent c.i. 1·12 to 5·92; P = 0·023). During follow‐up, wounds with alginate dressings had more fibrin than those with DACC‐coated dressings, but the difference was not significant (P = 0·079). There was no difference between the two arms in patients' assessment of the dressings.

Conclusion

The number of wounds completely healed at 75 days was significantly higher for DACC‐coated compared with alginate dressings. However, the preplanned, clinically significant improvement in healing of 20 per cent was not reached. Registration number: NCT02011802 ( https://clinicaltrials.gov/).

Chylothorax as a complication of extensive spontaneous left arm DVT

We present a case of right sided chylothorax in the setting of cirrhosis believed to be secondary to extensive venous thromboembolism of the left upper extremity and exacerbated by chylous ascites. Our patient responded to conservative management with anticoagulation and a repeat thoracentesis revealed transformation of the fluid back to straw coloured transudate. We also include a brief discussion of the diagnosis and management of chylothorax.