Smart Watch Detection of Supraventricular Tachycardia (SVT): First Case from Tanzania

Smartwatches like the Apple Watch have been on the rise worldwide and their use is gaining popularity in developing countries. Their ability to detect dysrhythmias is well documented. Present practice discourages the use of these devices as a diagnostic tool. Nevertheless, atypical findings from these devices should be clinically investigated. This case demonstrates an eventual diagnosis of supraventricular tachycardia (SVT) based on an Apple watch alert which was subsequently confirmed by electrophysiological evaluation.

Role of Clinical Pharmacists in Intensive Care Units

The cost of health care has been rising in the United States and globally and will continue to increase. Intensive care unit (ICU) care carries a significant portion of the cost for the hospitals. The Institute of Medicine and subsequent studies have suggested that medication errors account for significant morbidity, mortality, and cost, frequently encountered in the ICU. Over the past three decades, clinical pharmacists have emerged from dispensing medication to getting involved in direct patient care and have become an integral part of the multidisciplinary critical care team. Clinical pharmacists play a significant role in reducing medication errors and costs, medication reconciliation, antibiotic stewardship, and patient and health care provider education. This review will discuss the health care and ICU cost, the evolving role of clinical pharmacists in managing critically ill patients, and their contributions in the ICU to mitigate the risks, improve patient outcomes, and decrease health care costs.

Severe Photosensitivity Reaction After Pirfenidone Use

Idiopathic pulmonary fibrosis is a chronic and progressive disease with a significant mortality rate. Pirfenidone is one of two oral antifibrotic therapies approved to treat idiopathic pulmonary fibrosis (IPF). Pirfenidone helps decrease disease progression in patients with IPF and reduces vital capacity. This has led to widespread use of this medication in recent years. In this case report, we present a 60-year-old male who started treatment with pirfenidone for IPF and had severe skin reactions after initiation of therapy.

Current state of medical tourism involving liver transplantation-the risk of infections and potential complications

Liver transplant has been shown to significantly improve mortality and quality of life in various liver diseases such as acute liver failure, end-stage liver disease, and liver cancer. While the organ transplant demand is continuing to rise, the organ donation supply remains unmatched. The organ shortage, high cost, and long waiting lists have stimulated a desire for routes that may be unethical. This process which is named transplant tourism is the term used to describe traveling to another country to purchase an organ for transplant. Liver transplant tourism has been associated with post-transplant complications and higher mortality compared to a domestic liver transplant. Improper pre-and post-transplant infectious screening, inadequate opportunistic infection prophylaxis, and loss to follow-up were noted in patients who travel abroad for a liver transplant. It is crucial to understand the risk of transplant tourism to prevent morbidity and mortality.

Effectiveness of Mechanical Chest Compression Devices over Manual Cardiopulmonary Resuscitation: A Systematic Review with Meta-analysis and Trial Sequential Analysis

Introduction

Our goal was to systematically review contemporary literature comparing the relative effectiveness of two mechanical compression devices (LUCAS and AutoPulse) to manual compression for achieving return of spontaneous circulation (ROSC) in patients undergoing cardiopulmonary resuscitation (CPR) after an out-of-hospital cardiac arrest (OHCA).

Methods

We searched medical databases systematically for randomized controlled trials (RCT) and observational studies published between January 1, 2000–October 1, 2020 that compared mechanical chest compression (using any device) with manual chest compression following OHCA. We only included studies in the English language that reported ROSC outcomes in adult patients in non-trauma settings to conduct random-effects metanalysis and trial sequence analysis (TSA). Multivariate meta-regression was performed using preselected covariates to account for heterogeneity. We assessed for risk of biases in randomization, allocation sequence concealment, blinding, incomplete outcome data, and selective outcome reporting.

Results

A total of 15 studies (n = 18474), including six RCTs, two cluster RCTs, five retrospective case-control, and two phased prospective cohort studies, were pooled for analysis. The pooled estimates’ summary effect did not indicate a significant difference (Mantel-Haenszel odds ratio = 1.16, 95% confidence interval, 0.97 to 1.39, P = 0.11, I2 = 0.83) between mechanical and manual compressions during CPR for ROSC. The TSA showed firm evidence supporting the lack of improvement in ROSC using mechanical compression devices. The Z-curves successfully crossed the TSA futility boundary for ROSC, indicating sufficient evidence to draw firm conclusions regarding these outcomes. Multivariate meta-regression demonstrated that 100% of the between-study variation could be explained by differences in average age, the proportion of females, cardiac arrests with shockable rhythms, witnessed cardiac arrest, bystander CPR, and the average time for emergency medical services (EMS) arrival in the study samples, with the latter three attaining statistical significance.

Conclusion

Mechanical compression devices for resuscitation in cardiac arrests are not associated with improved rates of ROSC. Their use may be more beneficial in non-ideal situations such as lack of bystander CPR, unwitnessed arrest, and delayed EMS response times. Studies done to date have enough power to render further studies on this comparison futile.

Cardiac manifestations of the coronavirus disease-19: a review of pathogenesis, clinical manifestations, diagnosis, and treatment

The coronavirus disease-19 (COVID-19), first appearing in Wuhan, China, and later declared as a pandemic, has caused serious morbidity and mortality worldwide. Severe cases usually present with acute respiratory distress syndrome (ARDS), pneumonia, acute kidney injury (AKI), liver damage, or septic shock. However, with recent advances in severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) research, the virus´s effect on cardiac tissues has become evident. Reportedly, an increased number of COVID-19 patients manifested serious cardiac complications such as heart failure, increased troponin, and N-terminal pro-B-type natriuretic peptide levels (NT-proBNP), cardiomyopathies, and myocarditis. These cardiac complications initially present as chest tightness, chest pain, and heart palpitations. Diagnostic investigations such as telemetry, electrocardiogram (ECG), cardiac biomarkers (troponin, NT-proBNP), and inflammatory markers (D-dimer, fibrinogen, PT, PTT), must be performed according to the patient´s condition. The best available options for treatment are the provision of supportive care, anti-viral therapy, hemodynamic monitoring, IL-6 blockers, statins, thrombolytic, and anti-hypertensive drugs. Cardiovascular disease (CVD) healthcare workers should be well-informed about the evolving research regarding COVID-19 and approach as a multi-disciplinary team to devise effective strategies for challenging situations to reduce cardiac complications.

Stethoscope - An essential diagnostic tool or a relic of the past?

Rene Laennec came up with the idea of a stethoscope in 1816 to avoid the embarrassment of performing immediate auscultation on women. Soon many doctors around the world started using this tool because of its increased accuracy and ease of use. Stethoscopes hold great significance in the medical community. However, is the importance placed on stethoscopes justified today? We now have devices like portable ultrasound machines that make it much easier to visualize the body. These devices offset their higher initial cost by reducing downstream costs due to their greater accuracy and their capability of detecting diseases at an earlier stage. Also, because of the COVID-19 pandemic, new ways are being investigated to reduce the transmission of diseases. Stethoscopes being a possible vector for infectious agents coupled with the advent of newer devices that can visualize the body with greater accuracy put into question the continued use of stethoscopes today. With that said, the use of stethoscopes to diagnose diseases is still crucial in places where buying these new devices is not yet possible. The stethoscope is a great symbol of medicine, but its use needs to be in line with what is best for the patient.

Utilizing Artificial Intelligence in Critical Care: Adding A Handy Tool to Our Armamentarium

We have witnessed rapid advancement in technology over the last few decades. With the advent of artificial intelligence (AI), newer avenues have opened for researchers. AI has added an entirely new dimension to this technological boom. Researchers in medical science have been excited about the tantalizing prospect of utilizing AI for the benefit of patient care. Lately, we have come across studies trying to test and validate various models based on AI to improve patient care strategies in critical care medicine as well. Thus, in this review, we will attempt to succinctly review current literature discussing AI in critical care medicine and analyze its future utility based on prevailing evidence.

Aeromedical Transport of Critically Ill Patients: A Literature Review

The aeromedical transport of critically ill patients has become an integral part of practicing medicine on a global scale. The development of reliable portable medical equipment allows physicians, emergency medical technicians, and nurses to transport wounded and diseased patients under constant critical care attention. Air transportation involves utilizing a fixed-wing (airplane) or rotor-wing (helicopter) aircraft to accomplish different types of transports ranging from scene responses to international transfers. The proper preparation and management of patients undergoing aeromedical transport require a basic understanding of the physiological changes and unique challenges encountered within the aircraft environment at 8,000 ft above sea level. The purpose of this paper is to review the literature and provide guidelines for approaching the aeromedical transportation of critically ill patients.

Bee Attack or Heart Attack: Kounis Syndrome

Kounis syndrome (KS) is defined as an allergic or hypersensitivity reaction leading to coronary vasospasm and acute coronary syndrome. The inflammatory mediators released during the body's reaction to an allergen causes vasoconstriction, plaque rupture, platelet aggregation, and even thrombosis of an existing coronary stent. Over the years, many allergens including drugs, environmental exposures, and animal and insect bites have been implicated in KS. Patients may present with elevated cardiac enzymes and electrocardiographic changes. We describe a case of a patient with no prior cardiac history who presented to the emergency department seeking treatment after multiple bee stings. The patient had non-specific electrocardiogram (ECG) changes and elevated cardiac enzymes consistent with a non-ST-elevation myocardial infarction. The patient underwent a pharmacologic stress test and myocardial perfusion imaging, which showed a perfusion defect consistent with ischemia. Selective right and left coronary angiography revealed a critical lesion at the proximal left circumflex artery. This was managed with percutaneous coronary intervention utilizing a bare-metal stent.

Abdominal compartment syndrome among surgical patients

Abdominal compartment syndrome (ACS) develops when organ failure arises secondary to an increase in intraabdominal pressure. The abdominal pressure is determined by multiple factors such as blood pressure, abdominal compliance, and other factors that exert a constant pressure within the abdominal cavity. Several conditions in the critically ill may increase abdominal pressure compromising organ perfusion that may lead to renal and respiratory dysfunction. Among surgical and trauma patients, aggressive fluid resuscitation is the most commonly reported risk factor to develop ACS. Other conditions that have also been identified as risk factors are ascites, hemoperitoneum, bowel distention, and large tumors. All patients with abdominal trauma possess a higher risk of developing intra-abdominal hypertension (IAH). Certain surgical interventions are reported to have a higher risk to develop IAH such as damage control surgery, abdominal aortic aneurysm repair, and liver transplantation among others. Close monitoring of organ function and intra-abdominal pressure (IAP) allows clinicians to diagnose ACS rapidly and intervene with target-specific management to reduce IAP. Surgical decompression followed by temporary abdominal closure should be considered in all patients with signs of organ dysfunction. There is still a great need for more studies to determine the adequate timing for interventions to improve patient outcomes.

A Rare Case of Solid Pseudopapillary Neoplasm of the Pancreas

Solid pseudopapillary neoplasm of pancreas (SPN) is a rare entity. It is almost exclusively seen in females within the second and third decades of life with only small minority affecting children. Due to the paucity of the number of cases seen, the natural history of the disease is not fully understood. SPN tumors of the pancreas are usually found incidentally and usually have an excellent prognosis. We herein present a case of a 33-year-old lady diagnosed with SPN, who presented with abdominal fullness, two weeks post cesarean section.

Mediastinal lymphadenopathy in COVID-19: A review of literature

A novel coronavirus disease 2019 (COVID-19) is a progressive viral disease that affected people around the world with widespread morbidity and mortality. Patients with COVID-19 infection typically had pulmonary manifestation but can also present with gastrointestinal, cardiac, or neurological system dysfunction. Chest imaging in patients with COVID-19 commonly show bilateral lung involvement with bilateral ground-glass opacity and consolidation. Mediastinal lymphadenopathy can be found due to infectious or non-infectious etiologies. It is commonly found to be associated with malignant diseases, sarcoidosis, and heart failure. Mediastinal lymph node enlargement is not a typical computer tomography of the chest finding of patients with COVID-19 infection. We summarized the literature which suggested or investigated the mediastinal lymph node enlargement in patients with COVID-19 infection. Further studies are needed to better characterize the importance of mediastinal lymphadenopathy in patients with COVID-19 infection.

Tsunami of economic turmoil to hit the healthcare in 2021-2022: COVID-19 pandemic is just an earthquake

The COVID-19 pandemic caused the United States to hit record numbers of COVID-19 cases: peak unemployment of 14.7%, an increase in $4 trillion in national debt, and an estimated 3.4% GDP decline. The current socio-economic environment the pandemic created is just an earthquake that can create a tsunami that is bound to hit the healthcare system and can be felt around the globe. This tsunami is composed of a post-pandemic increase in healthcare facilities admission of indigent patients, decrease in medical reimbursement, and high operating costs to maintain healthcare workers, which can cause a synergistic effect that can lead to healthcare facilities experiencing significant negative total revenue. Time is of the essence, and it is imperative to make a collective effort from all healthcare professionals and legislatures to shift the nation's attention to the issue at hand that can threaten the closure of many healthcare facilities post-pandemic.

Current Utility of Sequential Organ Failure Assessment Score: A Literature Review and Future Directions

The Sequential Organ Failure Assessment (SOFA) score is commonly used in the Intensive Care Unit (ICU) to evaluate, prognosticate and assess patients. Since its validation, the SOFA score has served in various settings, including medical, trauma, surgical, cardiac, and neurological ICUs. It has been a strong mortality predictor and literature over the years has documented the ability of the SOFA score to accurately distinguish survivors from non-survivors on admission. Over the years, multiple variations have been proposed to the SOFA score, which have led to the evolution of alternate validated scoring models replacing one or more components of the SOFA scoring system. Various SOFA based models have been used to evaluate specific clinical populations, such as patients with cardiac dysfunction, hepatic failure, renal failure, different races and public health illnesses, etc. This study is aimed to conduct a review of modifications in SOFA score in the past several years. We review the literature evaluating various modifications to the SOFA score such as modified SOFA, Modified SOFA, modified Cardiovascular SOFA, Extra-renal SOFA, Chronic Liver Failure SOFA, Mexican SOFA, quick SOFA, Lactic acid quick SOFA (LqSOFA), SOFA in hematological malignancies, SOFA with Richmond Agitation-Sedation scale and Pediatric SOFA. Various organ systems, their relevant scoring and the proposed modifications in each of these systems are presented in detail. There is a need to incorporate the most recent literature into the SOFA scoring system to make it more relevant and accurate in this rapidly evolving critical care environment. For future directions, we plan to put together most if not all updates in SOFA score and probably validate it in a large database a single institution and validate it in multisite data base.

Cocaine-Induced Bronchial Laceration: A Rare Incidence

Tracheobronchial injuries are either traumatic or iatrogenic but can be lethal in a high dependency setting if not managed promptly. There are few reported cases of cocaine-induced airway damage and barotrauma due to thermal or ischemic injury and increased intra-alveolar pressure. We present a sui generis case of cocaine-induced bronchial laceration with pneumomediastinum which was challenging to diagnose based on the patient’s recent history of hospitalization, as well as the patient’s reluctance to share the history of cocaine use. The patient was successfully managed conservatively. Here, we discuss the mechanism involved and the various treatment options available, along with the role of early involvement of the multidisciplinary team to deliver the best possible outcome.

Diagnostic procedures and clinico-radiological findings of acute fibrinous and organizing pneumonia: a systematic review and pooled analysis

OBJECTIVES

To evaluate the clinico-radiological findings of acute fibrinous and organizing pneumonia (AFOP) in the literature according to whether a surgical or non-surgical biopsy was performed, as well as to identify prognostic predictors.

METHODS

We searched the Embase and OVID-MEDLINE databases to identify studies that presented CT findings of AFOP and had extractable individual patient data. We compared the clinical and CT findings of the patients depending on whether a surgical or non-surgical biopsy was performed and identified survival predictors using a multivariate logistic regression analysis.

RESULTS

Eighty-one patients (surgical biopsy, n = 52; non-surgical biopsy, n = 29) from 63 studies were included. The surgical biopsy group frequently experienced an acute fulminant presentation (p = .011) and dyspnea (p = .001) and less frequently had a fever (p = .006) than the non-surgical biopsy group. The surgical biopsy group had a worse prognosis than the non-surgical biopsy group in terms of mechanical ventilation and mortality (both, p = .023). For survival analysis, the patients with the predominant CT finding of patchy or mass-like air-space consolidation survived more frequently (p < .001) than those with other CT findings. For prognostic predictors, subacute indolent presentation (p = .001) and patchy or mass-like air-space consolidation on CT images (p = .002) were independently associated with good survival.

CONCLUSIONS

Approximately one-third of alleged AFOP cases in the literature were diagnosed via non-surgical biopsy, but those cases had different symptomatic presentations and prognosis from surgically proven AFOP. Subacute indolent presentation and patchy or mass-like air-space consolidation at the presentation on CT images indicated a good prognosis in patients with AFOP.

KEY POINTS

• Acute fibrinous and organizing pneumonia (AFOP) cases diagnosed via non-surgical biopsy had different symptomatic presentations and prognosis from surgically proven AFOP. • Subacute indolent presentation and patchy or mass-like air-space consolidation on CT images indicated a good prognosis in patients with acute fibrinous and organizing pneumonia.

Pulmonary Hypertension in Pregnancy: A Review

Pulmonary hypertension (PH) is a disease, which targets the pulmonary vasculature affecting the heart and the lungs, and is characterized by a vast array of signs and symptoms. These manifestations of PH in pregnancy are highly variable and non-specific hence, it is prudent to have a very keen and high index of suspicion while evaluating these patients. This rare disease can be extremely debilitating and can be associated with a poor overall prognosis. Pregnancy in women with PH puts them at an elevated risk because the physiological changes associated with pregnancy are not well endured leading to even higher morbidity and mortality in these patients. Although there are various modalities for evaluation and workup of PH, right heart catheterization (RHC) remains the gold standard. A mean pulmonary artery pressure (PAP) of more than 20 mm of Hg is considered diagnostic. It is indeed heartening to see that in the past decade many novel therapeutic modalities have emerged and along with a better understanding of the disease process have proved to be promising in terms of reducing the adverse outcomes and preventing death in this population of patients.

Achromobacter xylosoxidans/denitrificans Bacteremia in a Patient With Good's Syndrome

Good's syndrome is a rare, adult-onset immunodeficiency syndrome associated with thymomas. Here, we present a 71-year-old, previously healthy male with a history of opportunistic infections status post-thymectomy, who presented with a septic knee complicated with bacteremia without any inciting factor. Therefore, a diagnosis of Good syndrome was made. While this is a rare disease, clinicians should have a high suspicion in patients with a history of thymoma. Early diagnosis and treatment can reduce opportunistic infections and improve morbidity and mortality.

COVID-19 pandemic: from origins to outcomes. A comprehensive review of viral pathogenesis, clinical manifestations, diagnostic evaluation, and management

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), the causative pathogen for the COVID-19, first emerged in Wuhan, China, in December 2019 and by March 2020, it was declared a pandemic. COVID-19 pandemic has overburdened healthcare systems in most countries and has led to massive economic losses. SARS-CoV-2 transmission typically occurs by respiratory droplets. The average incubation period is 6.4 days and presenting symptoms typically include fever, cough, dyspnea, myalgia or fatigue. While the majority of patients tend to have a mild illness, a minority of patients develop severe hypoxia requiring hospitalization and mechanical ventilation. Management is mostly supportive. However, several direct anti-viral agents, and immunomodulatory therapy with steroids and various cytokine blockers seem promising in early results. However, an effective vaccine has been established, which will help curb the pandemic.

The Role of Extra Corporeal Membrane Oxygenation in Amniotic Fluid Embolism: A Case Report and Literature Review

Amniotic fluid embolism (AFE) is a rare and life-threatening complication related to pregnancy. Early diagnosis and prompt intervention are important tools for the survival of the patient. Despite early intervention, mortality rate remains high. We present a case of a 19-year-old female who was admitted for labor induction and delivery. Her delivery course was complicated by meconium-stained amniotic fluid. The patient went into acute hypoxic respiratory failure (AHRF) and hemodynamic compromise within half an hour following delivery secondary to AFE. We hereby discuss the role of timely initiation of extra corporeal membrane oxygenation (ECMO) in a case of AFE which could have otherwise turned out to be fatal.

Foreign Body Aspiration Getting Weird: Crack Pipe Aspiration

Inhalation of cocaine derivatives is associated with a number of pulmonary and systemic complications. We report a case of less recognized complication, the aspiration of a metallic object used as a screen for crack cocaine abuse. A 42-year-old female presented with a two-day history of gradually worsening cough and a history of “food aspiration.” Her lung examination revealed wheezing and fine crackles with diminished air entry at the left base. A chest X-ray revealed an 8 mm radiopaque foreign body overlying the region of the left lower lobe bronchus, with a confirmatory computed tomography scan of the chest. An urgent bronchoscopy revealed a metallic foreign body impacted into the left lower lobe bronchus proper, soon after the takeoff of the superior segment, which was removed with forceps. The patient signed out against medical advice soon after. Though relatively uncommon, this case highlights a possible complication associated with crack cocaine abuse that may require emergent intervention.

An infrequently encountered case of spontaneous subcapsular liver hematoma with hepatic artery pseudoaneurysm

Hepatic artery pseudoaneurysm (HAP) is a rare complication of liver trauma and liver transplant, and spontaneous subcapsular liver hematoma is not frequently encountered outside the setting of preeclampsia and hemolysis, elevated liver enzyme and low platelet (HELLP) syndrome. We report a rare case of spontaneous subcapsular liver hematoma with hepatic artery pseudoaneurysm without any apparent liver trauma or recent interventional procedures of the hepatobiliary system. Although subcapsular hepatic hematoma and HAP are uncommon diagnoses, clinicians should be aware of these diagnoses to promptly diagnose and effectively treat them. Clinicians should also not forget these diseases could be masked by other common etiologies, such as gastritis.