ST-Elevation Myocardial Infarction in a 27-Year-Old Male With COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a virus that led to a global public health emergency causing coronavirus disease 2019 (COVID-19). It was initially identified in Wuhan, China after causing significant respiratory illness. Although respiratory symptoms are the most common presenting symptoms, it is now recognized that COVID-19 encompasses multiple organ systems including the cardiovascular system. Acute myocardial injury and ST-elevation myocardial infarction (STEMI) have now been associated with COVID-19. COVID-19 patients with cardiovascular manifestations are at risk for increased severity of illness. Here we present a case of a very young 27-year-old patient without any past history of hypertension, coronary artery disease, or any risk factors for coronary artery disease except obesity, who developed STEMI while in the hospital.

Case Report: Sudden Splenic Rupture in a Plasmodium falciparum-Infected Patient

Spontaneous splenic rupture is a rare and life-threatening complication of severe malaria. It demands particular attention since delayed or missed diagnosis can be potentially fatal. The exact incidence is unknown largely due to underreporting. Acute malarial infection accounts for most of the spontaneous splenic rupture. Plasmodium vivax has been associated with the majority of them; however, on rare occasion, other Plasmodium infections have also resulted in splenic rupture. We report the case of a 74-year-old male who was diagnosed with severe malaria caused by Plasmodium falciparum (P. falciparum) infection and developed an acute abdomen while on treatment due to spontaneous splenic rupture which necessitated emergency splenectomy.

Reversing Bleeding Associated With Antiplatelet Use: The Role of Tranexamic Acid

Dual antiplatelet therapy (DAPT) is the mainstay of therapy in patients that have been diagnosed with coronary artery disease. DAPT has known risk factors such as an increased risk of bleeding, and, currently, no specific medication is indicated to reverse bleeding associated with antiplatelet use. One medication that may help reduce blood loss is tranexamic acid (TXA). A retrospective review of the literature regarding TXA in the setting of antiplatelet associated bleeding through a systematic search strategy was conducted. This review of the literature followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines and included seven studies. Multiple studies demonstrated the impact on platelet function resulting from administering TXA through lower volumes of blood loss, lower transfusion requirements, and lower incidence of reoperations. TXA is not widely recommended to reverse antiplatelet medications; however, it is widely available, has a positive track record for use in various types of bleeding, and is relatively inexpensive and safe. Large-scale randomized trials are warranted to make a strong recommendation for TXA in reversing bleeding associated with antiplatelet therapy.

Risk factors for and prediction of post-intubation hypotension in critically ill adults: A multicenter prospective cohort study

Objective

Hypotension following endotracheal intubation in the ICU is associated with poor outcomes. There is no formal prediction tool to help estimate the onset of this hemodynamic compromise. Our objective was to derive and validate a prediction model for immediate hypotension following endotracheal intubation.

Methods

A multicenter, prospective, cohort study enrolling 934 adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 was conducted to derive and validate a prediction model for immediate hypotension following endotracheal intubation. We defined hypotension as: 1) mean arterial pressure <65 mmHg; 2) systolic blood pressure <80 mmHg and/or decrease in systolic blood pressure of 40% from baseline; 3) or the initiation or increase in any vasopressor in the 30 minutes following endotracheal intubation.

Results

Post-intubation hypotension developed in 344 (36.8%) patients. In the full cohort, 11 variables were independently associated with hypotension: increasing illness severity; increasing age; sepsis diagnosis; endotracheal intubation in the setting of cardiac arrest, mean arterial pressure <65 mmHg, and acute respiratory failure; diuretic use 24 hours preceding endotracheal intubation; decreasing systolic blood pressure from 130 mmHg; catecholamine and phenylephrine use immediately prior to endotracheal intubation; and use of etomidate during endotracheal intubation. A model excluding unstable patients’ pre-intubation (those receiving catecholamine vasopressors and/or who were intubated in the setting of cardiac arrest) was also developed and included the above variables with the exception of sepsis and etomidate. In the full cohort, the 11 variable model had a C-statistic of 0.75 (95% CI 0.72, 0.78). In the stable cohort, the 7 variable model C-statistic was 0.71 (95% CI 0.67, 0.75). In both cohorts, a clinical risk score was developed stratifying patients’ risk of hypotension.

Conclusions

A novel multivariable risk score predicted post-intubation hypotension with accuracy in both unstable and stable critically ill patients.

Study registration

Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.

Interstitial lung disease and diabetes

Diabetes mellitus (DM) is a chronic metabolic disease and its prevalence has been steadily increasing all over the world. DM and its associated micro and macrovascular complications result in significant morbidity and mortality. The microvascular complications are usually manifested as retinopathy, neuropathy, nephropathy and macrovascular complications generally affect the cardiovascular system. In addition to these complications, DM also affects the lungs because of its rich vascularity and abundance in connective tissue (collagen and elastin). DM has been found to cause microvascular complications and proliferation of extracellular connective tissue in the lungs, leading to decline in lung function in a restrictive pattern. Interstitial lung disease (ILD) includes a diverse group of disease conditions characterized by different degrees of inflammation and fibrosis in the pulmonary parenchyma. Idiopathic pulmonary fibrosis (IPF) is one of the common type of idiopathic interstitial pneumonia with a high mortality rate. IPF is characterized by chronic progressive fibrosis leading to progressive respiratory failure. In this review we focus on lung as the target organ in DM and the association of DM and ILD with special emphasis on IPF.

The Impact of Clostridium Difficile Infections on In-Hospital Outcomes of Venous Thromboembolism (Deep Vein Thrombosis or Pulmonary Embolism) Hospitalizations

Background

Clostridium difficile infection (CDI) is associated with high mortality. Studies have shown an increased rate of venous thromboembolism (VTE) in patients with CDI. However, literature regarding the impact of CDI on outcomes of VTE-related hospitalizations is scarce. Our study aimed to assess the impact of CDI on in-hospital outcomes among VTE hospitalizations.

Methods

The 2016 National Inpatient Sample (NIS) was used to identify all adult hospitalizations in the United States with a primary discharge diagnosis of acute VTE. Hospitalizations with deep vein thrombosis (DVT) or pulmonary embolism (PE) were included under VTE. The sample was stratified based on the presence or absence of active CDI. Chi-square test and weighted Student’s t-test were used to analyze categorical and continuous variables, respectively. The adjusted odds ratio (OR) for clinical outcomes were calculated using multivariate logistic regression analysis. Subgroup analyses for DVT and PE hospitalizations were performed. All analyses were completed in SAS (SAS Institute Inc., Cary, NC), and a p-value of <0.05 was considered statistically significant.

Results

We identified 382,585 weighted hospitalizations for VTE. Among them, 0.8% had concomitant CDI. The presence of CDI was associated with a statistically significant increase in in-hospital mortality (6% vs. 3%), hospitalization cost ($147,356.5 vs. $55,193), and length of stay (13.7 vs. 5.4 days). There were more incidents of bleeding and acute respiratory failure requiring prolonged ventilation in patients with CDI. The odds of stroke were significantly higher in patients with CDI and DVT.

Conclusion

CDI independently increased in-hospital mortality in VTE. Preventing CDI in the VTE population may mitigate complications, improve in-hospital outcomes, and reduce treatment costs.

Urinary Incontinence in Older Adults Takes Collaborative Nursing Efforts to Improve

There is a misconception that urinary incontinence (UI) in older adults, usually above the age of 65 is a part of aging. More than 50% of residents in long-term care (LTC) settings are affected by UI and it is associated in many cases with markedly reduced quality of life. It has become evident that incontinence can be cured or successfully managed. However, many nurses lack sufficient knowledge to intervene appropriately. The purpose of this review is to share how the collaborative efforts of nurses at all levels may lead to increased assessment and interventions of UI in this population.

Rifampin-Induced Acute Intravascular Hemolysis Leading to Heme Pigment-Related Kidney Injury

Rifampin-induced acute kidney injury is very rare. Most cases of acute renal injury from rifampin use are related to acute tubular necrosis and acute interstitial nephritis. In this case report, we detail a unique presentation of rifampin-associated acute intravascular hemolysis and subsequent tubular injury in a tuberculosis patient. The patient had presented to the hospital with acute kidney injury and oliguria from intravascular volume depletion secondary to intractable vomiting. The patient had stopped taking his antituberculosis medications two weeks before hospitalization. At the time of hospital admission, his antituberculosis regimen of rifampin and isoniazid was reinstituted. Within four days of initiation of rifampin, he developed acute hemolytic anemia. His kidney biopsy revealed hemoglobin pigment deposition in the kidney tubules. Rifampin was discontinued, and he received a total of eight hemodialysis treatments spanning over 17 days. Subsequently, after discontinuing rifampin, his anemia and oliguria resolved with renal function markedly improved to near normal baseline levels. This case report also offers a review of known mechanisms of rifampin-induced acute hemolysis and acute renal failure, along with a discussion of contemporary literature.

Myocardial Echinococcosis: Rare Manifestation of a Common Parasitic Disease in Northern Tanzania

Hydatid (Echinococcal) disease often involves the liver and lungs but in sporadic cases, it can involve cardiac structures. A 24-year-old male was referred with symptoms of cough and shortness of breath and a provisional diagnosis of metastatic disease of unknown primary to the lung, which was based on a chest X-ray (CXR). Incidentally, on echocardiogram, he was found to have right ventricular (RV) and myocardial multiseptated cysts, which were compatible with cardiac echinococcosis, as the patient had multiple bilateral lung cysts as well. Imaging with ultrasound, computed tomography (CT) scan, and magnetic resonance imaging (MRI) has ameliorated the diagnosis of hydatid disease location in various body parts. However, for earlier and accurate diagnosis, a high index of suspicion is required in endemic areas, especially in vulnerable populations such as pastoralists.

Cystic fibrosis-related diabetes: The unmet need

Cystic fibrosis (CF) is a common autosomal recessive disease. Life expectancy of patients with CF continues to improve mainly driven by the evolving therapies for CF-related organ dysfunction. The prevalence of CF-related diabetes (CFRD) increases exponentially as patients’ age. Clinical care guidelines for CFRD from 2010, recommend insulin as the mainstay of treatment. Many patients with CFRD may not require exogenous insulin due to the heterogeneity of this clinical entity. Maintenance of euglycemia by enhancing endogenous insulin production, secretion and degradation with novel pharmacological therapies like glucagon-like peptide-1 agonist is an option that remains to be fully explored. As such, the scope of this article will focus on our perspective of glucagon-like peptide-1 receptor agonist in the context of CFRD. Other potential options such as sodium-glucose cotransporter-2 and dipeptidyl peptidase 4 inhibitors and their impact on this patient population is limited and further studies are required.

Critical care practice in India: Results of the intensive care unit need assessment survey (ININ2018)

BACKGROUND

A diverse country like India may have variable intensive care units (ICUs) practices at state and city levels.

AIM

To gain insight into clinical services and processes of care in ICUs in India, this would help plan for potential educational and quality improvement interventions.

METHODS

The Indian ICU needs assessment research group of diverse-skilled individuals was formed. A pan- India survey "Indian National ICU Needs" assessment (ININ 2018-I) was designed on google forms and deployed from July 23^rd-August 25^th, 2018. The survey was sent to select distribution lists of ICU providers from all 29 states and 7 union territories (UTs). In addition to emails and phone calls, social medial applications-WhatsApp™, Facebook™ and LinkedIn™ were used to remind and motivate providers. By completing and submitting the survey, providers gave their consent for research purposes. This study was deemed eligible for category-2 Institutional Review Board exempt status.

RESULTS

There were total 134 adult/adult-pediatrics ICU responses from 24 (83% out of 29) states, and two (28% out of 7) UTs in 61 cities. They had median (IQR) 16 (10-25) beds and most, were mixed medical-surgical, 111(83%), with 108(81%) being adult-only ICUs. Representative responders were young, median (IQR), 38 (32-44) years age and majority, n = 108 (81%) were males. The consultants were, n = 101 (75%). A total of 77 (57%) reported to have 24 h in-house intensivist. A total of 68 (51%) ICUs reported to have either 2:1 or 2≥:1 patient:nurse ratio. More than 80% of the ICUs were open, and mixed type. Protocols followed regularly by the ICUs included sepsis care, ventilator- associated pneumonia (83% each); nutrition (82%), deep vein thrombosis prophylaxis (87%), stress ulcer prophylaxis (88%) and glycemic control (92%). Digital infrastructure was found to be poor, with only 46 % of the ICUs reporting high-speed internet availability.

CONCLUSION

In this large, national, semi-structured, need-assessment survey, the need for improved manpower including; in-house intensivists, and decreasing patient-to-nurse ratios was evident. Sepsis was the most common diagnosis and quality and research initiatives to decrease sepsis mortality and ICU length of stay could be prioritized. Additionally, subsequent surveys can focus on digital infrastructure for standardized care and efficient resource utilization and enhancing compliance with existing protocols.

Shrinking Lung Syndrome: A Rare Manifestation of Systemic Lupus Erythematosus

Shrinking lung syndrome (SLS) is a pulmonary complication of systemic lupus erythematosus (SLE) characterized by dyspnea, pleuritic chest pain, and progressive decrease in lung volumes with no evidence of pleural or interstitial disease on chest CT. We present a 51-year-old female with a 14-year history of SLE with symptoms of progressive shortness of breath, pleuritic chest pains, low grade fevers, and productive cough which was unresponsive to multiple courses of antibiotics. After careful review of her course of SLE and timeline of symptoms, she was diagnosed with SLS. Even though rare, clinicians should have a high suspicion of SLS in patients with a long-term history of SLE and worsening dyspnea. Early treatment can be initiated to help reduce long-term morbidity and mortality and maintain the quality of life.

Role of Tranexamic Acid in the Clinical Setting

Tranexamic acid (TXA) is labeled as an antifibrinolytic agent that decreases mortality, reduces blood loss after trauma or surgery, and lowers transfusion requirements in trauma patients with bleeding. This review of the literature is related to TXA use in a variety of settings, with a specific focus on trauma patients, to assess therapeutic efficacy and safety. As seen in large, randomized, placebo-controlled trials, TXA has been shown to decrease mortality over placebo in trauma patients, It is also noted to have good safety parameters upon administration and should be recommended for use in trauma patients with bleeding. Further studies are warranted for the use of TXA in gastrointestinal bleeding and pediatric trauma.

COVID-19: A Review of Emerging Preventative Vaccines and Treatment Strategies

COVID-19, which was first detected in the Hubei province of China, has become a global phenomenon. The effects and devastation on both health and economy have been global. At present, there is a substantial amount of research being done to discover suitable treatment modalities. Efforts have been made on the development of potential efficacious vaccines. The development of a vaccine can be complex, expensive as well as time-consuming. Currently, various ongoing clinical trials are in progress that are investigating either pharmacologic therapies or vaccines against this virus. We, in this brief review have tried to address the process and current development efforts of vaccine in progress.

Current practice patterns, challenges, and educational needs of asthma care providers in the United States

OBJECTIVE

For severe, uncontrolled asthma (SUA), a gap exists between recent scientific advances and their incorporation into clinical practice. Using a Knowledge-to-Action Framework, new knowledge can be translated into evidence-based interventions to improve outcomes. The AstraZeneca U.S. PRECISION initiative aims to apply this Framework to improve recognition and management of SUA. The study objective was to identify factors contributing to gaps in care for patients with SUA. Results from a needs assessment survey of U.S. pulmonologists and allergists/immunologists were assessed within the Knowledge-to-Action Framework to advance bench-to-bedside care.

METHODS

Pulmonologists and allergists/immunologists from across the United States were invited to complete a customized, quantitative severe asthma survey in person at the 2017 American Thoracic Society annual meeting or via the Internet. Responses were summarized descriptively, and chi-squared tests evaluated associations between variables of interest.

RESULTS

Overall, 140 U.S. providers responded, most of whom were pulmonologists (84%). Most (60%) practiced in a community-based setting; 40% practiced at an academic medical center. Key challenges to providing care for patients with severe asthma included insurance company requirements and identification of the pathophysiology of an individual patient's severe asthma. Traditional measures of asthma-related morbidity were ranked as highly important by significantly more respondents compared with assessment of biomarkers (p < 0.0001). Respondents generally valued online virtual self-education.

CONCLUSIONS

Survey results identified unmet needs for the identification and management of patients with SUA and opportunities to improve patient outcomes through evidence-based management of SUA, including testing for biologic eligibility and subsequent use of biologic therapies.

A Review of Neurological Complications of COVID-19

The SARS-CoV-2, a novel virus has shown an association with central nervous system (CNS) symptoms. Initial retrospective studies emerging from China and France, as well as case reports from different parts of the world revealed a spectrum of neurological symptoms ranging from a simple headache to more serious encephalitis and dysexecutive syndromes. Authors have tried to explain this neurotropism of the virus by comparing invasion mechanisms with prior epidemic coronavirus like severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). Concrete evidence on those viruses has been limited. This review attempts to discuss various pathophysiological mechanisms as it relates to neurological complications of SARS-CoV-2. We will also discuss the neurological manifestations seen in various retrospective studies, systemic reviews, and case reports.

Endobronchial Tuberculosis: A Rare Presentation

Endobronchial tuberculosis (EBTB) is an infection of the tracheobronchial tree by Mycobacterium tuberculosis. It is common among young females. Patient can present with fever, cough, wheeze, with or without any constitutional symptoms. It presents as a diagnostic dilemma, as patient sputum smear can be false negative. CT scan may or may not show any abnormality, or any endobronchial lesion. Bronchoscopy with bronchoalveolar lavage and biopsy offers the diagnostic choice. We hereby report a case of a young immunocompetent Asian female who was found to have endobronchial pathology, leading to diagnosis and timely therapy. 

A Review of Cardiac Complications in Coronavirus Disease 2019

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has shown an association with acute myocardial injury, cardiomyopathy, and myocarditis. Individuals with myocardial involvement in association with the coronavirus disease 2019 (COVID-19) may be at increased risk of developing severe illness. Cardiomyopathies are a heterogeneous group of diseases of the myocardium associated with mechanical and/or electrical dysfunction that usually exhibit inappropriate ventricular hypertrophy or dilation and are due to a variety of causes that frequently are genetic. It has been primarily divided into three subsets: genetic, mixed, and acquired cardiomyopathy. We anticipate that, because of the high inflammatory response, other cardiovascular complications may also occur in COVID-19 patients with severe symptoms. This review explores new information as it pertains to COVID-19 and cardiac complications.

Heyde Syndrome: A Case Report and Literature Review

Heyde syndrome is characterized by an association between gastrointestinal (GI) bleeding and calcific aortic stenosis (AS). Although the course of disease progression that links AS and GI bleeding has not been determined, overlaps among AS, intestinal dysplasia, and acquired von Willebrand's syndrome are thought to result in GI bleeding. Aortic valve repair in some patients has been reported to result in marked improvement or the complete resolution of signs and symptoms of Heyde syndrome. The prevalence of Heyde syndrome is higher among elderly persons than among other age groups, suggesting that a degenerative process may be a significant factor in the disease progression. This report describes a patient with Heyde syndrome, as well as a review of the current literature.