Remdesivir, dexamethasone and angiotensin-converting enzyme inhibitors use and mortality outcomes in COVID-19 patients with concomitant troponin elevation

BACKGROUND

There are indications that viral myocarditis, demand ischemia, and renin-angiotensin-aldosterone system pathway activation play essential roles in troponin elevation in coronavirus disease 2019 (COVID-19) patients. Antiviral medications and steroids are used to treat viral myocarditis, but their effect in patients with elevated troponin, possibly from myocarditis, has not been studied.

AIM

To evaluate the effect of dexamethasone, remdesivir, and angiotensin-converting enzyme (ACE) inhibitors (ACEI) on mortality in COVID-19 patients with elevated troponin.

METHODS

Our retrospective observational study involved 1788 COVID-19 patients at seven hospitals in Southern California, United States. We did a backward selection Cox multivariate regression analysis to determine predictors of mortality in our study population. Additionally, we did a Kaplan Meier survival analysis in the subset of patients with elevated troponin, comparing survival in patients that received dexamethasone, remdesivir, and ACEI with those that did not.

RESULTS

The mean age was 66 years (range 20-110), troponin elevation was noted in 11.5% of the patients, and 29.9% expired. The patients' age [hazard ratio (HR) = 1.02, P < 0.001], intensive care unit admission (HR = 5.07, P < 0.001), and ventilator use (HR = 0.68, P = 0.02) were significantly associated with mortality. In the subset of patients with elevated troponin, there was no statistically significant difference in survival in those that received remdesivir (0.07), dexamethasone (P = 0.63), or ACEI (P = 0.8) and those that did not.

CONCLUSION

Although elevated troponin in COVID-19 patients has been associated with viral myocarditis and ACE II receptors, conventional viral myocarditis treatment, including antiviral and steroids, and ACEI did not show any effect on mortality in these patients.

Use of intravascular lithotripsy in non-coronary artery lesions

BACKGROUND

Intravascular lithotripsy (IVL) is a novel technique increasingly used for plaque modification and endovascular revascularization in patients with severe calcification and peripheral artery disease. However, much of the available literature on IVL is focused on its use in coronary arteries, with relatively limited data on non-coronary artery use.

AIM

To analyze the safety and efficacy of current IVL use in non-coronary artery lesions, as reported in case reports and case series.

METHODS

We searched EMBASE, PubMed, and Reference Citation Analysis databases for case reports and case series on IVL use in peripheral artery disease. We then extracted variables of interest and calculated the mean and proportions of these variables.

RESULTS

We included 60 patients from 33 case reports/case series. Ninety-eight percent of the cases had IVL usage in only one blood vessel, while four had the IVL used in two vessels (2.0%), resulting in 64 Lesions treated with IVL. The mean age of the patients was 73.7 (SD 10.9). IVL was successfully used in severe iliofemoral artery stenosis (51.6%), severe innominate, subclavian, and carotid artery stenosis (26.7% combined), and severe mesenteric vessel stenosis (9.4%). Additionally, IVL was successfully used in severe renal (7.8%) and aortic artery (4.7%) stenosis. There were complications in 12% of the cases, with dissection being the commonest.

CONCLUSION

IVL has successfully used in plaque modification and endovascular revascularization in severely calcified and challenging lesions in the iliofemoral, carotid, subclavian, aorta, renal, and mesenteric vessels. The most severe but transient complications were with IVL use in the aortic arch and neck arteries.

Treating sepsis with vitamin C, thiamine, and hydrocortisone: Exploring the quest for the magic elixir

The administration of ascorbic acid (vitamin C) alone or in combination with thiamine (vitamin B1) and corticosteroids (VCTS) has recently been hypothesized to improve hemodynamics, end-organ function, and may even increase survival in critically ill patients. There are several clinical studies that have investigated the use of vitamin C alone or VCTS in patients with sepsis and septic shock or are ongoing. Some of these studies have demonstrated its safety and potential benefit in septic patients. However, many questions remain regarding the optimal dosing regimens and plasma concentrations, timing of administration, and adverse effects of vitamin C and thiamine. These questions exist because the bulk of research regarding the efficacy of vitamin C alone or in combination with thiamine and corticosteroids in sepsis is limited to a few randomized controlled trials, retrospective before-and-after studies, and case reports. Thus, although the underlying rationale and mechanistic pathways of vitamin C and thiamine in sepsis have been well described, the clinical impact of the VCTS regimen is complex and remains to be determined. This review aims to explore the current evidence and potential benefits and adverse effects of the VCTS regimen for the treatment of sepsis.

Cerebro-spinal lactate status in childhood pyogenic meningitis in Nigeria

This study was undertaken to ascertain the status of cerebrospinal (CSF) lactate level in Nigerian children with pyogenic meningitis. Forty patients aged from 1 month to 12 years with proven meningitis were the subjects in the study which lasted 8 months. All the patients who had pyogenic meningitis had mean cerebrospinal lactate level over 25 mg/dl. The patients who recovered with neurological deficit had higher level of cerebrospinal lactate than those who recovered without any neurological deficit, on admission and on-discharge, although the differences were not statistically significant. The patients who died had persistently high mean CSF lactate on admission and at death. The study suggests that persistently elevated CSF lactate in cases of pyogenic meningitis receiving adequate antibiotic therapy might indicate poor prognosis with increased mortality. It is not being suggested that CSF lactate determination should replace the conventional tests for meningitis. However, it can provide pertinent, rapid, and reliable diagnostic information, and can also provide useful evaluation information at different stages of treatment of proven meningitis with appropriate antibiotics.