Stress cardiomyopathy in critical care: A case series of 109 patients

BACKGROUND

Critically ill patients are at risk of developing stress cardiomyopathy (SC) but can be under-recognized.

AIM

To describe a case series of patients with SC admitted to critical care units.

METHODS

We conducted a retrospective observational study at a tertiary care teaching hospital. All adult (≥ 18 years old) patients admitted to the critical care units with stress cardiomyopathy over 5 years were included.

RESULTS

Of 24279 admissions to the critical care units [19139 to medical-surgical intensive care units (MSICUs) and 5140 in coronary care units (CCUs)], 109 patients with SC were identified. Sixty (55%) were admitted to the coronary care units (CCUs) and forty-nine (45%) to the medical-surgical units (MSICUs). The overall incidence of SC was 0.44%, incidence in CCU and MSICU was 1.16% and 0.25% respectively. Sixty-two (57%) had confirmed SC and underwent cardiac catheterization whereas 47 (43%) had clinical SC, and did not undergo cardiac catheterization. Forty-three (72%) patients in the CCUs were diagnosed with primary SC, whereas all (100%) patients in MSICUs developed secondary SC. Acute respiratory failure that required invasive mechanical ventilation and shock developed in twenty-nine (59%) MSICU patients. There were no statistically significant differences in intensive care unit (ICU) mortality, in-hospital mortality, use of inotropic or mechanical circulatory support based on type of unit or anatomical variant.

CONCLUSION

Stress cardiomyopathy can be under-recognized in the critical care setting. Intensivists should have a high index of suspicion for SC in patients who develop sudden or worsening unexplained hemodynamic instability, arrhythmias or respiratory failure in ICU.

Epidemiology, Risk Factors and Outcomes of Pneumomediastinum in Patients with Coronavirus Disease 2019: A Case-Control Study

Background: Since the beginning of the ongoing Coronavirus Disease 2019 (COVID-19) pandemic, pneumomediastinum has been reported in patients with COVID-19 pneumonia and acute respiratory distress syndrome. It has been suggested that pneumomediastinum may portend a worse outcome in such patients although no investigation has established this association definitively. Research Question: We hypothesized that the finding of pneumomediastinum in the setting of COVID-19 disease may be associated with a worse clinical outcome. The purpose of this study was to determine if the presence of pneumomediastinum was predictive of increased mortality in patients with COVID-19. Study Design and Methods: A retrospective case-control study utilizing clinical data and imaging for COVID-19 patients seen at our institution from 3/7/2020 to 5/20/2020 was performed. 87 COVID-19 positive patients with pneumomediastinum were compared to 87 COVID-19 positive patients without pneumomediastinum and to a historical group of patients with pneumomediastinum during the same time frame in 2019. Results: The incidence of pneumomediastinum was increased more than 6-fold during the COVID-19 pandemic compared to 2019 (P = <.001). 1.5% of all COVID-19 patients and 11% of mechanically ventilated COVID-19 patients at our institution developed pneumomediastinum. Patients who developed pneumomediastinum had a significantly higher PEEP and lower P/F ratio than those who did not (P = .002 and .033, respectively). Pneumomediastinum was not found to be associated with increased mortality (P = .16, confidence interval [CI]: 0.89-2.09, 1.37). The presence of concurrent pneumothorax at the time of pneumomediastinum diagnosis was associated with increased mortality (P = .013 CI: 1.15-3.17, 1.91). Conclusion: Pneumomediastinum is not independently associated with a worse clinical prognosis in COVID-19 positive patients. The presence of concurrent pneumothorax was associated with increased mortality.

Effects of pre-induced fatigue vs. concurrent pain on exercise tolerance, neuromuscular performance and corticospinal responses of locomotor muscles

KEY POINTS

Fatigue and muscle pain induced in a remote muscle group has been shown to alter neuromuscular performance in exercising muscles. Inhibitory neural feedback associated with activation of mechano- and metabo-sensitive muscle afferents has been implicated in this phenomenon. The present study aimed to quantify and compare the effects of pre-induced fatigue and concurrent rising pain (evoked by muscle ischaemia) on the contralateral leg exercise capacity, neuromuscular performance, and corticomotor excitability and inhibition of knee extensor muscles. Pre-induced fatigue in one leg had a greater detrimental effect than the concurrent rising pain on the contralateral limb cycling capacity. Furthermore, pre-induced fatigue, but not concurrent rising pain, reduced corticospinal inhibition recorded from tested contralateral muscles. Regardless of the origin or mechanisms modulating sensory afferents during single-leg cycling exercise (i.e. pre-induced fatigue vs. concurrent rising pain), the limit of exercise tolerance remained the same and exercise was terminated upon achievement of a sensory tolerance limit.

ABSTRACT

Individuals often need to maintain voluntary contractions during high intensity exercise in the presence of fatigue and pain. This investigation examined the effects of pre-induced fatigue and concurrent rising pain (evoked by muscle ischaemia) in one leg on motor fatigability and corticospinal excitability/inhibition of the contralateral limb. Twelve healthy males undertook four experimental protocols including unilateral cycling to task failure at 80% of peak power output with: (i) the right-leg (RL); (ii) the left-leg (LL); (iii) RL immediately preceded by LL protocol (FAT-RL); and (iv) RL when blood flow was occluded in the contralateral (left) leg (PAIN-RL). Participants performed maximal and submaximal 5 s right-leg knee extensions during which transcranial magnetic and femoral nerve electrical stimuli were delivered to elicit motor-evoked and compound muscle action potentials, respectively. The pre-induced fatigue reduced the right leg cycling time-to-task failure (mean ± SD; 332 ± 137 s) to a greater extent than concurrent pain (460 ± 158 s), compared to RL (580 ± 226 s) (P < 0.001). The maximum voluntary contraction force declined less following FAT-RL (P < 0.019) and PAIN-RL (P < 0.032) compared to RL. Voluntary activation declined and the corticospinal excitability recorded from knee extensors increased similarly after the three conditions (P < 0.05). However, the pre-induced fatigue, but not concurrent pain, reduced corticospinal inhibition compared to RL (P < 0.05). These findings suggest that regardless of the origin and/or mechanisms modulating sensory afferent feedback during single-leg cycling (e.g. pre-induced fatigue vs. concurrent rising pain), the limit of exercise tolerance remains the same, suggesting that exercise will be terminated upon achievement of sensory tolerance limit.

Impact of a Critical Care Specialist Intervention on First Pass Success for Emergency Airway Management Outside the ICU

BACKGROUND

There has been limited investigation into the procedural outcomes of patients undergoing emergent endotracheal intubation (EEI) by a critical care medicine (CCM) specialist outside the intensive care unit (ICU). We hypothesized that EEI outside an ICU would be associated with lower rates of first pass success (FPS) as compared to inside an ICU.

METHODS

We performed a retrospective cohort study of all adult patients admitted to our academic medical center between January 1, 2016, and July 31, 2018, who underwent EEI by a CCM practitioner. The primary outcome of FPS was identified in the EEI procedure note. Secondary outcomes included difficult intubation (> 2 attempts at laryngoscopy) and mortality following EEI.

RESULTS

In total, 1958 patients (1035 [52.9%] inside ICU and 923 [47.1%]) outside an ICU) were included in the final cohort. Unadjusted rate of FPS was not different between patients intubated out of the ICU and patients intubated inside of the ICU (689 [74.7%] vs 775 [74.9%]; P = .91). There was also no difference in FPS between groups after adjusting for predictors of difficult intubation and baseline covariates (odds ratio: 0.95; 95% confidence interval, 0.75-1.2, P = .65). Mortality of patients undergoing EEI out of the ICU was higher at each examined time interval following EEI.

DISCUSSION

For EEI done by CCM practitioners, rate of FPS is not different between patients undergoing EEI outside an ICU as compared to inside an ICU. Despite the lack of difference between rates of procedural success, patient mortality following EEI outside an ICU is higher than EEI inside an ICU at all examined time points during hospitalization.

Characteristics and Management of Blunt Renal Injury in Children

BACKGROUND

Renal trauma in the pediatric population is predominately due to blunt mechanism of injury. Our purpose was to determine the associated injuries, features, incidence, management, and outcomes of kidney injuries resulting from blunt trauma in the pediatric population in a single level I trauma center.

METHODS

This was a retrospective chart and trauma registry review of all pediatric blunt renal injuries at a regional level I trauma center that provides care to injured adults and children. The inclusion dates were January 2001-June 2014.

RESULTS

Of 5790 pediatric blunt trauma admissions, 68 children sustained renal trauma (incidence: 1.2%). Only two had nephrectomies (2.9%). Five renal angiograms were performed, only one required angioembolization. Macroscopic hematuria rate was significantly higher in the high-grade injury group (47% vs. 16%; P = 0.031). Over half of the patients had other intra-abdominal injuries. The liver and spleen were the most frequently injured abdominal organs.

CONCLUSION

Blunt renal trauma is uncommon in children and is typically of low American Association for the Surgery of Trauma injury grade. It is commonly associated with other intra-abdominal injuries, especially the liver and the spleen. The nephrectomy rate in pediatric trauma is lower compared to adult trauma. Most pediatric blunt renal injury can be managed conservatively by adult trauma surgeons.

Incidence of platinum-induced ototoxicity in pediatric patients in Quebec

BACKGROUND

The antineoplastic agents cisplatin and carboplatin are widely-used and highly-effective against a variety of pediatric cancers. Unfortunately, ototoxicity is a frequently encountered side effect of platinum-based chemotherapy. There is currently no treatment or prevention for platinum-induced ototoxicity and development of hearing loss may lead to devastating consequences on the quality of life of pediatric cancer survivors. The objective of this study is to determine the incidence of platinum-induced ototoxicity in a large series of pediatric patients and to evaluate the incidence of progression of ototoxicity after completion of treatment.

PROCEDURES

A retrospective chart review of pediatric patients treated with cisplatin or carboplatin between 2000 and 2012 was conducted. The incidence of ototoxicity was determined based on the American-Speech-Language-Hearing Association (ASHA) criteria and severity was based on the Chang classification.

RESULTS

Four hundred and sixty-six patients received platinum-based chemotherapy. Patients were excluded due to congenital hearing loss (n = 1) and insufficient data for calculating the platinum dose (n = 24) or for assessing ototoxicity (n = 135). Three hundred and six patients were included in the analysis. Post-chemotherapy ototoxicity was detected in 148 (48%) patients, and clinically-significant ototoxicity was present in 91 (30%). In addition, based on the ASHA criteria, 48% of patients (97/204) with long-term follow-up had further deterioration of their hearing after completion of treatment.

CONCLUSIONS

Ototoxicity following chemotherapy with cisplatin or carboplatin is common and can frequently progress after the completion of treatment. Long-term follow-up is strongly recommended.

Chronic tympanic membrane perforation in an animal model

OBJECTIVE

The aim of this study was to revalidate and reproduce a chronic tympanic membrane perforation animal model.

STUDY DESIGN

Prospective, animal study.

METHODS

Eight female chinchillas underwent bilateral thermal myringotomy. The edges of the perforation were folded inward using microflaps. The perforations were followed over time to monitor the course of closure.

RESULTS

Two animals were excluded from the study because of ear infection. None of the other tympanic membrane perforations remained open. The closing time varied from 4 to 6 weeks.

CONCLUSIONS

Our findings demonstrate that the thermal myringotomy combined with infolding technique is not a reliable and consistent method to create a chronic tympanic membrane perforation. The closing time is shorter than expected and varies among the study subjects. There is a clear need for developing a reliable chronic tympanic membrane perforation model.

Ototoxicity of olive oil in a chinchilla animal model

OBJECTIVES/HYPOTHESIS

Olive oil is often used by patients to soften ear wax or to relieve ear canal obstruction. It is also sold in drugstores as a cerumenolytic. To date, no study has assessed the safety of ototopical olive oil on hearing in the presence of tympanic membrane perforation. The present study aimed to assess the safety of ototopic olive oil on hearing in the presence of tympanic membrane perforation.

STUDY DESIGN

Prospective, randomized, controlled trial in a chinchilla animal model.

MATERIALS AND METHODS

Eleven chinchillas underwent bilateral myringotomy. In each animal, one ear was randomly assigned to receive olive oil (experimental ear), while the contralateral control ear received normal saline. Auditory brain response (ABR) test was performed at baseline and then 7, 14, and 30 days following the application.

RESULTS

At 30 days follow-up, there was no significant change in auditory brain response thresholds at 8, 16, 20, or 25 kHz. Scanning electron microscope imaging showed no damage to the hair cells.

CONCLUSION

Olive oil does not seem to cause hearing loss in chinchillas with perforated tympanic membranes. Future clinical studies are required.

Assessment of the ototoxicity of docusate sodium (colace) in a guinea pig animal model

OBJECTIVE

Docusate sodium (Colace) is an off-label ceruminolytic agent used to soften ear wax and relieve ear canal obstruction. At present, its effect on hearing in the presence of tympanic membrane (TM) perforation is not clear. The present study aimed to assess the safety of ototopic docusate sodium on hearing in the presence of TM perforation.

STUDY DESIGN

A prospective, randomized, controlled trial in a guinea pig animal model.

MATERIALS AND METHODS

Ten guinea pigs underwent bilateral myringotomy. In each animal, one ear received docusate sodium, serving as the experimental ear, and the other received normal saline as the control. Auditory brain response (ABR) was performed at baseline and then 1, 7, and 14 days following the application.

RESULTS

At day 14 following application, there was no significant change in ABR thresholds at 8, 12, 16, 20, or 25 kHz.

CONCLUSION

In guinea pigs with perforated TMs, docusate sodium does not seem to cause ototoxicity. Future clinical studies are required.

Acute bilateral blindness as a presenting symptom of Non-Hodgkin's lymphoma

NHL usually presents with lymphadenopathy or symptoms related to compression by the primary tumor of surrounding structures. While the head and neck region is a common site of involvement, blindness is rarely a presenting symptom. We report here the case of a child who presented to the emergency room with acute bilateral loss of vision and no other symptoms. Cranial imaging studies revealed a solid mass of the skull base with compression on optic nerves. Diagnosis of Burkitt's lymphoma was confirmed after biopsy. The patient had partial vision improvement two days after optic nerve decompression which was done immediately at the night of presentation.

Young's modulus and degree of conversion of different combination of light-cure dental resins

OBJECTIVES

To evaluate Young's modulus and degree of conversion of several combinations of bisGMA, UEDMA, TEGDMA light-cure dental resin.

METHODS

Young's modulus and DC% were studied for 21 different resin combinations of bisGMA, TEGDMA and UEDMA. Small universal testing machine and photo-calorimetry were used for the tests. The results were evaluated using ANOVA and Duncan's multiple range tests and regular t-test.

RESULTS

Young's modulus varied between 2.37±0.2 GPa (100% TEGDMA) and 4.15±0.2 GPa (100% bisGMA). By adding TEGDMA to bisGMA or UEDMA, the Young's modulus decreased significantly (p<0.05). Degree of conversion was significantly (p<0.05) higher when the wt% of TEGDMA was high in the mixtures than for highly concentrated bis-GMA (resin mixtures with TEGDMA in comparison to mixture with bisGMA had higher degree of conversion). DC% was significantly higher (p<0.05) for binary mixtures of UEDMA and TEGDMA, and significantly lower for 100 wt% bis-GMA (p<0.05). The DC% values were between 53.1%±0.9% (100% bisGMA) and 85.6%+/-1% (80% UEDMA-20% TEGDMA). The concentration of bisGMA, in the monomer mixture, affected DC% and Young's modulus oppositely.

CONCLUSIONS

The differences in the values for DC% were mostly justified by the differences in the molecular structures of the different monomers. It was also revealed that higher DC% does not always result in a higher Young's modulus, because molecular and network structural parameters play major roles in the final physical properties of the mixtures.

Influence of light-curing procedures and photo-initiator/co-initiator composition on the degree of conversion of light-curing resins

OBJECTIVE

The hypothesis that the degree and rate of conversion can be modified favourably by using different light-curing procedures and different photo initiator/co-initiator combinations was tested.

METHOD

A photo-initiator (0.02 mM/g resin); either camphorquinone (CQ) or 1-phenyl-1,2-propanedione (PPD), was mixed with bisGMA:TEGDMA (50:50 by weight). In addition, a co-initiator (0.04 mM/g resin); either N,N-dimethyl-p-aminobenzoic acid ethylester (DABE), N,N-cyanoethylmethylaniline (CEMA), or 2-dimethylaminoethyl methacrylate (DMAEMA), was added. These six combinations were subjected to three curing conditions (standard curing, soft-start curing or LED curing). The conversion levels (DC) were determined with differential scanning calorimetry (DSC). The DSC results were analysed using a general linear model (GLM) and Duncan's multiple range test and regular t-test.

RESULTS

The fastest conversion initially was obtained by standard curing, followed by LED curing and soft-start curing. After 40 s of curing, conventional curing and soft-start curing produced a higher DC than LED curing. However, strong interactions occurred between the different variables (curing method, initiator and co-initiator). Initially, CQ was more efficient than PPD, but after 40 s, this difference was insignificant.

CONCLUSION

By using soft-start curing and an appropriate photo initiator/co-initiator combination it is possible to achieve slow curing and a high DC at within a curing time of 40 s.