COVID-19 in patients with Down syndrome: A systematic review

INTRODUCTION

Down syndrome (DS) is associated with multiple comorbid conditions and chronic immune dysfunction. Persons with DS who contract COVID-19 are at high risk for complications and have a poor prognosis. We aimed to study the clinical symptoms, laboratory and biochemical profiles, radiologic findings, treatment, and outcomes of patients with DS and COVID-19.

METHOD

We systematically searched PubMed, MEDLINE, Web of Science, Scopus, and the Cochrane Library using the keywords COVID-19 or coronavirus or SARS-CoV-2 and DS or trisomy 21. Seventeen articles were identified: eight case reports and nine case series published from December 2019 through March 2022, with a total of 55 cases.

RESULTS

Patients averaged 24.8 years (26 days to 60 years); 29 of the patients were male. The most common symptoms were fever, dyspnea, and cough. Gastrointestinal and upper respiratory tract symptoms were commonly reported for pediatric patients. The most common comorbidities present in patients with DS were obesity (49.0%), hypothyroidism (21.6%) and obstructive sleep apnea (15.6%). The patients were hospitalized for a mean of 14.8 days. When the patients were compared with the general COVID-19 population, the mean number of hospitalized days was higher. Most patients had leukopenia, lymphopenia, and elevated inflammatory markers (d-dimer and C-reactive protein). Bilateral infiltrations and bilateral ground-glass opacifications were frequently seen in chest radiographs and chest computed tomographic imaging. Most of the patients were treated with methylprednisolone, macrolides, and hydroxychloroquine. Of the 55 patients, 22 died. The mean age of the patients who died was 42.8 years. Mortality rate was higher in individuals with DS over 40 years of age.

CONCLUSION

More studies are needed to better understand COVID-19 infections among persons with DS. In addition, the study was limited by a lack of statistical analyses and a specific comparison group.

Plasmapheresis in the ICU

Therapeutic plasma exchange (TPE) is a treatment paradigm used to remove harmful molecules from the body. In short, it is a technique that employs a process that functions partially outside the body and involves the replacement of the patient's plasma. It has been used in the ICU for a number of different disease states, for some as a first-line treatment modality and for others as a type of salvage therapy. This paper provides a brief review of the principles, current applications, and potential future directions of TPE in critical care settings.

Role of Sodium-Glucose Co-Transporter 2 Inhibitors in Chronic Kidney Disease, Congestive Heart Failure and Stroke-A Review and Clinical Guide for Healthcare Professionals

Diabetic kidney disease (DKD) causes a progressive decline in renal function, leading to end-stage kidney disease (ESKD), and increases the likelihood of cardiovascular events and mortality. The recent introduction of the sodium-glucose co-transporter 2 (SGLT-2) inhibitor has been a game changer in managing chronic kidney disease (CKD) and congestive heart failure (CHF). These agents not only slow down the progression of kidney disease but also have cardioprotective benefits, including for patients with congestive heart failure and atherosclerotic cardiovascular disease. Some evidence suggests that they can decrease the risk of stroke as well. This review aims to provide a comprehensive overview of the role of SGLT-2 inhibitors in CKD and CHF and their efficacy in stroke prevention. This review includes a comparison with glucagon-like peptide-1 (GLP-1) agonist and finerenone; focuses on safety data, the potential benefits beyond glycemic control, and a review of significant trials; and provides guidance in clinical practice.

Diagnosis of Obstructive Sleep Apnea Using Feature Selection, Classification Methods, and Data Grouping Based Age, Sex, and Race

Obstructive sleep apnea (OSA) is a prevalent sleep disorder that affects approximately 3-7% of males and 2-5% of females. In the United States alone, 50-70 million adults suffer from various sleep disorders. OSA is characterized by recurrent episodes of breathing cessation during sleep, thereby leading to adverse effects such as daytime sleepiness, cognitive impairment, and reduced concentration. It also contributes to an increased risk of cardiovascular conditions and adversely impacts patient overall quality of life. As a result, numerous researchers have focused on developing automated detection models to identify OSA and address these limitations effectively and accurately. This study explored the potential benefits of utilizing machine learning methods based on demographic information for diagnosing the OSA syndrome. We gathered a comprehensive dataset from the Torr Sleep Center in Corpus Christi, Texas, USA. The dataset comprises 31 features, including demographic characteristics such as race, age, sex, BMI, Epworth score, M. Friedman tongue position, snoring, and more. We devised a novel process encompassing pre-processing, data grouping, feature selection, and machine learning classification methods to achieve the research objectives. The classification methods employed in this study encompass decision tree (DT), naive Bayes (NB), k-nearest neighbor (kNN), support vector machine (SVM), linear discriminant analysis (LDA), logistic regression (LR), and subspace discriminant (Ensemble) classifiers. Through rigorous experimentation, the results indicated the superior performance of the optimized kNN and SVM classifiers for accurately classifying sleep apnea. Moreover, significant enhancements in model accuracy were observed when utilizing the selected demographic variables and employing data grouping techniques. For instance, the accuracy percentage demonstrated an approximate improvement of 4.5%, 5%, and 10% with the feature selection approach when applied to the grouped data of Caucasians, females, and individuals aged 50 or below, respectively. Furthermore, a comparison with prior studies confirmed that effective data grouping and proper feature selection yielded superior performance in OSA detection when combined with an appropriate classification method. Overall, the findings of this research highlight the importance of leveraging demographic information, employing proper feature selection techniques, and utilizing optimized classification models for accurate and efficient OSA diagnosis.

Sleep and Safety among Healthcare Workers: The Effect of Obstructive Sleep Apnea and Sleep Deprivation on Safety

Almost one billion people worldwide are affected by Obstructive Sleep Apnea (OSA). Affected individuals experience disordered breathing patterns during sleep, which results in fatigue, daytime drowsiness, and/or sleep deprivation. Working under the influence of these symptoms significantly impairs work productivity and leads to occupational accidents and errors. This impact is seen in healthcare workers (HCWs) who are not immune to these conditions. However, poorly controlled OSA in this subset of individuals takes a heavy toll on patient care due to the increased risk of medical errors and can also alter the mental and physical well-being of the affected HCW in various ways. OSA and safety issues have been recognized and mitigated among the airline and transport industries; however, the healthcare industry lags in addressing these concerns. This article reviews hypersomnolence and sleep disorder as key clinical features of OSA and their effect on HCW safety.

Hypotension Prediction Score for Endotracheal Intubation in Critically Ill Patients: A Post Hoc Analysis of the HEMAIR Study

BACKGROUND

Hypotension with endotracheal intubation (ETI) is common and associated with adverse outcomes. We sought to evaluate whether a previously described hypotension prediction score (HYPS) for ETI is associated with worse patient outcomes and/or clinical conditions.

METHODS

This study is a post hoc analysis of a prospective observational multicenter study involving adult (age ≥18 years) intensive care unit (ICU) patients undergoing ETI in which the HYPS was derived and validated on the entire cohort and a stable subset (ie, patients in stable condition). We evaluated the association between increasing HYPSs in both subsets and several patient-centered outcomes and clinical conditions.

RESULTS

Complete data for HYPS calculations were available for 783 of 934 patients (84%). Logistic regression analysis showed increasing odds ratios (ORs) for the highest risk category for new-onset acute kidney injury (OR, 7.37; 95% CI, 2.58-21.08); new dialysis need (OR, 8.13; 95% CI, 1.74-37.91); ICU mortality (OR, 16.39; 95% CI, 5.99-44.87); and hospital mortality (OR, 18.65; 95% CI, 6.81-51.11). Although not increasing progressively, the OR for the highest risk group was significantly associated with new-onset hypovolemic shock (OR, 6.06; 95% CI, 1.47-25.00). With increasing HYPSs, median values (interquartile ranges) decreased progressively (lowest risk vs. highest risk) for ventilator-free days (23 [18-26] vs. 1 [0-21], P < .001) and ICU-free days (20 [11-24] vs. 0 [0-13], P < .001). Of the 729 patients in the stable subset, 598 (82%) had complete data for HYPS calculations. Logistic regression analysis showed significantly increasing ORs for the highest risk category for new-onset hypovolemic shock (OR, 7.41; 95% CI, 2.06-26.62); ICU mortality (OR, 5.08; 95% CI, 1.87-13.85); and hospital mortality (OR, 7.08; 95% CI, 2.63-19.07).

CONCLUSIONS

As the risk for peri-intubation hypotension increases, according to a validated hypotension prediction tool, so does the risk for adverse clinical events and certain clinical conditions.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (NCT02508948).

Infection risk with the use of interleukin inhibitors in hospitalized patients with COVID-19: A narrative review

INTRODUCTION

To date, only corticosteroids and interleukin-6 (IL-6) inhibitors have been shown to reduce mortality of hospitalized patients with COVID-19. In this literature review, we aimed to summarize infection risk of IL inhibitors, with or without the use of corticosteroids, used to treat hospitalized patients with COVID-19.

METHODS

A literature search was conducted using the following evidence-based medicine reviews: Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Embase; Ovid Medline; and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, Daily and Versions 1946 to April 28, 2021. All relevant articles were identified using the search terms COVID-19 or SARS-coronavirus-2, infections, interleukins, inpatients, adults, and i ncidence.

RESULTS

We identified 36 studies of which 2 were meta-analyses, 5 were randomized controlled trials, 9 were prospective studies, and 20 were retrospective studies. When anakinra was compared with control, 2 studies reported an increased risk of infection, and 3 studies reported a similar or decreased incidence of infection. Canakinumab had a lower associated incidence of infection compared with placebo in one study. When sarilumab was compared with placebo, one study reported an increased risk of infection. Nine studies comparing tocilizumab with placebo reported decreased or no difference in infection risk (odds ratio [OR] for the studies ranged from 0.39-1.21). Fourteen studies comparing tocilizumab with placebo reported an increased risk of infection, ranging from 9.1% to 63.0% (OR for the studies ranged from 1.85-5.04). Infection most commonly presented as bacteremia. Of the 6 studies comparing tocilizumab and corticosteroid use with placebo, 4 reported a nonsignificant increase toward corticosteroids being associated with bacterial infections (OR ranged from 2.76-3.8), and 2 studies reported no increased association with a higher infection risk.

CONCLUSIONS

Our literature review showed mixed results with variable significance for the association of IL-6 inhibitors with risk of infections in patients with COVID-19.

Performance in mortality prediction of SAPS 3 And MPM-III scores among adult patients admitted to the ICU of a private tertiary referral hospital in Tanzania: a retrospective cohort study

Background

Illness predictive scoring systems are significant and meaningful adjuncts of patient management in the Intensive Care Unit (ICU). They assist in predicting patient outcomes, improve clinical decision making and provide insight into the effectiveness of care and management of patients while optimizing the use of hospital resources. We evaluated mortality predictive performance of Simplified Acute Physiology Score (SAPS 3) and Mortality Probability Models (MPM₀-III) and compared their performance in predicting outcome as well as identifying disease pattern and factors associated with increased mortality.

Methods

This was a retrospective cohort study of adult patients admitted to the ICU of the Aga Khan Hospital, Dar- es- Salaam, Tanzania between August 2018 and April 2020. Demographics, clinical characteristics, outcomes, source of admission, primary admission category, length of stay and the support provided with the worst physiological data within the first hour of ICU admission were extracted. SAPS 3 and MPM₀-III scores were calculated using an online web-based calculator. The performance of each model was assessed by discrimination and calibration. Discrimination between survivors and non-survivors was assessed by the area under the receiver operator characteristic curve (ROC) and calibration was estimated using the Hosmer-Lemeshow goodness-of-fit test.

Results

A total of 331 patients were enrolled in the study with a median age of 58 years (IQR 43-71), most of whom were male (n = 208, 62.8%), of African origin (n = 178, 53.8%) and admitted from the emergency department (n = 306, 92.4%). In- hospital mortality of critically ill patients was 16.1%. Discrimination was very good for all models, the area under the receiver-operating characteristic (ROC) curve for SAPS 3 and MPM₀-III was 0.89 (95% CI [0.844-0.935]) and 0.90 (95% CI [0.864-0.944]) respectively. Calibration as calculated by Hosmer-Lemeshow goodness-of-fit test showed good calibration for SAPS 3 and MPM₀-III with Chi- square values of 4.61 and 5.08 respectively and P-Value > 0.05.

Conclusion

Both SAPS 3 and MPM₀-III performed well in predicting mortality and outcome in our cohort of patients admitted to the intensive care unit of a private tertiary hospital. The in-hospital mortality of critically ill patients was lower compared to studies done in other intensive care units in tertiary referral hospitals within Tanzania.

An Adrenocortical Carcinoma Evolving After Nine Years of Latency From a Small Adrenal Incidentaloma

Adrenal incidentalomas (AIs) are common incidental findings in medical practice with clinical significance. Although most AIs are nonsecretory and nonmalignant, they require a short course of follow-up over one to two years to rule out malignancy or hormonal secretion according to clinical practice guidelines. However, this can result in some adrenocortical carcinomas (ACCs) being missed if they transform at a later stage or evolve slowly. Here, we report one such case of an AI, which although remained indolent, eventually transformed into an ACC many years after the initial detection.

What we learned in the past year in managing our COVID-19 patients in intensive care units?

Coronavirus disease 2019 is a pandemic, was first recognized at Wuhan province, China in December 2019. The disease spread quickly across the globe, spreading stealthily from human to human through both symptomatic and asymptomatic individuals. A multisystem disease which appears to primarily spread via bio aerosols, it has exhibited a wide clinical spectrum involving multiple organ systems with the respiratory system pathology being the prime cause of morbidity and mortality. Initially unleashing a huge destructive trail at Wuhan China, Lombardy Italy and New York City, it has now spread to all parts of the globe and has actively thrived and mutated into new forms. Health care systems and Governments responded initially with panic, with containment measures giving way to mitigation strategies. The global medical and scientific community has come together and responded to this huge challenge. Professional medical societies quickly laid out "expert" guidelines which were conservative in their approach. Many drugs were re formulated and tested quickly with the help of national and international collaborative groups, helping carve out effective treatment strategies and help build a good scientific foundation for evidence-based medicine. Out of the darkness of chaos, we now have an orderly approach to manage this disease both from a public health preventive and therapeutic standpoint. With preventive measures such as masking and social distancing to the development of highly effective and potent vaccines, the public health success of such measures has been tempered by behavioral responses and resource mobilization. From a therapy standpoint, we now have drugs that were promising but now proven ineffective, and those that are effective when given early during viral pathogenesis or later when immune dysregulation has established, and the goal is to help reign in the destructive cascade. It has been a fascinating journey for mankind and our work here recapitulates the evolution of various aspects of critical care and other inpatient practices which continue to evolve.

Comorbid insomnia and sleep apnea: characterization of the syndrome and understanding its associations with comorbid sleep conditions

PURPOSE

Obstructive sleep apnea (OSA) is traditionally associated with excessive daytime sleepiness. Insomnia is characterized by hyperarousal, and is seen as a predominant feature in a subgroup of patients with OSA. The aim of this study was to describe the prevalence of comorbid insomnia and sleep apnea (COMISA) in a sleep apnea population and to characterize its features.

METHODS

This was a chart review of patients who underwent overnight polysomnography (PSG). All patients completed questionnaires with the Epworth Sleepiness Scale (ESS), and symptoms of insomnia and other sleep-related comorbidities. Patients with OSA on the PSG were included.

RESULTS

A total of 296 patients with OSA were included, of which 80% reported at least 1 major symptom of insomnia: 57% reported sleep onset insomnia, 68% sleep maintenance insomnia, and 48% had early morning awakenings. COMISA (OSA plus 2 or more major symptoms of insomnia) was seen in 63%. These patients were more likely to report an abnormal ESS score, gastroesophageal reflux (GER), and restless legs (RL) than those without; no difference was seen in self-reported sleep bruxism. Among the patients with COMISA, 85% reported at least 1 representative symptom of psychophysiological insomnia (PPI); each of the 5 PPI symptoms was present in at least 40% of patients with COMISA.

CONCLUSIONS

Insomnia is extremely prevalent in our population of patients with OSA, accompanied by daytime sleepiness and symptoms of PPI, GER, and RL. Further study is needed to determine the interactions between symptoms and OSA treatments in these patients.

Medical chart validation of inpatient diagnosis codes for transfusion-related acute lung injury 2013-2015

INTRODUCTION

Transfusion-related acute lung injury (TRALI), an adverse event occurring during or within 6 hours of transfusion, is a leading cause of transfusion-associated fatalities reported to the US Food and Drug Administration. There is limited information on the validity of diagnosis codes for TRALI recorded in inpatient electronic medical records (EMRs).

STUDY DESIGNS AND METHODS

We conducted a validation study to establish the positive predictive value (PPV) of TRALI International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes recorded within a large hospital system between 2013 and 2015. A physician with critical care expertise confirmed the TRALI diagnosis. As TRALI is likely underdiagnosed, we used the specific code (518.7), and codes for respiratory failure (518.82) in combination with transfusion reaction (999.80, 999.89, E934.7).

RESULTS

Among almost four million inpatient stays, we identified 208 potential TRALI cases with ICD-9-CM codes and reviewed 195 medical records; 68 (35%) met clinical definitions for TRALI (26 [38%] definitive, 15 [22%] possible, 27 [40%] delayed). Overall, the PPV for all inpatient TRALI diagnoses was 35% (95% confidence interval (CI), 28-42). The PPV for the TRALI-specific code was 44% (95% CI, 35-54).

CONCLUSION

We observed low PPVs (<50%) for TRALI ICD-9-CM diagnosis codes as validated by medical charts, which may relate to inconsistent code use, incomplete medical records, or other factors. Future studies using TRALI diagnosis codes in EMR databases may consider confirming diagnoses with medical records, assessing TRALI ICD, Tenth Revision, Clinical Modification codes, or exploring alternative ways for of accurately identifying TRALI in EMR databases.

KEY POINTS

In 169 hospitals, we identified 208 potential TRALI cases, reviewed 195 charts, and confirmed 68 (35%) cases met TRALI clinical definitions. As many potential TRALI cases identified with diagnosis codes did not meet clinical definitions, medical record confirmation may be prudent.

Hydrocortisone, ascorbic acid and thiamine for sepsis: Is the jury out?

Sepsis and septic shock remain a major cause of morbidity and mortality among patients admitted in the intensive care unit. Diabetes is a major risk factor for the development of sepsis. The global mortality of sepsis remains high, despite significant interventions and guidelines. It has been known for decades that patients with sepsis have reduced levels of antioxidants, most notably vitamin C. Furthermore, experimental data has demonstrated multiple beneficial effects of vitamin C in sepsis. In addition, corticosteroids and thiamine may have synergistic biological effects together with vitamin C. Preliminary data suggests that therapy with hydrocortisone, ascorbic acid and thiamine improves the outcome of patients with sepsis with the potential to save millions of lives. However, this intervention has met with much resistance and has not been widely adopted. Ultimately, we await the final jury verdict on this simple, safe and cheap intervention.

Pulmonary Infection Caused by Mycobacterium terrae: A Case Report and Literature Review

Mycobacterium terrae infection can cause progressive debilitating disease. A case of a 63-year-old man with localized pulmonary infection characterized by extensive, thick-walled cavitary lesions is presented. A pneumonectomy was considered as definitive treatment, but the patient would not have tolerated the procedure given his severe deconditioning. Instead, he was placed on lifelong antibiotic treatment, but he continued to deteriorate and passed away. The slow-growing microorganism, Mycobacterium terrae, was isolated from bronchoalveolar lavage cultures seven weeks after specimen collection, five and a half weeks after the patient's death. Clinical, microbiological and therapeutic data from this case and 16 other pulmonary cases from the literature are reviewed. Increased awareness of this microorganism will allow clinicians to consider Mycobacterium terrae in their differential diagnosis when dealing with nontuberculous mycobacteria infections.

Socioeconomic Status in Pregnant Women and Sleep Quality During Pregnancy

This review focuses on factors contributing to sleep quality among pregnant women with low socioeconomic statuses during the third trimester of their pregnancy. Electronic searches were conducted, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We searched for published, peer reviewed, English language primary research articles using electronic databases including PubMed, EMBASE, Ovid, MEDLINE and Google Scholar ending June 2019. All references were reviewed manually and independently by authors. After applying the inclusion criteria, 56 articles were selected; 38 of which are full-text and included in this review. All articles related to the analysis of poor sleep quality among uncomplicated pregnant women were included. Pregnant women with a specific pathology were excluded.

We found poor sleep quality among pregnant women is correlated with low socioeconomic levels. Pregnant women with lower incomes tend to have inadequate diets, which further complicates the health of the mother and the baby. External factors including low income, poor quality of life and poor diet tend to increase the possibility of future health complications in both mother and child, and can result in complications such as preterm labor, low birth weight, preeclampsia, perinatal death, and spontaneous abortion.

A Case Report of Secondary Spontaneous Pneumothorax Induced by Vape

Electronic cigarettes (referred here as E-cigarettes or vapes) are devices that contain heated nicotine/cannabinol vaporized aerosol solution for consumption. While long-term toxicities of E-cigarettes are unknown, the acute adverse events of vaping that have occurred are concerning. There have been variations of pneumonitis presentations so far, however, very few case reports have been shown to have a complication of a pneumothorax. We hereby present a case of a 35-year-old male who presented with spontaneous pneumothorax and pneumonitis due to vaping.

A Case of Pancytopenia Caused by an Unusual Habit of Eating Pasta

Pure nutritional deficiency of folate and vitamin B12 is very unusual in developed countries, where most of the food items are fortified with essential vitamins and minerals. We hereby present a case of a middle-aged lady who declined to eat any other food items and survived only on pasta and sea salt for two years before presenting to the emergency department with pancytopenia. 

Inter-rater Reliability of the Ramsay Sedation Scale for Critically-ill Intubated Patients

Introduction: Titratable palliative sedation (TPS) is frequently applied in sedative therapeutics to ameliorate unendurable and refractory distress via reduction in patient consciousness. TPS may be adjusted based on objective and subjective data: vitals, labs, Ramsay Sedation Scale (RSS), and Richmond Agitation-Sedation Scale (RASS). Inappropriate dosing, including over-sedation from variability in clinician assessment of sedation scales, can contribute to significant negative clinical outcomes. We evaluated inter-rater reliability (IRR) and its relationship to variations in dosing to determine whether additional training in sedation scale assessment is necessary at our community institution.

Methods: This was a prospective study assessing sedation in intensive care unit (ICU) mechanically ventilated patients without neurogenic abnormalities. Non-nursing healthcare personnel conducted independent sedation assessments using the RSS and compared their evaluations to those documented by the nursing staff. Data obtained from the patients' chart included: demographics, Ramsay Score, past medical history, diagnosis, and body mass index (BMI). Post-analysis, non-nursing healthcare personnel scores were classified into three categories: equal to, higher than, or lower than those charted by nursing staff.

Results: There were 83 random RSS assessments conducted in 44 patients with a mean age of 63.6 +/10.09 years (range: 38-82) and a mean BMI of 31.2 +/12.4 (range: 15-77). 19/42 (45%) patients had a diagnosis of respiratory failure or pneumonia. Other diagnoses included congestive heart failure (3), seizures (5), aortic valve replacement (1), small bowel obstruction (1), drug overdose (2), cardiac arrest (2), and urinary tract infection (1), ST-elevated myocardial infarction (2), pulmonary embolism (2), coronary artery bypass graft (1), sepsis (1), hemoptysis (1), altered mental status (1). Non-nursing healthcare professionals' assessments were compared to nurses' and observed to be equal in 29%, higher in 59%, and lower in 12% of the cases. Of the 83 assessments, the average RSS score non-nursing healthcare professionals assigned was 4.8 +/1.6 while the nurses' charted average was3.39 +/- 0.97; a mean difference of 1.45, 95% CI (1.04 - 1.85)p< 0.0001.

Conclusions: Our data demonstrated equal RSS ratings in only 29% of cases for non-nursing healthcare personnel and nurses’ evaluations. Without proper education, the RSS may not be a reliable tool for sedation assessments and may result in over-sedation of critically ill patients. Recurrent nursing education is warranted to ensure proper use and optimization of the RSS.

A Study to Assess the Relationship between Attention Deficit Hyperactivity Disorder and Obstructive Sleep Apnea in Adults

The association between obstructive sleep apnea (OSA) and attention deficit hyperactivity disorder (ADHD) is well-established in children. However, there is a paucity of literature regarding this association in adults. The aim of this study was to determine if ADHD is more common in adult patients with OSA. All patients referred to a sleep center for sleep evaluation were administered the Adult ADHD Self-Report Scale and diagnostic polysomnogram. The ADHD screen is considered positive if 4 of 6 questions in part A of the screening questionnaire were answered abnormally. The study population consisted of 194 participants, predominantly male (62%), Caucasian (54%), and Hispanic (44%). OSA was identified in 160 (83%) of participants, with 116 (60%) having moderate to severe OSA. The ADHD screen was positive in 37 (19%) of participants. There was no significant association between the severity of OSA and presence of ADHD symptoms. Patients with OSA who screened positive for ADHD had higher Epworth Sleepiness Scale scores than those that did not. These data suggest that ADHD is more prevalent in patients with OSA, but do not demonstrate a relationship between OSA severity and ADHD symptoms. Interestingly, sleepiness is more prominent in patients with ADHD.

An Unusual Case of Iatrogenic Tracheal Diverticulum Found in a Mechanically Ventilated Patient: To Treat or Not to Treat

A tracheal diverticulum is an out pouching arising from the wall of the trachea, and its lumen is in communication with the tracheal lumen. It is a small air collection in the para-tracheal region and is an infrequently encountered clinical entity. This condition is often found incidentally on thoracic imaging and should be considered when para-tracheal air is present. It can be congenital or acquired. In the absence of symptoms, management is mainly conservative with close monitoring for complications such as para-tracheal abscess. We present a case of iatrogenic tracheal diverticulum that formed likely due to increased cuff pressure of the mispositioned endotracheal tube seated against a tracheal wall already vulnerable to injury due to multi-organ failure.

Effectiveness of Hyperbaric Oxygenation Versus Normobaric Oxygenation Therapy in Carbon Monoxide Poisoning: A Systematic Review

Carbon monoxide (CO) is a gas product of combustion, considered highly poisonous. Prolonged CO exposure is responsible for more than half of fatal poisonings and is also one of the leading causes of poisoning in Western countries. We aimed to compare the effectiveness of therapy with hyperbaric oxygen (HBO) versus normobaric oxygen (NBO) in the setting of carbon monoxide poisoning (COP). We independently searched the National Library of Medicine's Medline (PubMed™), ScienceDirect™, and Scielo™ for any relevant studies published from 1989 to 2017, using the following keywords: hyperbaric therapy, hyperbaric oxygenation, normobaric therapy, carbon monoxide poisoning, carboxyhemoglobin, Haldane effect. We analyzed the studies that suggested the effectiveness of HBO or NBO. Also, we searched for studies related to COP; including history, epidemiology (risk factors, incidence, demographics), pathophysiology, clinical manifestations, diagnosis, and treatment. Sixty-eight articles were found, sixteen of which dealt with either HBO or NBO or both. Twelve suggested HBO as the treatment of choice in COP; four studies indicated that NBO was an adequate treatment due to its cost-effectiveness and availability in the emergency department (ED). HBO has been shown in several studies to be effective in moderate to high-risk COP situations, being the therapy of choice to avoid sequelae, especially neurologically. NBO can be considered as a reasonable alternative due to its cost-effectiveness. The availability and understanding of different therapeutic interventions are critical in the management of patients with COP in ED and the Critical Care unit.

Posterior Alien Hand Syndrome from Acute Ischemic Left Parietal Lobe Infarction

Alien hand syndrome (AHS) is defined as an involuntary goal-directed movement of the hand as if acting on its own will, or as being under the control of someone else. Moreover, the affected hand typically does not show any signs of weakness or convulsive movement. The cause of AHS is associated with an insult to the brain from various conditions such as stroke, trauma, tumor, aneurysm, neurosurgical intervention, infection, and degenerative brain diseases. We hereby illustrate a case of a patient with chronic atrial dysrhythmia whose oral anticoagulation therapy was placed on hold by his gastroenterologist for a scheduled colonoscopy. The patient presented to the hospital with symptoms of right-hand paresthesia with uncontrolled movement. These symptoms were seen along ST-segment elevation in the inferior leads on a 12 lead electrocardiogram. The case report acknowledges an unusual presentation of acute ischemic stroke, which may be frightening and bewildering to patients, their families, and any healthcare providers, including neurologists, who may have encountered it for the first time. Also, our patient had posterior AHS, likely from infarction involving the left inferior parietal lobe, which is reported to have a low prevalence.

Hypertrophic Cardiomyopathy and the Brockenbrough-Braunwald-Morrow Phenomenon: A Case Report

The Brockenbrough-Braunwald-Morrow phenomenon provides objective evidence of the existence and degree of left ventricular outflow tract (LVOT) obstruction, which can be improved with pharmacological therapy, surgical myectomy, or interventional alcohol septal ablation (ASA). This article incorporates contemporary research findings that are useful for the diagnosis and management of this entity.

We present the case of a 67-year-old lady with a past medical history significant for hypertension, hyperlipidemia, and coronary artery disease. The patient presented with a complaint of functional class-3 dyspnea on exertion with associated substernal chest tightness radiating to her back that had been worsening for two days prior to admission. An echocardiogram showed left ventricular hypertrophy with septal predominance measuring 17.5 mm in end-diastole and a left ventricular ejection fraction greater than 65%. The LVOT peak gradient was elevated and a positive Brockenbrough-Braunwald-Morrow phenomenon was observed for which a septal myectomy and coronary bypass of the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery were performed. The patient had an uneventful postoperative course and her symptoms improved significantly.

The Brockenbrough-Braunwald-Morrow phenomenon is useful to determine the degree of LVOT and to confirm the resolution of obstruction after treatment.

A Review of Respiratory Biologic Agents in Severe Asthma

Asthma is a common but complex chronic inflammatory heterogeneous lung disease, punctuated by the pathophysiological phenomenon of airway narrowing, coupled with symptoms of wheezing and coughing. The mechanism behind these symptoms is due to migration of eosinophils, mast cells, and CD4 T-helper cells into the submucosa of the airway, leading to hyperresponsiveness to common allergens, microorganisms, oxidants, pollutants, and consequently, airway remodeling. There is evidence that this migration is mediated by inflammatory cytokines derived from T-helper 2 (Th2) cells and type 2 innate lymphoid cells (ILC2), such as interleukins 4, 5, and 13. These cytokines lead to an increase in immunoglobulin E (IgE) production. Additionally, thymic stromal lymphopoietin (TSLP) released from airway epithelium can activate Th2 cells, innate lymphoid cells, or both. All have proven significant in the promotion of chronic airway inflammation and remodeling. In the past, most treatment strategies for this condition focused on two drug classes: β2 agonists (both short- and long-acting), and inhaled corticosteroids. Other treatments have included maintenance drugs, such as leukotriene receptor antagonists, long-acting anticholinergic agents, and theophylline. None of these, however, directly impact the interleukin or IgE pathways in a meaningful manner. Clinical trials of novel agents impacting these pathways have demonstrated efficacy and improved outcomes in asthma exacerbations, control, and forced expiratory volume in 1 second (FEV₁) in patients with severe asthma. Future treatments in asthma will focus on drugs that target these aforementioned cytokines.

Impact of Conservative Versus Conventional Oxygenation on Outcomes of Patients in Intensive Care Units: A Systematic Review and Meta-analysis

Background: There is mixed evidence in the superiority of conservative versus conventional approach to oxygen therapy among patients admitted into the intensive care unit (ICU). The purpose of this study was to determine if conservative versus conventional oxygenation results in a statistically significant difference in outcomes in ICU patients.

Methods: A systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria consisted of Level I-IV investigations of conservative versus conventional oxygenation among ICU patients. ICU mortality, 28-day mortality, in-hospital mortality, ICU length-of-stay, hospital length-of-stay, rate of new infections, and rate of new non-respiratory organ failure were compared using two-sample Z-tests using p-value less than 0.05.

Results: Three thousand four hundred thirty-three articles were screened. Four articles were included in the analysis. Three hundred seventy-two patients under the conservative oxygenation arm (Minimum target SpO2: 88-94%) and 370 patients under the conventional oxygenation arm (Minimum target SpO2: 96-97%) were analyzed. ICU mortality (16.7 ± 9.5% vs. 22.7 ± 6.0%; P<0.01), 28-day mortality (34.6 ± 26.4% vs. 41.6 ± 14.6%; P=0.02), and in-hospital mortality (30.2 ± 22.5% vs. 37.7 ± 14.2%; P<0.01) were all significantly lower in the conservative oxygenation arm versus the conventional oxygenation arm, respectively. Rate of new non-respiratory organ failure was also significantly lower in the conservative oxygenation arm (20.0 ± 8.5% vs. 29.7 ± 11.7%; P<0.01).

Conclusion: The authors conclude that conservative oxygenation therapy could result in significantly lower rates of ICU mortality, 28-day mortality, in-hospital mortality, and new-onset non-respiratory organ failure. Further randomized controlled studies that show clinical outcome improvement in multiple parameters may be worthwhile to assess the true efficacy of this practice.

Pulmonary complications of hepatic diseases

Severe chronic liver disease (CLD) may result from portal hypertension, hepatocellular failure or the combination of both. Some of these patients may develop pulmonary complications independent from any pulmonary pathology that they may have. Among them the hepatopulmonary syndrome (HPS), portopulmonary hypertension (PPH) and hepatic hydrothorax (HH) are described in detail in this literature review. HPS is encountered in approximately 15% to 30% of the patients and its presence is associated with increase in mortality and also requires liver transplantation in many cases. PPH has been reported among 4%-8% of the patient with CLD who have undergone liver transplantation. The HH is another entity, which has the prevalence rate of 5% to 6% and is associated in the absence of cardiopulmonary disease. These clinical syndromes occur in similar pathophysiologic environments. Most treatment modalities work as temporizing measures. The ultimate treatment of choice is liver transplant. This clinical review provides basic concepts; pathophysiology and clinical presentation that will allow the clinician to better understand these potentially life-threatening complications. This article will review up-to-date information on the pathophysiology, clinical features and the treatment of the pulmonary complications among liver disease patients.

Delayed complication of abdominal aortic stent: a rare complication

We hereby present a case of recurrent abdominal aortic aneurysm due to endoleak to outline complications and secondary intervention strategies post endovascular aneurysm repair.

Glucose control in critical care

Glycemic control among critically-ill patients has been a topic of considerable attention for the past 15 years. An initial focus on the potentially deleterious effects of hyperglycemia led to a series of investigations regarding intensive insulin therapy strategies that targeted tight glycemic control. As knowledge accumulated, the pursuit of tight glycemic control among critically-ill patients came to be seen as counterproductive, and moderate glycemic control came to dominate as the standard practice in intensive care units. In recent years, there has been increased focus on the importance of hypoglycemic episodes, glycemic variability, and premorbid diabetic status as factors that contribute to outcomes among critically-ill patients. This review provides a survey of key studies on glucose control in critical care, and aims to deliver perspective regarding glycemic management among critically-ill patients.

Effect of animated movie in combating child sleep health problems

Objective

Sleep deprivation among teens is a major health issue. Only 15% of teens get 8.5 h of sleep on school nights. Sleep deprivation can lead to poor grades, sleepiness and moodiness. We undertook a study to assess the prevalence of sleep habit disturbance among elementary school students in South Texas with Hispanic ethnicity predominance. We also found how much a video based on sleep education had an impact on these children.

Method

Once the Corpus Christi Independent School District (CCISD) approved the collection of baseline sleep data, questionnaires were administered using the Children’s Sleep Habit Questionnaire (CSHQ.) These questionnaires were distributed prior to the viewing of the educational and animated movie KNIGHTS (Keep Nurturing and Inspiring Good Habits in Teen Sleep). Four months later, a random follow-up was performed and the children were requested to respond to the same CSHQ.

Results

264 children from two elementary schools participated in this educational program. At baseline, 55.56% of the children had trouble sleeping. When the questionnaire was administered four months later, only 23.26% (p < 0.05) had trouble sleeping. Additionally, at baseline, approximately 60–70% children had some baseline bedtime resistance, anxiety dealing with sleep, issues with sleep duration and/or awakenings in the middle of the night. In the follow up questionnaire, results showed significant improvements in overall sleep habits, bedtime resistance, sleep anxiety and night awakenings amongst students (p < 0.05). However, no significant differences were seen in sleep duration and daytime sleepiness.

Conclusion

Sleep deprivation and good sleep habits remain as a pervasive challenge among elementary school students. Administering an animated video about sleep education along with a provider-based education may be an effective tool for educating elementary school students and decreasing the prevalence of these sleep-related issues. Future prospective randomized studies are suggested.

Role of preoperative screening for adult patients for obstructive sleep apnea

Obstructive sleep apnea (OSA) is a chronic disease with increasing prevalence. Underdiagnosed in the surgical population, OSA can reach a prevalence of up to 70% in bariatric surgery, and be associated with difficult airways and postoperative cardiopulmonary adverse events. Despite its association with escalation of care, increased health care resource utilization, and length of hospital stay, < 25% of health care institutions in the United States have OSA perioperative protocols to improve patient safety. This is explained in part by a lack of studies that support a widely accepted systematic approach to preoperative screening and risk stratification. This review evaluates the role of preoperative screening tools for adult patients with suspected OSA.

Comorbidity of diabetes and obstructive sleep apnea in hospitalized patients

Obstructive sleep apnea (OSA) and type 2 diabetes are two morbidities commonly encountered in the hospitalized setting. Both diseases will present with an array of complications if not managed in a timely, competent manner. However, a growing body of evidence suggests a link between these two pathologies. It is our hope that through careful review of the literature, we may generate heightened awareness of the OSA/diabetes comorbidity. Through better understanding of these conditions and their interactions, we may insure efficient management in the clinical setting and prevent exacerbation of common complications.

Obstructive sleep apnea in the perioperative setting: complications and management strategies

Obstructive sleep apnea (OSA) is frequently encountered in an undiagnosed, untreated state in perioperative patients. It increases the risk of respiratory, cardiac, and infectious complications following surgical procedures. Patients with OSA may require additional monitoring, unplanned escalations in care, and prolonged hospitalization. It is important to identify patients at risk for OSA during the preoperative assessment so that appropriate anesthesia, postsurgical monitoring, and pain control can be planned. Herein, we discuss data regarding perioperative outcomes in patients with OSA, methods to quickly identify patients at high risk for OSA, and implementation of clinical safeguards to minimize OSA-associated complications. An algorithm is provided to guide the perioperative management of patients with OSA.

Prolonged ventricular asystole: a rare adverse effect of hydrocodone use

Patient: Female, 56

Final Diagnosis: Ventricular asystole

Symptoms: Dizziness, headache, near-syncope, weakness

Medication: —

Clinical Procedure: —

Specialty: Cardiology

Diabetes, sleep apnea, obesity and cardiovascular disease: Why not address them together?

Obesity, sleep apnea, diabetes and cardiovascular diseases are some of the most common diseases encountered by the worldwide population, with high social and economic burdens. Significant emphasis has been placed on obtaining blood pressure, body mass index, and placing importance on screening for signs and symptoms pointing towards cardiovascular disease. Symptoms related to sleep, or screening for sleep apnea has been overlooked by cardiac, diabetic, pulmonary and general medicine clinics despite recommendations for screening by several societies. In recent years, there is mounting data where obesity and obstructive sleep apnea sit at the epicenter and its control can lead to improvement and prevention of diabetes and cardiovascular complications. This editorial raises questions as to why obstructive sleep apnea screening should be included as yet another vital sign during patient initial inpatient or outpatient visit.

Severe insulin resistance treatment with intravenous chromium in septic shock patient

Insulin resistance has been well documented in critically ill patients. Adequate blood sugar control has been associated with better wound healing, and better outcomes in selected patient populations. Chromium is an essential component of human diet. It is believed to affect changes in glucose uptake. Several studies have shown beneficial effects of oral chromium in diabetic patients with insulin resistance, but role of intravenous chromium infusion has not been completely evaluated. We present a case of extreme insulin resistance in a 62-year-old woman with history of diabetes who suffered a cardiac arrest and respiratory failure, leading to aspiration pneumonia and septic shock requiring greater than 7000 units of insulin over a period of 12 h which was successfully treated with intravenous chromium replacement.

Pylephlebitis: an uncommon complication of intra-abdominal infection

We present a case of pylephlebitis, which is an infective suppurative thrombosis of the portal vein. Pylephlebitis is an uncommon complication of intra-abdominal infections and carries with it significant morbidity and mortality.

The NAMES assessment: a novel combined-modality screening tool for obstructive sleep apnea

PURPOSE

Obstructive sleep apnea (OSA) remains underdiagnosed, despite our understanding of its impact on general health. Current screening methods utilize either symptoms or physical exam findings suggestive of OSA, but not both. The purpose of this study was to develop a novel screening tool for the detection of OSA, the NAMES assessment (neck circumference, airway classification, comorbidities, Epworth scale, and snoring), combining self-reported historical factors with physical exam findings.

METHODS

Subjects were adults without previously diagnosed OSA, referred to a community sleep center for suspicion of OSA. General health, Epworth Sleepiness Scale (ESS), and Berlin questionnaires were completed, and a physical exam focusing on modified Friedman (MF) grade, body mass index (BMI), and neck circumference (NC) was performed prior to polysomnography. OSA was defined by a respiratory disturbance index ≥15. Each variable was dichotomized, and cutoff values were determined for the NAMES tool in a pilot group of 150 subjects. The NAMES score was calculated from NC, MF, comorbidities, ESS, and loud snoring values. The performances of the NAMES, Berlin questionnaire, and ESS screening tests in predicting OSA were then compared in a validation group of 509 subjects.

RESULTS

In the pilot population, the cutoff value for the composite NAMES tool was calculated at ≥3 points. In the validation group, NAMES demonstrated similar test characteristics to the Berlin questionnaire, and sensitivity was better than that seen with the Epworth scale. The addition of BMI and gender to the tool improved screening characteristics.

CONCLUSIONS

The NAMES assessment is an effective, inexpensive screening strategy for moderate to severe OSA.