Benign inoperable tracheal stenosis in COVID versus non-COVID patients at the pandemic epicenter: a case series.

Background: The COVID-19 pandemic has exponentially expanded the number of patients requiring treatment for chronic respiratory failure. One consequence is an increase in the number of patients requiring intubation and mechanical ventilation. Benign inoperable tracheal stenosis presents a challenge, especially in COVID-19 patients. Methods: We describe a case series of 15 patients with Benign inoperable tracheal stenosis treated with interventional bronchoscopy over a 15-month period. These patients were divided into two groups, COVID and non-COVID. We used an electrocautery snare as an electrocautery knife to cut the stenotic segment followed by four injections of 1 mg submucosal Decadron via a Wang needle. Patients were subsequently followed by the pulmonary clinic. Institutional review board approval was not required as per our institutional policy for a retrospective case series. Results: There was a high degree of success with this intervention, with a low rate of recurrence. We also noticed the following differences between the two subgroups. COVID tracheal stenosis was longer in length, had a higher percentage of cartilage involvement, and was located more distal to cords than the non-COVID group. The median age was younger in the COVID group. Conclusions: COVID pandemic an enormous number of intubations and tracheotomies have been performed. As a result, there will be an increased prevalence of tracheal stenosis. Most of these cases can be effectively treated with surgery. Dealing with complex inoperable cases remains a dilemma. Our case series/research article is an attempt to provide an easy technique with a high cure rate.

Endobronchial blood-patch: A novel technique for a persistent pleural air leak.

Introduction: Patients with severe COVID-19 Pneumonia requiring prolonged mechanical ventilation have an increased incidence of pneumothorax. Mechanically ventilated patients who are critically ill and develop a persistent air leak from pneumothorax are poor candidates for surgical repair. As the persistent air leak can be a significant barrier to vent-weaning and clinical stability, these patients present a unique clinical challenge. Clinical case: A 65-year-old male intubated and on prolonged mechanical ventilation for severe COVID-19 Pneumonia developed a pneumothorax complicated by a persistent alveolar-pleural fistula with a persistent air-leak. Given his critical state with ongoing pressor requirements and elevated vent requirements, surgical repair was not an option. A bedside bronchoscopy occlusion study with isolation of the air leak, and subsequent autologous endobronchial blood-patch repair with thrombin was performed with rapid and definitive resolution of the air leak. The patient progressed favorably, ultimately being weaned from the ventilator, decannulated, and walking out of the hospital. Conclusion: In critically ill ventilated patients with pneumothorax complicated by a persistent air-leak, bedside endobronchial evaluation and blood-patch repair is a feasible approach to management.

Increased Secondary Infection in COVID-19 Patients Treated with Steroids in New York City.

Steroids are expected to be effective in the treatment of cytokine release syndrome, which is considered to be associated with severe cases of coronavirus disease 2019 (COVID-19). We aimed to investigate the use of steroids and its effects. We conducted a retrospective chart review and an analysis of 226 consecutive hospitalized patients with confirmed COVID-19. Patients were divided into those who received steroids (steroid group) and those who did not (no steroid group). Inverse probability weighted analysis was performed to assess the effect of steroids on in-hospital mortality. The steroid group had higher rates of preexisting hypertension and peripheral vascular disease as well as higher lactate dehydrogenase levels, d-dimer levels, and inflammatory markers than the no steroid group (all P <0.05). The steroid group had significantly higher rates of multifocal pneumonia than the no steroid group at admission (75.4% vs. 50.3%, P = 0.001). Notably, the steroid group had higher rates of developing bacterial infection (25% vs. 13.1%, P = 0.041) and fungal infection (12.7% versus 0.7%, P <0.001) during the hospital course than the no steroid group. After adjustment, it was observed that steroids did not decrease or increase in-hospital mortality (odds ratio [95% confidence interval]: 1.02 [0.60-1.73, P = 0.94]). There was an increase in bacterial and fungal infections with steroid use.

The association of interleukin-6 value, interleukin inhibitors, and outcomes of patients with COVID-19 in New York City.

Since cytokine release syndrome with elevation of interleukin-6 (IL-6) is considered to be associated with severe cases of coronavirus disease 2019 (COVID-19); IL-6 inhibitors, such as tocilizumab, are expected to be effective for its treatment. This was a retrospective study using a consecutive cohort of 224 patients hospitalized with COVID-19 in March 2020. Patients were divided into those admitted to the intensive care unit (ICU group) and those not (no ICU group), and clinical data including usage of tocilizumab were compared. Correlation between IL-6 value at admission and at peak, and tocilizumab use, as well as clinical outcomes were also investigated. The ICU group had higher rates of pre-existing comorbidities such as hypertension, diabetes, and coronary disease, and higher IL-6 than no ICU group (all P < .05). Age, peak IL-6, and peak d-dimer were significant predictors of in-hospital mortality (1.05 [1.01-1.09], P = .012; 1.001 [1.000-1.002], P = .002; 1.10 [1.03-1.18], P = .008). Receiver operating characteristics curve showed higher predictability of in-hospital mortality with IL-6 at peak than others (area under curve; IL-6 at peak: 0.875 [0.87-0.942], IL-6 at admission: 0.794 [0.699-0.889], d-dimer at peak 0.787 [0.690-0.883], d-dimer at admission 0.726 [0.625-0.827]). Incidence of fungal infections was significantly higher in patients who were given tocilizumab than those who were not (13.0% vs 1.1%, P < .001). Notably, tocilizumab did not affect in-hospital mortality after adjustment including IL-6 (odds ratio [95% confidential interval]: 1.00 [0.27-3.72, P = .998]). Age, peak IL-6, and peak d-dimer levels were significant predictors of in-hospital mortality. Tocilizumab did not decrease in-hospital mortality in our cohort.

Cardiac Injury and Outcomes of Patients With COVID-19 in New York City.

BACKGROUND: Prior studies demonstrated that elevated troponin in patients with COVID-19 was associated with increased in-hospital mortality. However, the association of cardiac injury and electrocardiogram (ECG) changes remains unclear. The aim of this study was to investigate the association of cardiac injury with ECG abnormality and with in-hospital mortality. METHODS: We conducted a retrospective cohort study of patients who were hospitalised with COVID-19 between 13 March and 31 March 2020. Those patients with troponin I measurement were included in the study and divided into those who had elevated troponin I (cardiac injury group) and those who did not (no cardiac injury group). Statistical analyses were performed to compare differences between the groups, and a multivariate logistic regression model was constructed to assess the effect of cardiac injury on in-hospital mortality. RESULTS: One hundred and eight-one (181) patients were included, 54 of whom were in the cardiac injury group and 127 in the no cardiac injury group. The mean age was 64.0±16.6 years and 55.8% were male. The cardiac injury group was more likely to be older, have a history of coronary artery disease, atrial fibrillation and congestive heart failure compared to the no cardiac injury group (all p<0.05); there was no difference in presence of chest pain (cardiac injury group versus no cardiac injury group: 17.0% versus 22.5%, p=0.92); the cardiac injury group had a significantly higher value of brain natriuretic peptide, procalcitonin, interleukin-6 and D-dimer (all p<0.05); they had numerically more frequent ECG abnormalities such as T wave inversion (13.2% versus 7.5%, p=0.23) and ST depression (1.9% versus 0.0%, p=0.13) although statistically not significant; they had significantly higher in-hospital mortality (42.3% versus 12.6%, p<0.001). With a multivariate logistic regression model, age (odds ratio [95% confidence interval]: 1.033 [1.002-1.065], p=0.034) and cardiac injury (3.25 [1.40-7.54], p=0.006) were independent predictors of in-hospital mortality. CONCLUSIONS: Patients with COVID-19 with elevated troponin I had a relatively low proportion of chest pain and ECG abnormality. Cardiac injury was independently associated with in-hospital mortality.

Marijuana-related Reversible Cerebral Vasoconstriction Syndrome.

The legalization of recreational marijuana in some countries has been accompanied by an increased number of case reports of serious cardiovascular and cerebrovascular complications. However, there have been few studies describing the detailed clinical course of reversible cerebral vasospasm syndrome (RCVS) associated with marijuana use. We herein report a unique case of recurrent bi-fronto-parietal subcortical (watershed) infarction in the setting of chronic daily marijuana use for several years, with evidence of bilateral anterior cerebral artery vasoconstriction. The quick resolution of symptoms with treatment and the normalization of cerebral vasoconstriction on follow-up imaging lend high certainty to the diagnosis of RCVS.

Aphasia and confusion - influenza encephalopathy: atypical presentation of influenza.

Influenza encephalopathy, a rare manifestation of influenza infection in the adult population which is not widely recognised, can present with confusion and focal neurological symptoms, including aphasia. The aim of this report is to illustrate the unique presentation of influenza encephalopathy and discuss the need for close attention to and monitoring of this rare but highly fatal disease.A 28-year-old woman was admitted with acute-onset confusion and incoherent speech. CT of the head was unremarkable. Cerebrospinal fluid analysis showed elevation of protein, but was otherwise unremarkable. A detailed history revealed recent upper respiratory symptoms which prompted a rapid influenza test which was positive and oseltamivir was started. The patient's confusion and aphasia gradually improved and her speech was back to her baseline by the next day.

Palliative Care Team Involvement in Patients With COVID-19 in New York City.

BACKGROUND: With the highest number of cases in the world as of April 13, 2020, New York City (NYC) became the epicenter of the global coronavirus disease 2019 (COVID-19) pandemic. The data regarding palliative team involvement in patients with COVID-19, however, remains scarce. We aimed to investigate outcomes of palliative team involvement for the patients with COVID-19 in NYC. METHODS: Consecutive 225 patients with confirmed COVID-19 requiring hospitalization in our urban academic medical center in NYC were analyzed. Patients were divided into 2 groups, those with a palliative care consult (palliative group: 14.2% [n = 32]) versus those with no palliative care consult (no palliative group: 85.8% [n = 193]). RESULTS: The palliative group was older and had more comorbidities. During the hospital course, the palliative group had more intensive care unit stays, rapid response team activations, and more use of vasopressors (P < .05). Patients with palliative care had higher rates of invasive mechanical ventilation than those without (46.9% vs 10.4%, P < .001). Cardiopulmonary resuscitation was performed in 12 patients (6.5% vs 5.2%, P = .77) and death rate was 100% in both subsets. Notably, initial code status was not different between the 2 groups, however, code status at discharge was significantly different between them (P < .001). The rate of full code decreased by 70% in the palliative group and by 47.5% in the no palliative care group from admission to the time of death. CONCLUSIONS: Critically ill patients hospitalized for COVID-19 benefit from palliative team consults by helping to clarify advanced directives and minimize futile resuscitative efforts.

Cardiovascular comorbidities, cardiac injury, and prognosis of COVID-19 in New York City.

Using Mt. Sinai (New York City) EMR health system data, we retrospectively analyzed a cohort of 8438 COVID-19 patients seen between March 1 and April 22, 2020. Risk of intubation and of death rose as a function of increasing age and as a function of greater cardiovascular comorbidity. Combining age and specific comorbidity markers showed patterns suggesting that cardiovascular comorbidities increased relative risks for adverse outcomes most substantially in the younger subjects with progressively diminishing relative effects at older ages.

Severe acute respiratory distress syndrome in a patient with AIDS successfully treated with veno-venous extracorporeal membrane oxygenation: a case report and literature review.

CASE: Several successful uses of extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome in patients with novel HIV/AIDS infection have been reported; however, the therapeutic keys have not always been discussed.A 47-year-old man was admitted with progressive shortness of breath. He was in respiratory failure with a PaO2/FIO2 ratio of 110.8 requiring intubation. Chest computed tomography showed diffuse ground glass opacities. An HIV infection was suspected, and a diagnosis of acute respiratory distress syndrome was made. Based on clinical indications, treatment for Pneumocystis jirovecii pneumonia and concomitant bacterial infection was started. OUTCOME: Despite broad-spectrum antibiotics, the patient's oxygenation deteriorated, necessitating ECMO. After 19 days of ECMO therapy, the patient was successfully decannulated and was eventually discharged. CONCLUSION: In acute respiratory distress syndrome in patients with HIV/AIDS refractory to treatment, ECMO should be considered. Post-ECMO antiretroviral therapy could improve outcomes.