Coronary Artery Dissection and Myocarditis Caused by Eosinophilic Granulomatosis with Polyangiitis (EGPA): A Case Report.

Eosinophilic granulomatosis with polyangiitis (EGPA) also referred to as Churg-Strauss syndrome is a rare vasculitis of the small to medium vessels. We present a rare case of acute coronary artery dissection brought on by EGPA, which generally has a poor prognosis. A 41-year-old male with history of bronchial asthma presented to the emergency room with a 2-week history of dyspnea, cough with clear phlegm, and fever. For the past eight months he had experienced episodes with similar symptoms relieved by steroids. CT chest showed bilateral upper lobe patchy opacities with extensive workup for infectious etiology being negative. He had peripheral eosinophilia with sinusitis. He had acute coronary syndrome and Coronary angiogram showed Right coronary artery dissection. After making a diagnosis of EGPA based on American college of Rheumatology criteria, he was successfully treated with high dose immunosuppression. Coronary artery dissection is a fatal and uncommon complication of EGPA which is usually diagnosed postmortem. Early recognition of this condition ante mortem and aggressive treatment can be lifesaving as demonstrated in our case.

Quality Improvement Initiative in a Community Hospital to Reduce Central Line Device Utilization Rate.

Background The intensive care unit (ICU) in a community hospital in southwest Minnesota saw a steady increase in central line-associated bloodstream infections (CLABSI) and an increase in the utilization of central lines. The baseline CLABSI rate was 11.36 at the start of the project, which was the highest in the last five years. The corresponding device utilization rate (DUR) was 64%, which increased from a pre-COVID pandemic rate of 45%. Aim The aim of this project was to decrease the ICU DUR by 37.5% from a baseline of 64% to 40% within six months without adversely impacting staff satisfaction. Methods A multidisciplinary team using the define, measure, analyze, improve, and control (DMAIC) methodology reviewed the potential causes of the increased use of central lines in the ICU. The team identified the following major causal themes: process, communication, education, and closed-loop feedback. Once the root causes were determined, suitable countermeasures were identified and implemented to address these barriers. These included reviewing current guidelines, enhanced care team rounding, staff education, and the creation of a vascular access indication algorithm. The team met biweekly to study the current state, determine the future state, evaluate feedback, and guide implementation. Results The pandemic saw a surge in the number of severely ill patients in the ICU, which may have caused an increase in the DUR. The project heightened the awareness of the increased DUR and its impact on the CLABSI rate. The initiation of discussion around this project led to an immediate decline in DUR via increased awareness and focus. As interventions were introduced and implemented, the DUR continued to decrease at a steady rate. Post implementation, the DUR met the project goal of less than 40%. The team continued to track progress and monitor feedback. The DUR continued to meet the goal for three months post implementation. Since the start of the project, there have been no CLABSI events reported. This effort has positively impacted safety and patient outcomes. Conclusions Through a defined process, the central line utilization rate in our ICU was decreased to 37.5% to meet the target goal and has been sustained.

Case Report of Acute Q Fever with Hepatitis Progressing to Chronic Q Fever with Endocarditis.

A 35-year-old male greenhouse worker presented with myalgia, fatigue, and fever. Initially, he was thought to have an unspecified viral infection and was treated with conservative therapy. However, the patient's symptoms persisted, and he reported additional symptoms of mild abdominal pain and headaches. Laboratory evaluation was significant for elevated liver enzymes. Due to concern for acute hepatitis and persistent fever the patient was hospitalized. During his hospital course, no infectious etiology was found to explain his symptoms. After discharge from the hospital, additional testing showed positive serology for Q fever IgG phase II antibody (1:8192) and phase II antibody IgM (>1:2048). He was treated with doxycycline and had a good clinical response. Upon follow-up, he had worsening Phase I IgG serologies. Transesophageal echo demonstrated vegetations consistent with endocarditis.

An Unusual Case of Escherichia Coli Meningitis in an Immunocompetent Adult.

Spontaneous meningitis caused by Gram-negative bacilli is rare in adults. It typically occurs after a neurosurgical procedure or head injury but may also be related to the presence of a neurosurgical device, cerebrospinal fluid (CSF) leak syndrome, or seen in immunosuppressed patients. Escherichia coli (E. coli) is the leading cause of Gram-negative bacilli meningitis. We describe the case of a 47-year-old man who was hospitalized for spontaneous, community-acquired E. coli meningitis, which is unusual to see in an immunocompetent adult. CSF analysis was consistent with bacterial meningitis; his blood culture was positive for E. coli. Within 24 hours of initiation of antibiotics, his status improved.

Overlap of diabetic ketoacidosis and hyperosmolar hyperglycemic state.

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia state (HHS) are two life-threatening metabolic complications of diabetes that significantly increase mortality and morbidity. Despite major advances, reaching a uniform consensus regarding the diagnostic criteria and treatment of both conditions has been challenging. A significant overlap between these two extremes of the hyperglycemic crisis spectrum poses an additional hurdle. It has well been noted that a complete biochemical and clinical patient evaluation with timely diagnosis and treatment is vital for symptom resolution. Worldwide, there is a lack of large-scale studies that help define how hyperglycemic crises should be managed. This article will provide a comprehensive review of the pathophysiology, diagnosis, and management of DKA-HHS overlap.

Cardiovascular Complications of Obstructive Sleep Apnea in the Intensive Care Unit and Beyond.

Obstructive sleep apnea (OSA) is a common disease with a high degree of association with and possible etiological factor for several cardiovascular diseases. Patients who are admitted to the Intensive Care Unit (ICU) are incredibly sick, have multiple co-morbidities, and are at substantial risk for mortality. A study of cardiovascular manifestations and disease processes in patients with OSA admitted to the ICU is very intriguing, and its impact is likely significant. Although much is known about these cardiovascular complications associated with OSA, there is still a paucity of high-quality evidence trying to establish causality between the two. Studies exploring the potential impact of therapeutic interventions, such as positive airway pressure therapy (PAP), on cardiovascular complications in ICU patients are also needed and should be encouraged. This study reviewed the literature currently available on this topic and potential future research directions of this clinically significant relationship between OSA and cardiovascular disease processes in the ICU and beyond.

Role of octreotide in small bowel bleeding.

Gastrointestinal bleeding accounts for a drastic negative impact on the quality of the patients' lives as it requires multiple diagnostic and therapeutic interventions to identify the source of the bleeding. Small bowel bleeding is the least common cause of gastrointestinal bleeding. However, it is responsible for the majority of complaints from patients with persisting or recurring bleeding where the primary source of bleeding cannot be identified despite investigation. A somatostatin analog known as octreotide is among the medical treatment modalities currently used to manage small bowel bleeding. This medication helps control symptoms of gastrointestinal bleeding by augmenting platelet aggregation, decreasing splanchnic blood flow, and antagonizing angiogenesis. In this review article, we will highlight the clinical efficacy of octreotide in small bowel bleeding and its subsequent effect on morbidity and mortality.

Management of Vasopressor-Induced Acute Limb Ischemia (VIALI) in Septic Shock.

Vasopressors used in critically ill patients with refractory shock poses a serious risk of non-occlusive peripheral limb ischemia leading to tissue necrosis and amputation. Acute limb ischemia is associated with high morbidity and mortality. Evidence-based medical literature is scarce on the prevention and management of vasopressor-induced acute limb ischemia (VIALI). Despite being a well-known and frequent complication of vasopressors, there is no standardized guideline for the prevention and management of vasopressor-induced limb ischemia. Vasopressors are required for the management of refractory shock which is defined as hypotension not responsive to intravenous fluid resuscitation alone. Distributive shock, which includes septic shock, causes inadequate tissue perfusion in adjunct with vasopressor use and is the most common cause of non-occlusive peripheral limb ischemia. This case study will focus on how early recognition and prompt treatment of VIALI are crucial in minimizing tissue necrosis and preventing amputations. We present a case of a middle-aged woman who developed distributive shock from sepsis of a urinary source secondary to obstructive uropathy (ureteral calculi). She presented with refractory shock and continued to remain in shock while undergoing emergent rigid cystoscopy with the placement of a ureteral stent. Despite adequate volume resuscitation, she required high doses of vasopressors resulting in peripheral extremity ischemia and necrosis of all her fingers and toes. By promptly initiating mitigation and preventive management strategies, we succeeded in minimizing tissue ischemia and reducing morbidity resulting from iatrogenic vasopressor-induced peripheral non-occlusive ischemia. These strategies include but are not limited to external warming of bilateral lower extremities, nitroglycerin paste application over the entire extremity, arterial assist pump, and low-dose therapeutic anticoagulation. The novel use of the arterial pump in acutely ischemic lower extremities likely helped salvage the toes which appeared to be at high risk of amputation.