Sequential Extracorporeal Therapy of Pathogen Removal Followed by Cell-Directed Extracorporeal Therapy in Streptococcal Toxic Shock Syndrome Refractory to Venoarterial Extracorporeal Membrane Oxygenation: A Case Report.

BACKGROUND: Streptococcal toxic shock syndrome (STSS) is a fulminant complication of predominantly invasive group A streptococcal infections. STSS is often characterized by influenza-like symptoms, including fever, chills, and myalgia that can quickly progress to sepsis with hypotension, tachycardia, tachypnea, and multiple organ failure (kidney, liver, lung, or blood). Mortality can exceed 50% depending on the severity of symptoms. CASE SUMMARY: Here, we describe a novel, multi-extracorporeal intervention strategy in a case of severe septic shock secondary to STSS. A 28-year-old woman 5 days after cesarean section developed STSS with respiratory distress, hypotension, and multiple organ failure. Despite conventional therapy with intubation, antibiotics, vasopressors, and fluid resuscitation, her condition worsened. She was placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) with subsequent initiation of pathogen hemoperfusion using the Seraph 100 blood filter, followed by immunomodulation with the selective cytopheretic device (SCD). No device-related adverse events were observed. The patient's condition gradually stabilized with discontinuation of vasopressors after 4 days, ECMO decannulation after 6 days, evidence of renal recovery after 7 days, and extubation from mechanical ventilation after 14 days. She was transferred to conventional hemodialysis after 13 days and discontinued all kidney replacement therapy 11 days later. CONCLUSIONS: This is the first reported use of VA-ECMO, Seraph 100 hemoperfusion, and cell-directed immunomodulation with SCD. This multimodal approach to extracorporeal support represents a promising therapeutic strategy for the most refractory critical care cases. Further studies are needed to assess the safety and efficacy of this sequential approach.

Extracorporeal Membrane Oxygenation for Acute Respiratory Failure Due to COVID-19: A Multicenter Matched Cohort Study.

Mechanical ventilation for respiratory failure due to COVID-19 is associated with significant morbidity and mortality. Veno-venous extracorporeal membrane oxygenation (ECMO) is an attractive management option. This study sought to determine the effect of ECMO on hospital mortality and discharge condition in this population. We conducted a retrospective multicenter study to emulate a pragmatic targeted trial comparing ECMO to mechanical ventilation without ECMO for severe COVID-19. Data were gathered from a large hospital network database in the US. Adults admitted with COVID-19 were included if they were managed with ECMO or mechanical ventilation for severe hypoxemia and excluded if they had significant comorbidities or lacked functional independence on admission. The groups underwent coarsened exact matching on multiple clinical variables. The primary outcome was adjusted in-hospital mortality; secondary outcomes included ventilator days, intensive care days, and discharge destination. A total of 278 ECMO patients were matched to 2,054 comparison patients. Adjusted in-hospital mortality was significantly less in the ECMO group (38.8% vs. 60.1%, p < 0.001). Extracorporeal membrane oxygenation was associated with higher rates of liberation from mechanical ventilation, intensive care discharge, and favorable discharge destination. These findings support the use of ECMO for well-selected patients with severe acute respiratory failure due to COVID-19.

Lipidomics Detection of Brain Cardiolipins in Plasma Is Associated With Outcome After Cardiac Arrest.

OBJECTIVES: Brain mitochondrial dysfunction limits neurologic recovery after cardiac arrest. Brain polyunsaturated cardiolipins, mitochondria-unique and functionally essential phospholipids, have unprecedented diversification. Since brain cardiolipins are not present in plasma normally, we hypothesized their appearance would correlate with brain injury severity early after cardiac arrest and return of spontaneous circulation. DESIGN: Observational case-control study. SETTING: Two medical centers within one city. PARTICIPANTS (SUBJECTS): We enrolled 41 adult cardiac arrest patients in whom blood could be obtained within 6 hours of resuscitation. Two subjects were excluded following outlier analysis. Ten healthy subjects were controls. Sprague-Dawley rats were used in asphyxial cardiac arrest studies. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We developed a high-resolution liquid chromatography/mass spectrometry method and determined cardiolipins speciation in human brain, heart, and plasma within 6 hours of (return of spontaneous circulation) from 39 patients with cardiac arrest, 5 with myocardial infarction, and 10 healthy controls. Cerebral score was derived from brain-specific cardiolipins identified in plasma of patients with varying neurologic injury and outcome. Using a rat model of cardiac arrest, cardiolipins were quantified in plasma, brain, and heart. Human brain exhibited a highly diverse cardiolipinome compared with heart that allowed the identification of brain-specific cardiolipins. Nine of 26 brain-specific cardiolipins were detected in plasma and correlated with brain injury. The cerebral score correlated with early neurologic injury and predicted discharge neurologic/functional outcome. Cardiolipin (70:5) emerged as a potential point-of-care marker predicting injury severity and outcome. In rat cardiac arrest, a significant reduction in hippocampal cardiolipins corresponded to their release from the brain into systemic circulation. Cerebral score was significantly increased in 10 minutes versus 5 minutes no-flow cardiac arrest and naïve controls. CONCLUSIONS: Brain-specific cardiolipins accumulate in plasma early after return of spontaneous circulation and proportional to neurologic injury representing a promising novel biomarker.

The crashing patient: hemodynamic collapse.

PURPOSE OF REVIEW: Rapid restoration of tissue perfusion and oxygenation are the main goals in the resuscitation of a patient with circulatory collapse. This review will focus on providing an evidence based framework of the technological and conceptual advances in the evaluation and management of the patient with cardiovascular collapse. RECENT FINDINGS: The initial approach to the patient in cardiovascular collapse continues to be based on the Ventilate-Infuse-Pump rule. Point of care ultrasound is the preferred modality for the initial evaluation of undifferentiated shock, providing information to narrow the differential diagnosis, to assess fluid responsiveness and to evaluate the response to therapy. After the initial phase of resuscitative fluid administration, which focuses on re-establishing a mean arterial pressure to 65 mmHg, the use of dynamic parameters to assess preload responsiveness such as the passive leg raise test, stroke volume variation, pulse pressure variation and collapsibility of the inferior vena cava in mechanically ventilated patients is recommended. SUMMARY: The crashing patient remains a clinical challenge. Using an integrated approach with bedside ultrasound, dynamic parameters for the evaluation of fluid responsiveness and surrogates of evaluation of tissue perfusion have made the assessment of the patient in shock faster, safer and more physiologic.

Neonatal orbital abscess.

Orbital abscess generally occurs in older children but it can rarely affect infants and neonates too. We report a case of community acquired methicillin resistant staphylococcus aureus (CA-MRSA) neonatal orbital abscess in a 12-day-old term female neonate with no significant past medical history or risk factor for developing the infection. The case highlights the importance of consideration of CA-MRSA as a causative agent of neonatal orbital cellulitis even in a neonate without any obvious predisposing condition. Prompt initiation of appropriate medical therapy against MRSA and surgical drainage of the abscess prevents life threatening complications of orbital cellulitis which more often tend to be fatal in neonates.

Ophthalmic Manifestations of HIV Patients in a Rural Area of Western Maharashtra, India.

Introduction. HIV/AIDS is one of twenty first century's biggest global challenges to mankind with protean manifestations affecting all organs of our body, not even sparing the eyes. The purpose of this study was to determine the pattern of ocular manifestations of HIV/AIDS and their correlation with CD4-count in a rural area of India. Methods. A hospital based observational cross-sectional study was done on 40 HIV-positive patients presenting to ART center with ocular complaints. Data were collected using face-to-face interview, clinical examination, slit lamp examination, fundus examination, and laboratory investigations. Results. Out of 40 patients, 21 were males and 19 were females with mean age of 38.75 ± 13.9 years. HIV retinopathy was the most common HIV-associated ophthalmic lesion while anterior uveitis was the most common anterior segment finding. Posterior segment lesions showed significant association (P < 0.05) with low CD4-count of the patient. CMV retinitis, retinal detachment, tubercular chorioretinitis, and acute retinal necrosis were all seen in patients with CD4-count less than 100 cells/mm(3). Conclusions. HIV retinopathy, CMV retinitis, herpes zoster ophthalmicus, and anterior uveitis are common ocular manifestations associated with HIV infection. Low CD4-count is a risk as well as predictor for ocular manifestations. There needs to be awareness of ocular involvement among HIV infected individuals and an increased emphasis on regular ophthalmic examination.

Equipment errors: a prevalent cause for fallacy in blood pressure recording - a point prevalence estimate from an Indian health university.

BACKGROUND: Blood pressure (BP) recording is the most commonly measured clinical parameter. Standing mercury sphygmomanometer is the most widely used equipment to record this. However, recording by sphygmomanometer is subject to observer and instrumental error. The different sources of equipment error are faulty manometer tube calibration, baseline deviations and improper arm bladder cuff dimensions. This is further compounded by a high prevalence of arm bladder miss-cuffing in the target population. OBJECTIVES: The study was designed to assess the presence of equipment malcalibrations, cuff miss-matching and their effect on BP recording. MATERIALS AND METHODS: A cross-sectional check of all operational sphygmomanometers in a health university was carried out for the length of the manometer tube, deviation of resting mercury column from "0" level, the width and length of arm bladder cuff and extent of bladder cuff-mismatch with respect to outpatient attending population. RESULTS: From the total of 50 apparatus selected, 39 (78%) were from hospital setups and 11 (22%) from pre-clinical departments. A manometer height deficit of 13 mm was recorded in 36 (92.23%) of the equipment in hospital and 11 (100%) from pre-clinical departments. Instruments from both settings showed significant deviation from recommended dimensions in cuff bladder length, width and length to width ratio (P < 0.001). Significant number of apparatus from hospital setups showed presence of mercury manometer baseline deviation either below or above 0 mmHg at the resting state (χ(2) = 5.61, D. F. = 1, P = 0.02). Positive corelationship was observed between manometer height deficit, baseline deviation and width of arm cuff bladder (Pearson correlation, P < 0.05). Bladder cuff mismatching in response to the target population was found at 48.52% for males and 36.76% for females. The cumulative effect of these factors can lead to an error in the range of 10-12 mmHg. CONCLUSION: Faulty equipments and prevalent arm bladder cuff-mismatching can be important barriers to accurate BP measurement.

Metformin associated B12 deficiency.

According to the ADA guidelines, metformin and lifestyle modifications are the first line therapies in the treatment of type 2 diabetes mellitus. Metformin does, however, cause vitamin B-12 malabsorption, which may increase the risk of developing vitamin B-12 deficiency--a clinically important and treatable condition. Here we report a case of 60 year old diabetic male presenting with clinical features of Vitamin B-12 deficiency on long term metformin therapy, which was confirmed on investigations. Patient showed symptomatic improvement with change in treatment.