Thoracic Ultrasound in COVID-19: Use of Lung and Diaphragm Ultrasound in Evaluating Dyspnea in Survivors of Acute Respiratory Distress Syndrome from COVID-19 Pneumonia in a Post-ICU Clinic.

INTRODUCTION: Dyspnea is a common symptom in survivors of severe COVID-19 pneumonia. While frequently employed in hospital settings, the use of point-of-care ultrasound in ambulatory clinics for dyspnea evaluation has rarely been explored. We aimed to determine how lung ultrasound score (LUS) and inspiratory diaphragm excursion (DE) correlate with patient-reported dyspnea during a 6-min walk test (6MWT) in survivors of COVID-19 acute respiratory distress syndrome (ARDS). We hypothesize higher LUS and lower DE will correlate with dyspnea severity. STUDY DESIGN AND METHODS: Single-center cross-sectional study of survivors of critically ill COVID-19 pneumonia (requiring high-flow nasal cannula, invasive, or non-invasive mechanical ventilation) seen in our Post-ICU clinic. All patients underwent standardized scanning protocols to compute LUS and DE. Pearson correlations were performed to detect an association between LUS and DE with dyspnea at rest and exertion during 6MWT. RESULTS: We enrolled 45 patients. Average age was 61.5 years (57.7% male), with average BMI of 32.3 Higher LUS correlated significantly with dyspnea, at rest (r = + 0.41, p = < 0.01) and at exertion (r = + 0.40, p = < 0.01). Higher LUS correlated significantly with lower oxygen saturation during 6MWT (r = -0.55, p = < 0.01) and lower 6MWT distance (r = -0.44, p = < 0.01). DE correlated significantly with 6MWT distance but did not correlate with dyspnea at rest or exertion. CONCLUSION: Higher LUS correlated significantly with patient-reported dyspnea at rest and exertion. Higher LUS significantly correlated with more exertional oxygen desaturation during 6MWT and lower 6MWT distance. DE did not correlate with dyspnea.

Demographic factors associated with perceptions about water safety and tap water consumption among adults in Santa Clara County, California, 2011.

The objective of this study was to examine differences in tap water consumption and perceptions of bottle versus tap water safety for Hispanics and non-Hispanic whites, as well as associations with other demographic characteristics. Data are from the Santa Clara County, California, Dietary Practices Survey (2011; N = 306). We used logistic regression to examine associations between demographic characteristics and 1) perceptions that bottled water is safer than tap and 2) primarily consuming tap water. Hispanics were less likely than non-Hispanic whites to primarily drink tap water (OR = 0.33; 95% CI, 0.11-0.99), although there was no significant difference in perceptions that bottled water is safer between these groups (OR = 0.50; 95% CI, 0.11-2.27). Hispanics may be an important population for interventions promoting tap water consumption.

Isolated Sub-Pulmonic Valve Endocarditis in a Patient With a History of Konno Procedure and Mechanical Aortic Valve.

Pulmonic and sub-pulmonic valve endocarditis are rarely encountered in clinical practice. We present the first case of isolated sub-pulmonic endocarditis. A 30-year-old man with a history of mechanical aortic valve presented to the emergency department with multiple complaints including nausea, vomiting, body aches, and fevers. The patient underwent surgical resection for sub-aortic stenosis followed by a modified Konno procedure later in life. A modified basal short-axis view on the trans-thoracic echocardiogram revealed a sub-pulmonic mobile structure highly suggestive of infective endocarditis. Blood cultures grew methicillin-sensitive Staphylococcus aureus within 24 hours. Higher oxygen demand prompted chest imaging, chest CT showed the development of bilateral airspace consolidation, suggestive of pneumonia. After treatment with extended intravenous antibiotics, follow-up echocardiogram four months later showed no identifiable sub-pulmonic vegetation. This case describes a situation where clinicians may suspect infective endocarditis in a typical location such as a mechanical aortic valve. However, in patients who develop pneumonia, infective endocarditis of the right heart should be suspected. The pulmonic valve and sub-pulmonic ridge are often difficult to image given their anatomical location, a modified basal short-axis view on trans-thoracic echocardiogram can better image these structures.

Creating Disability-Competent Medical Students Via Community Outreach.

INTRODUCTION: Medical students often have limited exposure to providing care to physically and cognitively disabled patients. To address this gap, Involvement with Disability Education and Advancement (IDEA) was started in 2015 at Rutgers New Jersey Medical School (NJMS). The organization provides NJMS students the opportunity to visit a school dedicated to disabled students and lead educational sessions on health topics. MATERIALS AND METHODS: We conducted a survey study in 2018 to compare comfort levels between IDEA members and non-members in eliciting information from and providing medical attention to nonverbal, cognitively impaired, and physically disabled patients. The survey-based study utilized yes/no questions, and a Likert scale questionnaire to determine IDEA member and non-member comfort levels in working with various disabilities. Statistical analysis was performed using SAS Enterprise Guide 7.1; p value < 0.05 was considered statistically significant. RESULTS AND DISCUSSION: A total of 56 responses (19 members, 37 non-members) were analyzed. Regardless of IDEA membership, medical students of all years perceived themselves to have more comfort caring for physically disabled than cognitively impaired or nonverbal patients. IDEA members also recorded higher comfort levels with eliciting information from cognitively impaired patients and lower comfort levels with providing medical attention to physically disabled patients. IMPLICATIONS: IDEA members may have increased comfort interacting with cognitively impaired individuals due to their regular experience and lower levels of comfort providing medical attention to physically disabled patients due to awareness of complex problems specific to the population. The current results warrant continued data collection and further evaluation.

Immune checkpoint inhibitors and radiotherapy-concept and review of current literature.

Traditional chemotherapeutic agents non-selectively eliminate cancer cells at the expense of normal tissue; in an attempt to minimize such effects, a new class of targeted agents, immunotherapy, was introduced in the late 1950s with the discovery of interferons and the development of the first cancer vaccine. Ever since, immunotherapy evolved, exploiting different cellular mechanisms including dendritic cell therapy, monoclonal antibodies, and cytokines. Immune checkpoint inhibitors (ICPI) are the most recent subclass of this family and we herein review the basis of exploiting this new subclass of immunotherapy with radiotherapy in the context of studies evaluating their effects on human subjects and focusing on the synergism between the molecular pathways operating in the background. PubMed was searched for studies evaluating the combined use of ICPI and radiotherapy among human subjects. The majority of studies noted an increased response rate in patients receiving combined therapy with no significant increase in toxicity. Outcomes varied among the different ICPI, and treatment with combined anti-PD-1 and anti-CTLA-4 had a higher response rate compared to either modality alone. Synergistic use of ICPI and radiotherapy has the potential to improve survival, however the specifics regarding treatment plan is dependent on a myriad of factors including the genetic and molecular makeup of the tumor as well as the patient.

Improving Rigor in a Door-to-Door Health Survey: A Participatory Approach in a Low-Income Latino Neighborhood.

BACKGROUND: Engaging community partners in research has the potential to make findings higher quality, more actionable, and more meaningful. Less rigorous approaches, often used by community-engaged partnerships, may diminish data quality. OBJECTIVE: This study highlights the key guiding principles of a community-based participatory research (CBPR) approach, particularly in regards to improving rigor, for a door-to-door health survey conducted by promotoras in a low-income, Latino neighborhood in San Jose, California. METHODS: We describe the partnership formed to conduct the study and the participatory process used throughout the study in questionnaire and sample design, training, and survey administration that adheres to key CBPR principles. LESSONS LEARNED: Our participatory approach required building the capacity of partners, having all partners weigh in on issues that arose in the field, enlisting outside expertise, being responsive to partner concerns while adhering to validated survey methods, simplifying sample design, incorporating expectations for data quality into training, and dedicating sufficient staffing to survey administration. CONCLUSION: The procedures, materials, and tools used by the community-engaged partnership in this study can be replicated by other community partnerships seeking to improve the quality of data used for decision making, program planning, and resource allocation.

A Tool for Providing Data on Small Areas: Development of Neighborhood Profiles for Santa Clara County, California, 2014.

Data on small geographic areas that can be easily accessed and updated have become essential for targeting public health programs and services. Disaggregating data at the sub-county or sub-city level has the potential to reveal disparities not otherwise evident for large geographies. As important as such data are, the methods to produce data on small geographic areas are challenging and resource-intensive, and little description and analysis of such tools exists. We describe a tool--neighborhood profiles--that provides a way for public health agencies and their partners to define neighborhood boundaries, select indicators, and disseminate data in a user-friendly format. We also share lessons learned, including the importance of involving planning departments in boundary definition to ensure relevance to the community, selecting a framework that links indicators to broader conceptual categories that can highlight disparities, and forming a team with the diverse skills necessary for planning and developing the profiles.

Percutaneous left ventricular support for high-risk PCI and cardiogenic shock: who gets what?

BACKGROUND: Temporary use of a percutaneous left ventricular assist device (PLVAD) may be beneficial in patients undergoing high-risk percutaneous coronary intervention (PCI) and those with cardiogenic shock (CS). METHODS: Seventy-four consecutive patients undergoing high-risk PCI and those with CS receiving intraaortic balloon pump (IABP), TandemHeart (TH), or Impella device (IMP) were enrolled. Patient undergoing high-risk PCI (n=57) and those treated for CS (n=17) were analyzed as separate cohorts. Patients undergoing IABP-assisted PCI were compared to those undergoing PLVAD (TH and IMP)-assisted PCI. The primary end point was in-hospital major adverse cardiovascular events, and the secondary end point was in-hospital vascular complications. RESULTS: For the high-risk PCI cohort (n=57), 22 received PLVAD and 35 received IABP. Patients receiving IABP were younger and less likely to have a prior myocardial infarction (MI) and less likely to be on dialysis compared to those receiving PLVAD support. Patients receiving PLVAD support had a higher baseline Syntax score, had a higher prevalence of unprotected left main disease, underwent treatment of more coronary lesions, received more coronary stents, and more likely received drug-eluting stents compared to those receiving IABP support. The primary and secondary end points were similar between both groups. For the CS cohort (n=17), 4 received PLVAD and 13 received IABP. Patients receiving PLVAD support were more likely to have a prior MI, had a lower ejection fraction, underwent treatment of more coronary lesions, and received more coronary stents compared to those receiving IABP support. The primary and secondary end points were similar between both groups. CONCLUSIONS: IABP compared with PLVAD use for high-risk PCI and CS is associated with significantly different baseline patient, clinical, procedural, and angiographic characteristics. In-hospital clinical outcome was similar between both groups in both the high-risk PCI and the CS cohorts. When physicians have access to each of these devices, short-term clinical outcome appears to be similar.

Suspected Legionella-induced perimyocarditis in an adult in the absence of pneumonia: a rare clinical entity.

Legionella infection can manifest itself in many clinical forms, most commonly as pneumonia, but rarely in the form of myocardial involvement. Legionella with myocardial involvement independent of pneumonia is almost never seen in the adult population and therefore is cited only a handful of times in the medical literature. When reported, Legionella carditis itself typically occurs as an isolated pericarditis with effusion. Cases of isolated Legionella with myocardial involvement, but without associated pneumonia, have been reported among children. To our knowledge, there are no reported cases of Legionella myocarditis and pericarditis presenting concurrently with or without pneumonia, in either an adult or a pediatric population. Herein, we report a rare manifestation of Legionella pneumophila-induced perimyocarditis (strongly suspected, if not incontrovertibly proved) in an adult, in the absence of pneumonia.