Tocilizumab use in patients with moderate to severe COVID-19: A retrospective cohort study.

WHAT IS KNOWN AND OBJECTIVE: The coronavirus disease 2019 (COVID-19) associated cytokine activation can lead to a rapid progression into respiratory failure, shock and multiorgan failure. Interleukin-6 (IL-6) is a pro-inflammatory cytokine that likely contributes to the pathogenesis of cytokine release syndrome. It is hypothesized that modulating IL-6 levels or its effects with tocilizumab, a recombinant humanized anti-IL-6 receptor monoclonal antibody, may alter the course of disease. METHODS: We examined the association between tocilizumab use and intubation or death at a community hospital in New York City. Data were obtained regarding consecutive patients hospitalized with COVID-19. The primary end point was a composite of intubation or death in a time-to-event analysis. We compared outcomes in patients who received tocilizumab with those in patients who did not, using a multivariable Cox model with inverse probability weighting according to the propensity score. RESULTS AND DISCUSSION: In this single-centre retrospective cohort study involving 1225 hospitalized patients with SARS-CoV-2 infection, the probability to respiratory failure, which was measured as intubation or death, was less frequent in patients who received tocilizumab. WHAT IS NEW AND CONCLUSION: Tocilizumab and other IL-6 receptor monoclonal antibodies may evolve as a viable option in treating patients with moderate and severe COVID-19.

Extended-Spectrum Beta-Lactamase Escherichia coli-Associated Acute Cholangitis: Uncommon Patient Characteristics and Clinical Implications.

Acute cholangitis is a potentially life-threatening condition caused by an infection of the biliary tract resulting from biliary obstruction. This case report highlights an unusual presentation of acute cholangitis in an elderly patient characterized by the presence of extended-spectrum beta-lactamase-producing Escherichia coli. We aim to emphasize the significance of recognizing diverse clinical manifestations in the elderly population to enhance timely diagnosis and appropriate management. The case highlights the importance of better understanding patient risk factors for potential causative organisms and their susceptibility to selecting proper antibiotics and improving clinical outcomes.

Green Synthesis of Zinc Oxide Nanoparticles Using an Aqueous Extract of Punica granatum for Antimicrobial and Catalytic Activity.

The peel aqueous extract of Punica granatum was utilized to fabricate zinc oxide nanoparticles (ZnO-NPs) as a green approach. The synthesized NPs were characterized by UV-Vis spectroscopy, Fourier transform infrared (FT-IR), X-ray diffraction (XRD), transmission electron microscopy (TEM), and scanning electron microscopy, which was attached to an energy dispersive X-ray (SEM-EDX). Spherical, well arranged, and crystallographic structures of ZnO-NPs were formed with sizes of 10-45 nm. The biological activities of ZnO-NPs, including antimicrobial and catalytic activity for methylene blue dye, were assessed. Data analysis showed that the antimicrobial activity against pathogenic Gram-positive and Gram-negative bacteria, as well as unicellular fungi, was observed to occur in a dose-dependent manner, displaying varied inhibition zones and low minimum inhibitory concentration (MIC) values in the ranges of 6.25-12.5 µg mL-1. The degradation efficacy of methylene blue (MB) using ZnO-NPs is dependent on nano-catalyst concentration, contact time, and incubation condition (UV-light emission). The maximum MB degradation percentages of 93.4 ± 0.2% was attained at 20 µg mL-1 after 210 min in presence of UV-light. Data analysis showed that there is no significant difference between the degradation percentages after 210, 1440, and 1800 min. Moreover, the nano-catalyst showed high stability and efficacy to degrade MB for five cycles with decreasing values of 4%. Overall, P. granatum-based ZnO-NPs are promising tools to inhibit the growth of pathogenic microbes and degradation of MB in the presence of UV-light emission.

Role of Transcatheter Arterial Embolization in Acute Refractory Non-variceal Upper Gastrointestinal Bleeding Not Controlled by Endoscopy: A Single-Center Experience and a Literature Review.

Introduction Acute upper gastrointestinal bleeding (UGIB) is a medical emergency and a common cause of hospital admissions worldwide. It has traditionally been treated with resuscitation and endoscopic intervention as the first-line therapy. In this study, we assessed the adjunctive role of transcatheter arterial embolization (TAE) in patients with uncontrolled UGIB after an endoscopic intervention. Material and methods A retrospective chart review of patients requiring TAE of UGIB which was not controlled by endoscopic intervention in BronxCare Health System from 2018 to 2021 was done. Patients who were more than 18 years of age and required TAE during the time period of the study were included in the study. Patients' charts were reviewed for patients' demographics, comorbidities, hospital course, imaging findings, esophagogastroduodenoscopy findings and intervention, and interventional radiology intervention and clinical outcome. Results A total of 10 patients were included in the study. A majority of the patients were male. Transcatheter atrial embolization was successful in all the 10 patients. Coils were used in seven patients while particulate polyvinyl alcohol 500 micron particle was used in two patients and vascular plug was used in two patients. Out of the 10 patients, four expired during the hospital course. None of the patients died secondary to UGIB. Three of the patients expired due to severe sepsis with septic shock secondary to pneumonia while one patient died because of respiratory failure due to lung collapse secondary to endobronchial lesion. Conclusion Refractory acute UGIB is associated with significant morbidity and mortality. TAE is a minimally invasive measure that should be considered early in the treatment of UGIB which is refractory to conventional endoscopic management. Our case highlights the importance of TAE in a patient with refractory UGIB after endoscopic intervention.

Gastric Bezoar: Cause of Weight Loss in a Patient With Previous Bariatric Surgery.

Gastric bezoar is a concretion of undigested material found in the stomach and is classified by its composition. Patients may remain asymptomatic or present with a variety of gastrointestinal symptoms. Upper gastrointestinal endoscopy is required to establish the diagnosis. Treatment options include chemical dissolution, endoscopic removal, or surgical removal. Here, we present a rare case of gastric bezoar in a patient with a remote history of bariatric surgery presenting with acute weight loss.

Syphilitic Hepatitis: A Rare Cause of Acute Liver Injury.

Syphilitic hepatitis represents a rare manifestation of treponemal infection. Diagnosis is achieved with the presence of characteristic syphilitic signs and symptoms along with positive serological markers, characteristic elevated liver enzymes, and no other alternative cause of hepatobiliary insult. Here we detail a case of a patient presenting with recently diagnosed secondary syphilis causing abnormal liver enzymes. With the increasing incidence of venereal diseases in the United States, this case highlights the importance of identifying syphilis as a differential diagnosis for acute liver injury.

Ansa Pancreatica, an Uncommon Cause of Acute, Recurrent Pancreatitis.

The pancreatic duct is vulnerable to developmental anomalies which may produce variations in its course and/or its configuration. Ansa pancreatica is the least common anatomic variant. It is characterized by the formation of an "S-shaped loop" from the main pancreatic duct to the minor papilla. Ansa pancreatica has been implicated as a cause of recurrent acute pancreatitis. We review existing literature on pancreatitis secondary to the ansa deformity and present a case of recurrent acute pancreatitis in a patient who was ultimately found to have the ansa deformity on endoscopic ultrasound.

Patients with Clostridium difficile infection and prior appendectomy may be prone to worse outcomes.

BACKGROUND: Clostridium difficile infection (CDI) occurs due to a dysbiosis in the colon. The appendix is considered a 'safe house' for gut microbiota and may help repopulate gut flora of patients with CDI. AIM: To study the impact of prior appendectomy on the severity and outcomes of CDI. METHODS: We retrospectively reviewed data of 1580 patients with CDI, admitted to our hospital between 2008 to 2018. Patients were grouped based on the presence or absence of the appendix. The primary aim was to (1) assess all-cause mortality and (2) the severity of CDI. Severity was defined as per the Infectious Diseases Society of America criteria. Logistic regression, and propensity score analysis using inverse probability of treatment weights (IPTW) was performed. RESULTS: Of the 1580 patients, 12.5% had a history of appendectomy. There was no statistical difference in mortality between patients with a prior appendectomy or without (13.7% vs 14%, P = 0.877). However, a history of appendectomy affected the severity of CDI [odds ratio (OR) = 1.32, 95% confidence interval: 1.01-1.75]. On IPTW, this association remained significant (OR = 1.59, P < 0.05). On multivariable analysis of secondary outcomes, prior appendectomy was also associated with toxic megacolon (OR = 5.37, P < 0.05) and colectomy (OR = 2.77, P < 0.05). CONCLUSION: Prior appendectomy may affect the severity of CDI, development of toxic megacolon and the eventual need for colectomy. Since treatment of CDI is governed by its severity, stronger antibiotic regimens or earlier use of fecal microbiota transplant may be a viable option for patients with prior appendectomy.

Evaluate the Toxicity of Pyrethroid Insecticide Cypermethrin before and after Biodegradation by Lysinibacillus cresolivuorans Strain HIS7.

Herein, bacterial isolate HIS7 was obtained from contaminated soil and exhibited high efficacy to degrade pyrethroid insecticide cypermethrin. The HIS7 isolate was identified as Lysinibacillus cresolivuorans based on its morphology and physiology characteristics as well as sequencing of 16S rRNA. The biodegradation percentages of 2500 ppm cypermethrin increased from 57.7% to 86.9% after optimizing the environmental factors at incubation condition (static), incubation period (8-days), temperature (35 °C), pH (7), inoculum volume (3%), and the addition of extra-carbon (glucose) and nitrogen source (NH4Cl2). In soil, L. cresolivuorans HIS7 exhibited a high potential to degrade cypermethrin, where the degradation percentage increased from 54.7 to 93.1% after 7 to 42 days, respectively. The qualitative analysis showed that the bacterial degradation of cypermethrin in the soil was time-dependent. The High-Performance Liquid Chromatography (HPLC) analysis of the soil extract showed one peak for control at retention time (R.T.) of 3.460 min and appeared three peaks after bacterial degradation at retention time (R.T.) of 2.510, 2.878, and 3.230 min. The Gas chromatography-mass spectrometry (GC-MS) analysis confirmed the successful degradation of cypermethrin by L. cresolivuorans in the soil. The toxicity of biodegraded products was assessed on the growth performance of Zea mays using seed germination and greenhouse experiment and in vitro cytotoxic effect against normal Vero cells. Data showed the toxicity of biodegraded products was noticeably decreased as compared with that of cypermethrin before degradation.

Quality appraisal of educational websites about osteoporosis and bone health.

PURPOSE/INTRODUCTION: Bone health education publicly available through the Internet, if evidence-based and unbiased, could help patients deal with issues such as decision-making, maintaining healthy lifestyles, using medications correctly, and improving their communication with health professionals. METHODS: We performed an environmental scan and quality assessment of the currently available osteoporosis and bone health patient education information on the World Wide Web. The sample websites were identified by using three separate search tools: Google Advanced, Bing, and Ask.com . Two independent investigators collected data and appraised the quality of selected websites. RESULTS: We identified 48 websites. Most websites were focused on risks factors of osteoporosis, preventive measures, screening recommendations, and topics to discuss with the physician. All websites provided adequate information describing treatment options; however, only 36% had information addressing duration of treatment, what happens when treatment stops, and the benefits and risks of various treatments. A total of 55% of the websites had their content updated to 2019 and 68% cited their sources of information to support their content. Reading levels ranged from 7.5 to 15.2 (higher than the recommended 6-grade level). CONCLUSIONS: Websites with information about bone health and osteoporosis commonly present information about initial treatment choices, but most fail to address risk-benefit issues, and common barriers than can occur throughout the course of the disease. In addition, many websites did not update their content, did not cite their sources of information, or were written at a 9-grade level or above (rendering them unsuitable for low-literacy populations).

Terbinafine-Induced Hepatitis B Reactivation in a Patient With Chronic Hepatitis B.

Reactivation of chronic inactive hepatitis B infection can be spontaneous or triggered by chemotherapy or immunosuppression. Although the pathophysiology behind this remains unclear, several mechanisms have been proposed in the literature. Data describing hepatitis B flares caused by other classes of medications are sparse. We describe a case of reactivation of chronic hepatitis B in a 48-year-old man, who presented with generalized weakness after initiating terbinafine for a fungal toenail infection. He was found to have deranged liver function tests and elevated hepatitis B viral load. Both resolved after discontinuation of terbinafine and starting tenofovir.

Predictors of Mortality in Adults Admitted with COVID-19: Retrospective Cohort Study from New York City.

INTRODUCTION: Rapid spread of coronavirus disease 2019 (COVID-19) in the United States, especially in New York City (NYC), led to a tremendous increase in hospitalizations and mortality. There is very limited data available that associates outcomes during hospitalization in patients with COVID-19. METHODS: In this retrospective cohort study, we reviewed the health records of patients with COVID-19 who were admitted from March 9-April 9, 2020, to a community hospital in NYC. Subjects with confirmed reverse transcriptase-polymerase chain reaction (RT-PCR) of the nasopharyngeal swab for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were included. We collected data related to demographics, laboratory results, and outcome of hospitalization. Outcome was measured based on whether the patient was discharged home or died during hospitalization. RESULTS: There were 888 consecutive admissions with COVID-19 during the study period, of which 513 were excluded with pending outcome or incomplete information. We included a total of 375 patients in the study, of whom 215 (57%) survived and 160 (43%) died during hospitalization. The majority of patients were male (63%) and of Hispanic origin (66%) followed by Blacks (25%), and others (9%). Hypertension (60%) stands out to be the most common comorbidity followed by diabetes mellitus (47%), cardiovascular disease (17%), chronic kidney disease (17%), and human immunodeficiency virus/acquired immunodeficiency syndrome (9%). On multiple regression analysis, increasing odds of mortality during hospitalization was associated with older age (odds ratio [OR] 1.04; 95% confidence interval [CI], 1.01-1.06 per year increase; p < 0.0001), admission D-dimer more than 1000 nanograms per milliliter (ng/mL) (OR 3.16; 95% CI, 1.75-5.73; p<0.0001), admission C-reactive protein (CRP) levels of more than 200 milligrams per liter (mg/L) (OR 2.43; 95% CI, 1.36-4.34; p = 0.0028), and admission lymphopenia (OR 2.63; CI, 1.47-4.69; p 0.0010). CONCLUSION: In this retrospective cohort study originating in NYC, older age, admission levels of D-dimer of more than 1000 ng/mL, CRP of more than 200 mg/L and lymphopenia were associated with mortality in individuals hospitalized for COVID-19. We recommend using these risk factors on admission to triage patients to critical care units or surge units to maximize the use of surge capacity beds.

Malignant Peritoneal Mesothelioma Without Asbestos Exposure.

Malignant mesothelioma is a rare neoplasm of the serosal linings. Mesothelioma has been linked to asbestos exposure, with prior asbestos exposure linked to 33-50% of malignant peritoneal mesotheliomas. We describe a case of malignant peritoneal mesothelioma (MPM) without any prior exposure to asbestos in a 40-year-old Hispanic female who presented to the emergency department with worsening abdominal pain and distension. She had a history of beta thalassemia trait and iron deficiency anemia. Examination revealed a distended abdomen with protruding umbilicus and positive shifting dullness. Laboratory tests showed anemia. Computed tomography (CT) of the abdomen revealed massive complex ascites suspicious of a malignant process. Ascitic fluid analysis showed serum ascites albumin gradient (SAAG) of 1.1 g/dL with a total protein of 5.2 g/dL. She underwent laparoscopic peritoneal biopsy which yielded epithelioid type malignant mesothelioma. She was started on chemotherapy with cisplatin and pemetrexed. The last follow-up was 27 months after the diagnosis. MPM is a rare and life-threatening malignancy. Frequently, the symptoms are non-specific. This poses a diagnostic challenge for physicians and probably the reason why the diagnosis is often delayed, especially in the absence of risk factors.

Acute Abdomen with Ileus: A Heralding Presentation of Neuroleptic Malignant Syndrome.

The pathophysiology of neuroleptic malignant syndrome (NMS) with use of psychotropic drugs is still unclear. Although a rare event with an incidence of 0.02-3.2%, when not promptly recognized and managed, it carries a high mortality (10-20%) and morbidity rate. Presentation can be either typical, with muscle rigidity and hyperpyrexia, or atypical, the latter posing diagnostic and early management challenges in clinical practice. Our patient presented with delayed fever and ileus, making early diagnosis difficult. We propose that NMS be considered an alternate diagnosis in patients using psychotropic medications and manifest ileus and delayed fever, especially after other differentials have been excluded.

Fever is associated with higher morbidity and clot burden in patients with acute pulmonary embolism.

BACKGROUND: Fever is considered as a presenting symptom of pulmonary embolism (PE). We aim to evaluate the association between PE and fever, its clinical characteristics, outcomes and role in prognosis. METHODS: A retrospective chart review of patients who were hospitalised with the diagnosis of acute PE was conducted. Patients in whom underlying fever could also be attributable to an underlying infection were also excluded. RESULTS: A total of 241 patients met the study criteria. 63 patients (25.7%) had fever within 1 week of diagnosis of PE of which four patients had fever that could be due to underlying infection and were excluded. Patients in PE with fever group were younger compared with PE without fever group (52.52 vs 58.68, p=0.012) and had higher incidence of smoking (44.1% vs 20.9%, p<0.001). Patients in PE with fever group were more likely to require intensive care admission (69.5% vs 35.7%, p<0.001), had a longer hospital length of stay (19.80 vs 12.20, p<0.001) and higher requirement of mechanical ventilation (30.5% vs 6.6%, p<0.001) compared with those without fever. PE with fever group were more likely to have massive and submassive PE (55.9% vs 36.8%, p=0.015) and had higher incidence of deep vein thrombosis (33.3% vs 17.4%, p=0.0347) compared with PE without fever. In a univariate model, there was higher likelihood of in-hospital mortality in PE with fever group compared with PE without fever (22.0% vs 10.4%, p=0.039). CONCLUSION: Patients with acute PE and fever have higher morbidity and clot burden.