Neurally Adjusted Ventilatory Assist Versus Pressure Support Ventilation: A Comprehensive Review.

Mechanical ventilation serves as crucial life support for critically ill patients. Although it is life-saving prolonged ventilation carries risks and complications like barotrauma, Ventilator-associated pneumonia, sepsis, and many others. Optimizing patient-ventilator interactions and facilitating early weaning is necessary for improved intensive care unit (ICU) outcomes. Traditionally Pressure support ventilation (PSV) mode is widely used for weaning patients who are intubated and mechanically ventilated. Neurally adjusted ventilatory assist (NAVA) mode of the ventilator is an emerging ventilator mode that delivers pressure depending on the patient's respiratory drive, which in turn prevents over-inflation and improves the patient's ventilator interactions. Our article revises and compares the effectiveness of NAVA compared to PSV ventilation under different contexts. Overall we conclude that NAVA level of ventilation can be safely administered in a patient with acute respiratory failure, provided diaphragmatic paralysis is not considered. NAVA improves asynchrony index, wean-off time, and sleep quality and is associated with increased ventilator-free days. These results are based on small-scale studies with low power, and further studies are warranted in large-scale cohorts with more diverse populations to confirm these results.

Spontaneous Subdiaphragmatic Hemorrhage From an Aneurysm of Inferior Phrenic Artery.

Inferior phrenic artery (IPA) aneurysms are the rarest type of visceral aneurysms. It usually occurs secondary to trauma, surgery, or as a complication of pancreatitis. In addition, it can be a manifestation of underlying systemic pathology such as vasculitis, collagen vascular disorders, sepsis, or segmental arterial mediolysis. It can be associated with hypertension in 43% of cases. The presentation of IPA aneurysm is nonspecific with abdominal pain, melena, hematochezia, and anemia. The ruptured and actively bleeding aneurysm can lead to hemorrhagic shock, and immediate management is required with angiography and endovascular embolization with coil or gel foam or stent etc. Inaccessible locations are reached with surgical intervention, but it is associated with high morbidity and mortality. We here report a rare case of spontaneously ruptured IPA pseudoaneurysm extending from the posterior mediastinum to the subdiaphragmatic area and managed with coil and gel foam embolization.

Neurosarcoidosis: A Rare Presentation as a Seizure.

Neurosarcoidosis is a rare disorder that can develop in patients with a history of sarcoidosis or can develop even when sarcoidosis is not diagnosed. It is a granulomatous disease of the nervous system that causes different neurological disorders based on its location. However, diagnosing neurosarcoidosis remains a challenge as it mimics many other neurological disorders and does not have any biochemical markers of high specificity. A tissue-proven biopsy is the gold standard but is difficult to obtain in neurological illnesses. Thus, diagnosis is established based on the clinical syndrome and imaging, which mostly show meningeal/parenchymal lesion enhancement, in addition to the exclusion of other causes. Glucocorticoids, immunosuppressants, and anti-tumour necrosis factor (TNF) drugs are the mainstays of treatment. We discuss a case of neurosarcoidosis in a 52-year-old woman with a known history of sarcoidosis.

A Rare Presentation of Perivalvular Abscess and Infective Valve Endocarditis as Multiple Cerebral Septic Emboli Mimicking Ischemic Stroke.

The perivalvular cardiac abscess is a severe condition associated with infective endocarditis, leading to significant morbidity and mortality if not diagnosed and managed promptly. Neurological complications, particularly stroke, can occur due to embolic events resulting from cardiac abscesses. A 63-year-old female with end-stage renal disease and multiple comorbidities presented with altered mental status. Imaging revealed acute ischemic infarcts in the frontotemporal lobes, suggesting the embolic phenomenon. Blood cultures grew Enterococcus faecalis, and an echocardiogram showed severe aortic valve destruction with perivalvular abscess. Cardiac abscesses can cause severe complications, including tissue destruction, valve damage, and embolic events. Echocardiography is crucial for diagnosis, detecting vegetation, and assessing associated complications. Transthoracic echocardiography is reliable but has limitations, whereas transesophageal echocardiography is highly sensitive. Prompt antibiotic therapy and surgical intervention are crucial for treatment. Early initiation of appropriate antibiotic therapy and surgical intervention is crucial for positive outcomes. The choice of treatment should be individualized based on the patient's specific condition and the medical team's expertise.

Multicentric Reticulohistiocytosis Presenting As Acute Pericarditis With Moderate-Sized Pericardial Effusion: A Case Report and Review of Multicentric Reticulohistiocytosis Treatment.

Multicentric reticulohistiocytosis (MRH) is a rare, class IIb non-Langerhans cell histiocytosis associated with skin and joint involvement. It is more prevalent (80%) in Caucasian females in their fifth to sixth decade of life. Patients usually demonstrate symptoms and signs of symmetric polyarthritis and papulonodular cutaneous lesions. In addition to skin and joints, multiple organs can be involved, such as the lung (pleural effusion, interstitial fibrosis, hilar lymphadenopathy), heart (pericardial effusion, myocarditis), gastrointestinal system, and urogenital system (genital tract and kidney). Pericardial involvement is a rare manifestation, and around three cases have been reported in the literature so far. Our case report is a valuable contribution to the literature, which aids clinicians in contemplating MRH as one of the differentials among patients presenting with pericardial effusion. We described the characteristics of MRH along with its differentiating features from other autoimmune conditions and management.

Myxedema Coma: A Grave Phenomenon Partially Reversed CKD Status With Treatment of Hypothyroidism.

Myxedema coma is a grave medical condition that warrants emergent medical management to avoid adverse effects and unfavorable outcomes. Intravenous thyroid hormones (T3 and T4), along with intravenous hydrocortisone and frequent vital monitoring, are the mainstays of the management of myxedema coma. The interplay between CKD and hypothyroidism is fascinating and can affect each other. It is often very difficult for physicians to differentiate between sepsis and myxedema coma, especially in the early stages. Infections and medication non-compliance are the leading causes of precipitation myxedema coma. We describe a case report presented with myxedema coma and CKD, which was successfully managed and also led to a partial reversal of CKD status.

Aminotransferases in Relation to the Severity of Dengue: A Systematic Review.

A systematic review was conducted to investigate the relationship between aminotransferases and the severity of dengue infection, which is a prevalent and significant infection in tropical and subtropical regions. Aminotransferases are enzymes that are often elevated in dengue due to the liver's physiological and immunological response to the infection. This review focused on analyzing various studies that examined the correlation between aminotransferase levels and the severity of dengue. Extensive literature searches were performed using ("dengue*" OR "dengue fever*" OR "dengue haemorrhagic fever*" OR "dengue shock syndrome*") AND ("alanine aminotransferase*" OR "aspartate aminotransferase*") on PubMed. The selected articles were thoroughly reviewed, encompassing epidemiology, pathogenesis, and clinical manifestations of dengue. The consistent findings across the studies indicated that aminotransferases can serve as predictive markers for dengue severity. Therefore, early assessment of liver enzyme levels is crucial in dengue cases, and elevated levels should be closely monitored to prevent adverse outcomes.

Abnormal Longitudinal Strain in Takotsubo Cardiomyopathy: A Case Report.

In recent years, the prognostic utility of global longitudinal strain (GLS) has evolved significantly in the evaluation and management of a wide array of cardiac conditions. Various studies have described the use of GLS in the evaluation of various cardiac pathologies, including heart failure, aortic stenosis, and acute myocardial infarction. Evaluation utilizing speckle-tracking echocardiography (Echo) has been shown to be sensitive in the assessment of global and regional myocardial function. In that context, GLS can be used as a surrogate marker of myocardial function, especially in cases of acute myocardial infarction. Although GLS has been shown as a sensitive marker for myocardial ischemia, it has been a significantly underutilized modality in the evaluation of Takotsubo cardiomyopathy (TC); an acute myocardial stress reaction, which can mimic acute coronary syndrome on presentation. With this case report, we present a case of left ventricular TC with abnormal longitudinal strain affecting the entirety of the apex and all three major coronary artery distribution territories. Our case report illustrates how GLS can be a sensitive marker for myocardial dysfunction in cases of TC. The extent of abnormality and distribution of strain has a pathognomonic 'evil eye' appearance, which was described in previous studies and is consistent with TC. GLS may help identify patients with TC prior to proceeding with left heart catheterization and would be significantly beneficial in TC and may have further implications on the overall prognosis and management of TC in the future.

A Rare Case of Severe Manifestation of COVID-19 Infection Presenting as Immune-Related Thrombotic Thrombocytopenic Purpura With Multiorgan Involvement Treated With Plasmapheresis, Steroids, Rituximab, and Caplacizumab.

Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy (TMA) caused by decreased activity of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13). Platelet-rich thrombi in small vessels lead to fragmentation of RBCs causing microangiopathic hemolytic anemia (MAHA). Therapeutic plasma exchange is life-saving and is the mainstay of the treatment of TTP. Higher dose IV steroids along with rituximab are used as an adjunct to plasma exchange. Our case report describes a 26-year-old healthy male who presented with new onset seizures and encephalopathy. Blood work demonstrated anemia, severe thrombocytopenia, elevated lactate dehydrogenase, decreased haptoglobin, and elevated creatinine, and peripheral blood smear showed marked schistocytosis indicating MAHA. Plasma exchange and high-dose steroids were started on a presumptive diagnosis of TTP. ADAMTS13 activity was undetectable and ADAMTS13 inhibitor levels were elevated. Rituximab and caplacizumab were then added. Symptoms of encephalopathy improved by day five and platelet counts started improving by day nine. After several days of plasma exchange, he showed a "clinical response" with several weeks of active treatment. The association between coronavirus disease 2019 (COVID-19) infection and the severity of TTP with multiorgan failure is not well understood yet. Although we describe a successful multimodal approach to the management of TTP, which we believe is secondary to COVID-19 infection, further research is warranted to analyze and understand the pathophysiology by which COVID-19 infection causes TTP. It would help in establishing standardized therapy in the future.

Temporal Trends for Patients Hospitalized With Atrial Fibrillation in the United States: An Analysis From the National Inpatient Sample (NIS) Database 2011-2018.

BACKGROUND: Atrial fibrillation (AF) has historically been a growing burden on the global public health system. Previously, literature on the trends associated with AF-related hospitalizations has been published. However, there seems to be a gap in up-to-date information, notably within the last decade. PURPOSE: This study aims to investigate the trends, outcomes, and factors associated with AF hospitalization and the continued impact of AF on the United States health system. METHODS: Patient data were collected from the years 2011 to 2018 from the National Inpatient Sample (NIS) database using the International Classification of Diseases (ICD)-9 and ICD-10 codes. We selected patients hospitalized with a diagnosis of AF. Descriptive statistics, statistical analysis, and Mann-Whitney U testing were employed to compare continuous dichotomous variables. After respective adjustments, multivariate hierarchical logistic regression was used to establish mortality rates, length of stay (LOS), and hospital charges. RESULTS: The study included 509,305 patients hospitalized with a primary diagnosis of unspecified AF. The mean age of patients hospitalized with AF was 71 years. AF hospitalizations were slightly higher in women as compared to men (51.7% vs. 48.2%). The predominant race involved was Caucasians at 77.9% followed by African Americans and Hispanics at 7.4% and 5.4%, respectively. The three most frequent coexisting conditions noted were hypertension (69.9%), diabetes mellitus (24.3%), and chronic obstructive pulmonary disease (16.4%). Medicare/Medicaid was the primary payer associated with the majority of AF hospitalizations at 72.6%. Overall in-hospital mortality associated with AF hospitalizations was 0.96%. Comorbid conditions conferring the highest mortality risks included coagulopathies (644%) and cerebral vascular accidents (597%). Mean LOS was found to be 3.35 days. Hospitalization charges increased year-over-year and correlated with an increase in the national burden of cost for these patients of $3.6 billion. CONCLUSIONS: Our study investigates the national trends surrounding AF hospitalizations. Overall in-hospital mortality rates appear to be stable as compared to prior years and past literature. Comorbid conditions conferring significantly higher mortality rates included coagulopathies, cerebral vascular accidents, acute kidney injury, and end-stage renal disease. Additionally, suboptimal insurance status was also associated with increased mortality risk. The cost of hospitalization in AF patients has increased steadily, conferring a $3.6 billion burden on the US healthcare system.