Mechanically ventilated COVID-19 patients admitted to the intensive care unit in the United States with or without respiratory failure secondary to COVID-19 pneumonia: a retrospective comparison of characteristics and outcomes.

BACKGROUND: There is increasing heterogeneity in the clinical phenotype of patients admitted to the intensive care unit (ICU) with coronavirus disease 2019 (COVID-19,) and reasons for mechanical ventilation are not limited to COVID pneumonia. We aimed to compare the characteristics and outcomes of intubated patients admitted to the ICU with the primary diagnosis of acute hypoxemic respiratory failure (AHRF) from COVID-19 pneumonia to those patients admitted for an alternative diagnosis. METHODS: Retrospective cohort study of adults with confirmed SARS-CoV-2 infection admitted to nine ICUs between March 18, 2020, and April 30, 2021, at an urban university institution. We compared characteristics between the two groups using appropriate statistics. We performed logistic regression to identify risk factors for death in the mechanically ventilated COVID-19 population. RESULTS: After exclusions, the final sample consisted of 319 patients with respiratory failure secondary to COVID pneumonia and 150 patients intubated for alternative diagnoses. The former group had higher ICU and hospital mortality rates (57.7% vs. 36.7%, P<0.001 and 58.9% vs. 39.3%, P<0.001, respectively). Patients with AHRF secondary to COVID-19 pneumonia also had longer ICU and hospital lengths-of-stay (12 vs. 6 days, P<0.001 and 20 vs. 13.5 days, P=0.001). After risk-adjustment, these patients had 2.25 times higher odds of death (95% confidence interval, 1.42-3.56; P=0.001). CONCLUSIONS: Mechanically ventilated COVID-19 patients admitted to the ICU with COVID-19-associated respiratory failure are at higher risk of hospital death and have worse ICU utilization outcomes than those whose reason for admission is unrelated to COVID pneumonia.

Clinical presentations and outcomes in pulmonary embolism patients with cancer.

To study whether a diagnosis of cancer affects the clinical presentation and outcomes of patients with pulmonary embolism (PE). A retrospective analysis was performed of all consecutive patients diagnosed with PE on a computed tomography scan from 2014 to 2016 at an urban tertiary-referral medical center. Baseline characteristics, treatment decisions, and mortality data were compared between study subjects with and without a known diagnosis of active cancer. There were 581 subjects, of which 187 (33.0%) had a diagnosis of cancer. On average, cancer subjects tended to be older (64.8 vs. 58.5 years, p < 0.01), had lower body mass index (BMI) (29.0 vs. 31.5 kg/m2, p = 0.01), and were less likely to be active smokers (9.2% vs. 21.1%, p < 0.01), as compared to non-cancer subjects. Cancer subjects were also less likely to present with chest pain (18.2% vs. 37.4%, p < 0.01), syncope (2.7% vs. 6.6%, p = 0.05), bilateral PEs (50% vs. 60%, p = 0.025), and evidence of right heart strain (48% vs. 58%, p = 0.024). There was no difference in-hospital length of stay (8.9 vs. 9.4 days, p = 0.61) or rate of intensive care unit (ICU) admission (31.9% vs. 33.3%, p = 0.75) between the two groups. Presence of cancer increased the risk of all-cause one-year mortality (adjusted HR 9.7, 95% CI 4.8-19.7, p < 0.01); however, it did not independently affect in-hospital mortality (adjusted HR 2.9, 95% CI 0.86-9.87, p = 0.086). Patients with malignancy generally presented with less severe PE. In addition, malignancy did not independently increase the risk of in-hospital mortality among PE patients.

The Use of High-Flow Nasal Oxygen in the ICU as a First-Line Therapy for Acute Hypoxemic Respiratory Failure Secondary to Coronavirus Disease 2019.

OBJECTIVES: Limited evidence is available regarding the role of high-flow nasal oxygen in the management of acute hypoxemic respiratory failure secondary to coronavirus disease 2019. Our objective was to characterize outcomes associated with high-flow nasal oxygen use in critically ill adult patients with coronavirus disease 2019-associated acute hypoxemic respiratory failure. DESIGN: Observational cohort study between March 18, 2020, and June 3, 2020. SETTING: Nine ICUs at three university-affiliated hospitals in Philadelphia, PA. PATIENTS: Adult ICU patients with confirmed coronavirus disease 2019 infection admitted with acute hypoxemic respiratory failure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 266 coronavirus disease 2019 ICU admissions during the study period, 124 (46.6%) received some form of noninvasive respiratory support. After exclusions, we analyzed 83 patients who were treated with high-flow nasal oxygen as a first-line therapy at or near the time of ICU admission. Patients were predominantly male (63.9%). The most common comorbidity was hypertension (60.2%). Progression to invasive mechanical ventilation was common, occurring in 58 patients (69.9%). Of these, 30 (51.7%) were intubated on the same day as ICU admission. As of June 30, 2020, hospital mortality rate was 32.9% and the median hospital length of stay was 15 days. Among survivors, the most frequent discharge disposition was home (51.0%). In comparing patients who received high-flow nasal oxygen alone (n = 54) with those who received high-flow nasal oxygen in conjunction with noninvasive positive-pressure ventilation via face mask (n = 29), there were no differences in the rates of endotracheal intubation or other clinical and utilization outcomes. CONCLUSIONS: We observed an overall high usage of high-flow nasal oxygen in our cohort of critically ill patients with acute hypoxemic respiratory failure secondary to coronavirus disease 2019. Rates of endotracheal intubation and mortality in this cohort were on par with and certainly not higher than other published series. These findings should prompt further considerations regarding the use of high-flow nasal oxygen in the management algorithm for coronavirus disease 2019-associated acute hypoxemic respiratory failure.

First year experience of a pulmonary embolism response team with comparisons of outcomes between catheter directed therapy versus standard anticoagulation.

Objectives: The Pulmonary Embolism Response Team (PERT) model is now widely adopted in many institutions to provide multidisciplinary care for patients with acute pulmonary embolism (PE). However, descriptive experiences of PERT operations and studies on clinical outcomes remain limited.Methods: We performed a retrospective review of PERT activations at an academic tertiary care center, with secondary aims to study outcomes associated with performing catheter directed therapies (CDT).Results: The intermediate high-risk PE category was most frequent (n = 40, 76.9%) among the 52 total cases evaluated during the study period. There was one in-hospital mortality, associated with hospice admission for a non-PE diagnosis. Six patients (11.5%) experienced a bleeding complication of any severity. Anticoagulation (AC) alone was recommended in 30 patients (57.7%) and CDT was performed in 16 patients (30.8%). There were no significant differences in patient characteristics or disease severity between patients in the AC group versus the CDT group, except for a higher prevalence of malignancy in the AC group (p = 0.037). Patients who underwent CDT demonstrated a lower, albeit non-significant, median intensive care unit (ICU) length of stay (LOS) (3 vs. 4 days, p = 0.34) and hospital LOS (4 vs. 5 days, p = 0.25), as compared to patients receiving AC alone. Bleeding rates were similar between the two groups (6.7% vs. 6.3%, p = 1.0).Conclusions: Adoption of the PERT model at an academic tertiary care center was associated with acceptably low rates of mortality and bleeding, similar to other published studies. Performing CDT in select patients under PERT consultation may be associated with shorter ICU and hospital LOS; however, larger studies are needed to validate this finding.

Pulmonary Circulation in Obesity, Diabetes, and Metabolic Syndrome.

Obesity, diabetes mellitus, and the metabolic syndrome are important risk factors for the development of cardiovascular disease, with significant impact on human morbidity and mortality. Several decades of research have accumulated considerable knowledge about the mechanisms by which metabolic conditions precipitate systemic cardiovascular diseases. In short, these mechanisms are thought to involve changes in the external environment of vascular cells, which are mediated by the pro-inflammatory effects of adipokines, free fatty acids, and hyperglycemia. Thus, it has been hypothesized that the pulmonary circulation, witnessing similar insults as the systemic circulation, may be equally vulnerable to the development of vascular disease. Accordingly, recent attention has focused on exploring the mechanistic and epidemiological relationships among obesity, type 2 diabetes mellitus, metabolic syndrome, and pulmonary vascular diseases. In this article, we discuss in detail the preclinical evidence showing a modest but perceivable impact of metabolic disorders on the pulmonary circulation. In addition, we review the existing epidemiological studies examining the relationship among cardiovascular risk factors and pulmonary vascular diseases, using the acute respiratory distress syndrome and pulmonary arterial hypertension as examples. We conclude by discussing areas of limitations in the field and by suggesting future directions for investigation, including the notion that the pulmonary circulation may, in fact, be a resilient entity in the setting of some metabolic perturbations. © 2020 American Physiological Society. Compr Physiol 10:297-316, 2020.

A clean fuel cookstove is associated with improved lung function: Effect modification by age and secondhand tobacco smoke exposure.

Household air pollution (HAP) secondary to the burning of solid fuels is a major risk factor for the development of COPD. Our study seeks to examine the impact of a clean cookstove, liquid petroleum gas (LPG), on respiratory outcomes. Women (n = 200) from neighboring Indian communities, one cooking with LPG and one with biomass, were enrolled. Spirometry was performed. Relationships between primary cooking fuel and spirometry measures, as raw values, Global Lung Initiative (GLI) percent predicted (pp), and GLI z-scores, were examined using linear regression. Effect modification by age was explored. Women were young (average age 33.3 years), with low education (median 5.0 years), and the majority had multiple sources of air pollution exposures. Overall, the lung function in both groups was poor [FEV1 z-score median -2.05, IQR (-2.64, -1.41). Biomass was associated with lower FEV1/FVC (raw values -7.0, p = 0.04; GLI pp -7.62, p = 0.05, and z-score -0.86, p = 0.05) and FEF25-75 (GLI pp -25.78, p = 0.05, z-score -1.24, p = 0.05), after adjusting for confounders. Increasing impairment in lung function with age was found among biomass users (p-interaction = 0.01). In conclusion, use of a clean fuel cookstove may improve lung function. These findings have broad implications for research and public policy.

Meckel's diverticulum and ectopic epithelium: Evaluation of a complex relationship.

INTRODUCTION: Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract. Currently, for any incidentally discovered Meckel's diverticulum, the management approach is based on weighing the statistical odds of future complications against the risks of a diverticulectomy. MATERIALS AND METHODS: The temporal relationship between age at Meckel's diverticulectomy and the presence of ectopic epithelium was evaluated in our series. A meta-analysis of all reported recent literature on this condition was subsequently performed to evaluate the strength of the relationship between ectopic epithelium and symptomatic Meckel's diverticulum. RESULTS: There was a paucity of ectopic epithelium in Meckel's diverticulectomy specimens in infants operated on at less than 1 year of age. Having two or more ectopic epithelia in a diverticulum does not appear to carry an additive risk for complications. The meta-analysis confirmed that ectopic epithelium was the most significant factor that influenced surgical intervention in all series of Meckel's diverticulum. CONCLUSION: The relationship between ectopic epithelium and the development of symptomatic Meckel's diverticulum is complex. Further understanding of the development of ectopic rests in the diverticulum will facilitate elucidating the pathophysiology in symptomatic cases.