An Infrequently Encountered Cause of Hemoptysis.

Mitral stenosis (MS) is not a common entity in modern-day medicine, especially in developed countries, as the most common etiology is still rheumatic fever. MS can present mainly with a wide range of cardiac symptoms. However, infrequently, MS can cause extra-cardiac symptoms as well. We present a case report of a patient with severe bioprosthetic mitral valve stenosis with intermittent hemoptysis and cardiogenic shock. We aim to report this case to remind clinicians about this uncommon but significant cause of hemoptysis. This case report also emphasizes the importance of utilizing a team approach while treating patients with severe MS, especially if they have serious complications that could be life-threatening. We also aim to add to the current literature by reporting this case.

Randomized Open Investigation Determining Steroid Dose in Severe COVID-19: The ROIDS-Dose Clinical Trial.

Introduction Treatment with dexamethasone reduces mortality in patients with coronavirus disease 2019 (COVID-19) pneumonia requiring supplemental oxygen, but the optimal dose has not been determined. Objective To determine whether weight-based dexamethasone of 0.2 mg/kg is superior to 6 mg daily in reducing 28-day mortality in patients with COVID-19 and hypoxemia. Materials and methods A multicenter, open-label, randomized clinical trial was conducted between March 2021 and December 2021 at seven hospitals within Northwell Health. A total of 142 patients with confirmed COVID-19 and hypoxemia were included. Participants were randomized in a 1:1 ratio to dexamethasone 0.2 mg/kg intravenously daily (n = 70) or 6 mg daily (n = 72) for up to 10 days. Results There was no statistically significant difference in the primary outcome of 28-day all-cause mortality with deaths in 12 of 70 patients (17.14%) in the intervention group and 15 of 72 patients (20.83%) in the control group (p = 0.58). There were no statistically significant differences among the secondary outcomes. Conclusion In patients with COVID-19 and hypoxemia, the use of weight-based dexamethasone dosing was not superior to dexamethasone 6 mg in reducing all-cause mortality at 28 days. Clinical trial registration This study was registered under ClinicalTrials.gov (identifier: NCT04834375).

Effective use of monoclonal antibodies for treatment of persistent COVID-19 infection in a patient on rituximab.

As we are over a year into the COVID-19 pandemic, we have made many forward strides in therapeutics. These treatments, such as monoclonal antibodies, have help mitigate the detrimental and often fatal consequences of COVID-19. The current indication for the use of monoclonal antibodies is mild to moderate COVID-19 infection within 10 days of symptom onset in those who are at high risk of progression to severe disease. However, their role in patients with prolonged symptoms is not clear. We present a unique case of monoclonal antibodies use after 54 days of symptom onset in an immunosuppressed patient with persistent COVID-19 infection despite standard treatment. This case illustrates the potential use of monoclonal antibodies outside of the current recommended therapeutic window in immunosuppressed patients, who may have difficulty with viral clearance.

Insomnia: Pharmacologic Treatment.

Insomnia afflicts many geriatric patients worldwide and results in both clinical and economic consequences. Prescribing hypnotics to the elderly is particularly challenging due to multitudes of adverse effects and drug interactions. Although benzodiazepines and "Z" drugs such as zolpidem have been popular in the past, they carry a high risk of adverse effects in the elderly, such as devastating falls and injuries as well as potentially an increase in mortality. Newer classes of hypnotics such as dual orexin receptor antagonists are much better tolerated and can be explored as a potential treatment for insomnia in the elderly.

Advances in Treatment of Sleep-Disordered Breathing.

BACKGROUND: Sleep-disordered breathing, composed of obstructive sleep apnea (OSA) and central sleep apnea (CSA), affects millions of people worldwide carrying with it significant morbidity and mortality. Diagnosis is made by polysomnography, and severity of sleep apnea is determined by the apnea-hypopnea index (AHI). Positive airway pressure (PAP) therapy has been the gold standard in treating both OSA and CSA. PAP therapy can greatly reduce AHI burden as well as morbidity and mortality and improve quality of life. AREAS OF UNCERTAINTY: However, patients report difficulties adhering to PAP therapy because of discomfort with mask interface, sensation of excessive pressure, and claustrophobia. Although other options exist to treat sleep apnea, such as mandibular advancement oral appliance devices, positional therapy, and surgery, these additional therapeutic modalities as current options have limitations. Emerging technology is now available to overcome hindrances to standard therapy. DATA SOURCES: A literature search was performed from the following databases: PubMed, Cochrane Library (Cochrane Database of Systematic Reviews), and Cochrane Central Register of Controlled Trials, and FDA device database (clinicaltrial.gov). THERAPEUTIC ADVANCES: Other modalities of treating sleep-disordered breathing now include the hypoglossal nerve stimulator, which stimulates the hypoglossal nerve during sleep to alleviate airflow obstruction by contracting the genioglossus muscle thus treating OSA. Similarly, the phrenic nerve stimulator restores a more stable breathing pattern during sleep by stimulating the phrenic nerve to activate the diaphragm during CSA. Both nerve stimulators have been shown to reduce AHI severity and improve quality of life for patients suffering from sleep-disordered breathing. CONCLUSIONS: PAP therapy, although the gold standard, has limitations in the treatment of sleep apnea. New modalities such as hypoglossal nerve stimulator and phrenic nerve stimulator may help to overcome difficulties with adherence and offer new options for treatment of both obstructive and central sleep apnea.

Ultrasound Billing for Intensivists.

Point-of-care ultrasonography is a key skill for the critical care clinician and is gaining widespread acceptance by clinicians in all areas of medicine. In addition to mastery of image acquisition, image interpretation, and clinical application, intensivists need to be adept with billing for their scanning activity. This article summarizes the requirements for documentation and image storage that must be met to obtain reimbursement for point-of-care ultrasonography services.

Ataxia telangiectasia-mutated damage-signaling kinase- and proteasome-dependent destruction of Mre11-Rad50-Nbs1 subunits in Simian virus 40-infected primate cells.

Although the mechanism of simian virus 40 (SV40) DNA replication has been extensively investigated with cell extracts, viral DNA replication in productively infected cells utilizes additional viral and host functions whose interplay remains poorly understood. We show here that in SV40-infected primate cells, the activated ataxia telangiectasia-mutated (ATM) damage-signaling kinase, gamma-H2AX, and Mre11-Rad50-Nbs1 (MRN) assemble with T antigen and other viral DNA replication proteins in large nuclear foci. During infection, steady-state levels of MRN subunits decline, although the corresponding mRNA levels remain unchanged. A proteasome inhibitor stabilizes the MRN complex, suggesting that MRN may undergo proteasome-dependent degradation. Analysis of mutant T antigens with disrupted binding to the ubiquitin ligase CUL7 revealed that MRN subunits are stable in cells infected with mutant virus or transfected with mutant viral DNA, implicating CUL7 association with T antigen in MRN proteolysis. The mutant genomes produce fewer virus progeny than the wild type, suggesting that T antigen-CUL7-directed proteolysis facilitates virus propagation. Use of a specific ATM kinase inhibitor showed that ATM kinase signaling is a prerequisite for proteasome-dependent degradation of MRN subunits as well as for the localization of T antigen and damage-signaling proteins to viral replication foci and optimal viral DNA replication. Taken together, the results indicate that SV40 infection manipulates host DNA damage-signaling to reprogram the cell for viral replication, perhaps through mechanisms related to host recovery from DNA damage.