Diagnostic Dilemma: A Patient With Pulmonary Fibrosis Who Presented for Severe Tracheal Stenosis After COVID-19 Pneumonia.

A 44-year-old man with pulmonary fibrosis presented to our pulmonary hypertension clinic with biphasic stridor and dyspnea. He was sent to the emergency department, where he was found to have 90% subglottic tracheal stenosis and was successfully treated with balloon dilation. Seven months prior to the presentation, he required intubation for coronavirus disease 2019 (COVID-19) pneumonia complicated by hemorrhagic stroke. He was discharged after percutaneous dilatational tracheostomy, which was decannulated after three months. Our patient possessed several risk factors for tracheal stenosis, including endotracheal intubation, tracheostomy, and airway infection. Furthermore, our case is of great importance given the developing literature on COVID-19 pneumonia and its subsequent complications. Additionally, his history of interstitial lung disease may have confounded his presentation. Therefore, it is important to understand stridor, as it is an important exam finding that clinically distinguishes upper and lower airway disease. Our patient's biphasic stridor is consistent with the diagnosis of severe tracheal stenosis.

Outcome and Post-Surgical Lung Biopsy Change in Management of ARDS: A Proportional Prevalence Meta-Analysis.

BACKGROUND: Limited epidemiological data are available on changes in management, benefits, complications, and outcomes after open lung biopsy in patients with ARDS. METHODS: We performed a literature search of PubMed, Ovid, and Cochrane databases for articles from the inception of each database till November 2020 that provided outcomes of lung biopsy in ARDS patients. The primary outcome was the proportion of patients that had a change in management with alteration of treatment plan, after lung biopsy. Secondary outcomes included pathological diagnoses and complications related to the lung biopsy. Pooled proportions with a 95% confidence interval (CI) were calculated for the prevalence of outcomes. RESULTS: After analysis of 22 articles from 1994 to 2018, a total of 851 ARDS patients (mean age 59.28 ± 7.41, males 56.4%) that were admitted to the ICU who underwent surgical lung biopsy for ARDS were included. Biopsy changed the management in 539 patients (pooled proportion 75%: 95% CI 64-84%). There were 394 deaths (pooled proportion 49%: 95% CI 41-58%). The most common pathologic diagnosis was diffuse alveolar damage that occurred in 30% (95% CI 19-41%), followed by interstitial lung disease in 10% (95% CI 3-19%), and viral infection in 9% (95% CI 4-16%). Complications occurred among 201 patients (pooled proportion 24%, 95% CI 17-31%). The most common type of complication was persistent air-leak among 115 patients (pooled estimate 13%, 95% CI 9-17%). CONCLUSION: Despite the high mortality risk associated with ARDS, lung biopsy changed management in about 3/4 of the patients. However, 1/4 of the patients had a complication due to lung biopsy. The risks from the procedure should be carefully weighed before proceeding with lung biopsy.

Acute myocardial infarction and acute heart failure among renal transplant recipients: a national readmissions database study.

BACKGROUND: The literature on the mortality and 30-day readmissions for acute heart failure and for acute myocardial infarction among renal-transplant recipients is limited. OBJECTIVE: To study the in-hospital mortality, cardiovascular complications, and 30-day readmissions among renal transplant recipients (RTRs). METHODS: Data from the national readmissions database sample, which constitutes 49.1% of all hospitals in the United States and represents more than 95% of the stratified national population, was analyzed for the years 2012-2018 using billing codes. RESULTS: A total of 588,668 hospitalizations in renal transplant recipients (mean age 57.7 ± 14.2 years; 44.5% female) were recorded in the study years. A total of 15,788 (2.7%) patients had a diagnosis of acute heart failure; 11,320 (71.7%) had acute heart failure with preserved ejection fraction and 4468 (28.3%) had acute heart failure with reduced ejection fraction; 17,256 (3%) patients had myocardial infarction, 3496 (20%) had ST-Elevation myocardial infarction while 13,969 (80%) had non-ST-elevation myocardial infarction. Overall, 11,675 (2%) renal-transplant patients died, of whom 757 (6.5%) had acute heart failure, 330 (2.8%) had acute reduced and 427 (3.7%) had acute preserved ejection fraction failure. Among 1652 (14.1%) patient deaths with myocardial infarction, 465 (4%) were ST-elevation- and 1187 (10.1%) were non-ST-Elevation-related. The absolute yearly mortality rate due to acute heart failure increased over the years 2012-2018 (p-trend 0.0002, 0.001, 0.002, 0.05, respectively), while the mortality rate due to myocardial infarction with ST-elevation decreased (p-trend 0.002). CONCLUSION: Cardiovascular complications are significantly associated with hospitalizations among RTRs. The absolute yearly mortality, and rate of heart failure (with reduced or preserved ejection fraction) increased over the study years, suggesting that more research is needed to improve the management of these patients.

ST-Elevation Myocardial Infarction Outcomes: A United States Nationwide Emergency Departments Cohort Study.

BACKGROUND: Literature regarding trends in incidence and mortality of ST-elevation myocardial infarction (STEMI) in emergency departments (EDs) is limited. OBJECTIVE: To study the trends of incidence and mortality of STEMI. METHODS: Using the National Emergency Department Sample database in the United States, we identified all ED encounters for patients presenting with STEMI using International Classification of Diseases codes. A linear p-trend was used to assess the trends. RESULTS: Out of the 973 million ED encounters represented, 641,762 (65/100,000; mean age 69 [59-81] years, 35.8% female) adult patients were recorded with STEMI. Among the major complications associated with STEMI, a total of 49,401 (7.7%) had cardiac complications, which included acute heart failure (n = 9361, 1.6%), ventricular tachycardia or fibrillation (n = 12,267, 1.91%), conduction block (n = 20,165, 3.1%), and cardiogenic shock (n = 7608, 1.2%). There were 5675 (0.9%) patients recorded with cerebrovascular events, which included acute ischemic stroke among 5205 (0.8%) patients and 470 (0.1%) with transient ischemic attack. Acute kidney injury was recorded for 10,082 (1.6%) patients. The trend for incidence of STEMI in the ED had decreased from 7.76/10,000 in 2011 to 4.07/10,000 in 2018 (linear p-trend 0.0006). However, the yearly mortality of STEMI related to ED encounters had remained relatively steady: 7.56% in 2011 to 7.50% in 2018 (linear p-trend 0.2364). CONCLUSION: Despite the fact that the number of patients presenting to the ED with STEMI has been decreasing, the mortality trends have remained steady. Further research of in-hospital STEMI may yield opportunities to reduce the risk of complications, improve patient outcomes and decrease health care burden.

ST-Elevation Myocardial Infarction Among Septic Shock and Coronary Interventions: A National Emergency Database Study.

OBJECTIVE: To study coronary interventions and mortality among patients with ST-elevated myocardial infarction (STEMI) who were admitted with septic shock. METHODS: Data from the national emergency department sample (NEDS) that constitutes 20% sample of hospital-owned emergency departments in the United States was analyzed for the septic shock related visits from 2016 to 2018. Septic shock was defined by the ICD codes. RESULTS: Out of 1 375 507 adult septic shock patients, 521 300 had a primary diagnosis of septic shock (mean age 67.41±15.67 years, 51.1% females) in the national emergency database for the years 2016 to 2018. Of these patients, 2768 (0.53%) had STEMI recorded during the hospitalization. Mortality rates for STEMI patients were higher than patients without STEMI (52.3% vs 23.5%). Mortality rates improved with PCI among STEMI patients (43.8% vs 56.2%). Coronary angiography was performed among 16% of patients of which percutaneous coronary intervention (PCI) rates were 7.7% among patients with STEMI septic shock. PCI numerically improved mortality, however, had no significant difference than patients without PCI on multivariate logistic regression and univariate logistic regression post coarsened exact matching of baseline characteristics among STEMI patients. Among the predictors, STEMI was a significant predictor of mortality in septic shock patients (OR 2.87, 95% CI 2.37-3.49; P<.001). Age, peripheral vascular disease, were predominant predictors of mortality in STEMI with septic shock subgroup (P <.001). Pneumonia was the predominant underlying infection among STEMI (36.4%) and without STEMI group (29.5%). CONCLUSION: STEMI complicating septic shock worsens mortality. PCI and coronary angiography numerically improved mortality, however, had no significant difference from patients without PCI. More research will be needed to improve mortality in such a critically ill subgroup of patients.

Predictors and outcomes of cardiac arrest in the emergency department and in-patient settings in the United States (2016-2018).

BACKGROUND: Outcomes of cardiac arrest (CA) remain dismal despite therapeutic advances. Literature is limited regarding outcomes of CA in emergency departments (ED). OBJECTIVE: To study the possible causes, predictors, and outcomes of CA in ED and in-patient settings throughout the United States (US). METHODS: Data from the US national emergency department sample (NEDS) was analyzed for the episodes of CA for 2016-2018. In-hospital CA was divided into in-patient (IPCA) and in the ED (EDCA). Only patients who had cardiopulmonary resuscitation (CPR) within the hospital were included in the study (out-of-hospital were excluded). RESULTS: A total of 1,068,847 CA (mean age 63.7 ± 19.4 years, 24%females), of whom 325,062 (30.4%) EDCA and 177,104 (16.6%) IPCA were included in the study. Patients without CPR, 743,785 (69.6%), were excluded. Survival was higher among IPCA 55,821 (31.6%) than the EDCA 32,516 (10%). IPCA encounters had multifactorial associated etiologies including respiratory failure (73%), acidosis (38.7%) sepsis (36.8%) and ST-elevated myocardial infarction (STEMI) (7.3%). Majority of ED arrests (67.1%) had no possible identifiable cause. The predominant known causes include intoxication (7.5%), trauma (6.4%), respiratory failure (5%), and STEMI (2.7%). Cardiovascular interventions had significant survival benefits in IPCA on univariate logistic regression after coarsened exact matching for comorbidities. IPCA had higher intervention rates than EDCA. For all live discharges, a total of 40% of patients were discharged to hospice. CONCLUSION: Survival remains dismal among CA patients especially those occurring in the ED. Given that there are considerable variations in the etiology between the two studied cohorts, more research is required to improve the understanding of these factors, which may improve survival outcomes.

Trends and complications associated with acute new-onset heart failure: a National Readmissions Database-based cohort study.

Literature regarding recent trends and outcomes of acute new-onset heart failure (AHF) with preserved ejection fraction (AHFpEF) and reduced ejection fraction (AHFrEF) is limited. The objective of this study is to study the outcomes of AHFpEF and AHFrEF in the USA. Data from the National Readmissions Database (NRD) sample that constitutes 49.1% of the stratified sample of all hospitals in the USA, representing more than 95% of the national population, were analyzed for hospitalization visits for acute heart failure. ICD-9 and ICD-10 codes were used to identify AHF. A total of 2,559,102 adult index AHF patients (mean age 70.79 ± 14.58 years, 49.4% females), 1,028,970 (40.2%) AHFpEF and 1,330,999 (52%) AHFrEF, were recorded in the National Readmissions Database for the years 2016-2018. A total of 152,465 (5.96%) acute heart failure, 47,271 (4.6%) AHFpEF and 91,973 (6.91%) AHFrEF, died during hospitalization, and 45,810 (1.9%) were readmitted in 30 days among alive discharges. Higher complication rates which included ventricular arrhythmias, acute coronary, and cerebrovascular events were observed among AHFrEF than AHFpEF. Higher proportion of patients with AHFrEF needed intensive care unit and ventilatory support during the hospitalization. The trend of incidence of AHFrEF, mortality among AHFrEF, and overall mortality worsened while AHFpEF improved over the study years 2012-2018 (p-trend < 0.05). Coronary procedures improved mortality rates among AHFpEF and AHFrEF. AHF is very common and is associated with significant mortality. The incidence of AHFrEF and mortality among AHFrEF had worsened, which calls for urgent intervention. Improved recognition of AHF is needed, and guideline-directed treatment of underlying risk factors including coronary artery disease can improve mortality. Graphic abstract of the analysis presented (created with BioRender.com).

Thrombotic superior vena cava syndrome: a national emergency department database study.

Literature regarding etiology and trends of incidence of major thoracic vein thrombosis in the United States is limited. To study the causes, complications, in-hospital mortality rate, and trend in the incidence of major thoracic vein thrombosis which could have led to superior vena cava syndrome (SVCS) between 2010 and 2018. Data from the nationwide emergency department sample (NEDS) that constitutes 20% sample of hospital-owned emergency departments (ED) and in-patient sample in the United States were analyzed using diagnostic codes. A linear p-trend was used to assess the trends. Of the total 1082 million ED visits, 37,807 (3.5/100,000) (mean age 53.81 ± 18.07 years, 55% females) patients were recorded with major thoracic vein thrombosis in the ED encounters. Among these patients, 4070 (10.6%) patients had one or more cancers associated with thrombosis. Pacemaker/defibrillator-related thrombosis was recorded in 2820 (7.5%) patients, while intravascular catheter-induced thrombosis was recorded in 1755 (4.55%) patients. Half of the patients had associated complication of pulmonary embolism. A total of 59 (0.15%) patients died during these hospital encounters. The yearly trend for the thrombosis for every 100,000 ED encounters in the United States increased from 2.17/100,000 in 2010 to 5.98/100,000 in 2018 (liner p-trend < 0.001). Yearly trend for catheter/lead associated thrombosis was also up-trending (p-trend 0.015). SVCS is an uncommon medical emergency related to malignancy and indwelling venous devices. The increasing trend in SVCS incidence, predominantly catheter/lead induced, and the high rate of associated pulmonary embolism should prompt physicians to remain vigilant for appropriate evaluation.

Predictors of Complications Secondary to Infective Endocarditis and Their Associated Outcomes: A Large Cohort Study from the National Emergency Database (2016-2018).

INTRODUCTION: Literature regarding outcomes and predictors of complications secondary to infective endocarditis (IE) is limited. We aimed to study the outcomes and predictors of complications of IE. METHODS: Data from a national emergency department sample, which constitutes 20% sample of hospital-owned emergency departments in the USA, were analyzed for hospital visits for IE. Complications of endocarditis were obtained by using ICD codes. Multivariable generalized linear method was used to evaluate predictors of in-hospital mortality and complications. RESULTS: Out of 255,838 adult IE patients (mean age 60.3 ± 20.1 years, 48.5% females), 97,803 (38.2%) patients developed one or more major complications. The major complications were cardiovascular system complications [57,900 (22.6%)], neurologic [42,851 (16.7%)] complications, and renal [16,236 (6.4%)] complications. These included cardiogenic shock [3873 (1.5%)], septic shock [25,798 (10.1%)], acute heart failure [35,602 (14%)], systemic thromboembolism (STE) [21,390 (8.36%)], heart block [11,430 (4.47%)], in-hospital dialysis [2880 (1.1%)], and disseminated intravascular coagulation (DIC) [2704 (1.1%)]. Patients with complicated IE had risk of mortality (adjusted RR 1.12, 95% CI 1.11-1.13, p < 0.001). The complications strongly associated with mortality were septic shock (RR 1.29, 95% CI 1.27-1.30, p < 0.001), cardiogenic shock (RR 1.24, 95% CI 1.20-1.29, p < 0.001), DIC (RR 1.4, 95% CI 1.35-1.46, p < 0.001), and STE (RR 1.07, 95% CI 1.05-1.08, p < 0.001). Staphylococci were the predominant causative organisms (30.8%) among the complicated IE subgroups with higher associated mortality (42.8%). The main predictors of complications from IE were congenital heart disease, history of congestive heart failure, high Elixhauser comorbidity profile, staphylococcal infection, and fungal infections. The prevalence of cardiogenic shock increased over the study years from 1.13 to 1.98% (p-trend 0.04). CONCLUSION: Complicated IE is not uncommon and is associated with significant mortality. Staphylococcal infections were associated with high mortality rates. There has been an increasing trend of cardiogenic shock among IE patients across the US. Further research is needed to improve the outcomes of complicated endocarditis.

Trends in Incidence, and Mortality of Acute Exacerbation of Chronic Obstructive Pulmonary Disease in the United States Emergency Department (2010-2018).

Literature regarding trends of incidence, mortality, and complications of acute exacerbation of chronic obstructive pulmonary disease (COPD) in the emergency departments (ED) is limited. What are trends of COPD exacerbation in ED? Data were obtained from the Nationwide Emergency Department Sample (NEDS) that constitutes a 20% sample of hospital-owned EDs and inpatient sample in the US. All ED encounters were included in the analysis. Complications of AECOPD were obtained by using ICD codes. Out of 1.082 billion ED encounters, 5,295,408 (mean age 63.31 ± 12.63 years, females 55%) presented with COPD exacerbation. Among these patients, 353,563(6.7%) had AECOPD-plus (features of pulmonary embolism, acute heart failure and/or pneumonia) while 4,941,845 (93.3%) had exacerbation without associated features or precipitating factors which we grouped as AECOPD. The AECOPD-plus group was associated with statistically significantly higher proportion of cardiovascular complications including AF (5.6% vs 3.5%; p < 0.001), VT/VF (0.14% vs 0.06%; p < 0.001), STEMI (0.22% vs 0.11%; p < 0.001) and NSTEMI (0.65% vs 0.2%; p < 0.001). The in-hospital mortality rates were greater in the AECOPD-plus population (0.7% vs 0.1%; p < 0.001). The incidence of both AECOPD and AECOPD-plus had worsened (p-trend 0.004 and 0.0003) and the trend of mortality had improved (p-trend 0.0055 and 0.003, respectively). The prevalence of smoking for among all COPD patients had increased (p-value 0.004), however, the prevalence trend of smoking among AECOPD groups was static over the years 2010-2018. There was an increasing trend of COPD exacerbation in conjunction with smoking; however, mortality trends improved significantly. Moreover, the rising burden of AECOPD would suggest improvement in diagnostics and policy making regarding management.

High-flow nasal cannula therapy in a predominantly African American population with COVID-19 associated acute respiratory failure.

IMPORTANCE: Use of non-invasive respiratory modalities in COVID-19 has the potential to reduce rates of intubation and mortality in severe disease however data regarding the use of high-flow nasal cannula (HFNC) in this population is limited. OBJECTIVE: To interrogate clinical and laboratory features of SARS-CoV-2 infection associated with high-flow failure. DESIGN: We conducted a retrospective cohort study to evaluate characteristics of high-flow therapy use early in the pandemic and interrogate factors associated with respiratory therapy failure. SETTING: Multisite single centre hospital system within the metropolitan Detroit region. PARTICIPANTS: Patients from within the Detroit Medical Center (n=104, 89% African American) who received HFNC therapy during a COVID-19 admission between March and May of 2020. PRIMARY OUTCOME: HFNC failure is defined as death or intubation while on therapy. RESULTS: Therapy failure occurred in 57% of the patient population, factors significantly associated with failure centred around markers of multiorgan failure including hepatic dysfunction/transaminitis (OR=6.1, 95% CI 1.9 to 19.4, p<0.01), kidney injury (OR=7.0, 95% CI 2.7 to 17.8, p<0.01) and coagulation dysfunction (OR=4.5, 95% CI 1.2 to 17.1, p=0.03). Conversely, comorbidities, admission characteristics, early oxygen requirements and evaluation just prior to HFNC therapy initiation were not significantly associated with success or failure of therapy. CONCLUSIONS: In a population disproportionately affected by COVID-19, we present key indicators of likely HFNC failure and highlight a patient population in which aggressive monitoring and intervention are warranted.

Dexmedetomidine Induced Polyuria in the Intensive Care Unit.

Dexmedetomidine is an α2-adrenergic used as an adjunct therapy for sedation in the intensive care unit. While it is known to cause polyuria exclusively in perioperative conditions, not many cases are known in the intensive care unit, thus making the diagnosis challenging. We present the case of a 61-year-old male who had developed polyuria secondary to central diabetes insipidus after receiving dexmedetomidine intravenous infusion in the medical ICU. Increased awareness of this uncommon side effect of dexmedetomidine will help clinicians recognize and address it early.

Sinus Bradycardia and QT Interval Prolongation in West Nile Virus Encephalitis: A Case Report.

Cardiac arrhythmias were reported in cases of West Nile Virus (WNV) encephalitis; however, the underlying pathophysiology remains incompletely understood. We present a 67-year-old male with altered mental status, later diagnosed with WNV encephalitis. Hospital course was complicated by progressive sinus bradycardia and corrected QT (QTc) prolongation. These findings persisted despite the absence of classical causes and resolved only after improvement of the underlying encephalitis. After excluding classical causes, autonomic dysfunction is one of the proposed mechanisms behind cardiac arrhythmias in WNV encephalitis. Resolution of arrhythmias is expected after the improvement of underlying encephalitis and should be taken into consideration before proceeding for pacemaker placement or other cardiac intervention. Furthermore, this case highlights the importance of continuous cardiac monitoring in WNV encephalitis patients.

Prevalence, Predictors, and Outcomes of Pulmonary Hypertension in CKD.

Pulmonary hypertension (PH) is associated with poor outcomes in the dialysis and general populations, but its effect in CKD is unclear. We evaluated the prevalence and predictors of PH measures and their associations with long-term clinical outcomes in patients with nondialysis-dependent CKD. Chronic Renal Insufficiency Cohort (CRIC) Study participants who had Doppler echocardiography performed were considered for inclusion. PH was defined as the presence of estimated pulmonary artery systolic pressure (PASP) >35 mmHg and/or tricuspid regurgitant velocity (TRV) >2.5 m/s. Associations between PH, PASP, and TRV and cardiovascular events, renal events, and all-cause mortality were examined using Cox proportional hazards models. Of 2959 eligible participants, 21% (n=625) had PH, with higher rates among those with lower levels of kidney function. In the multivariate model, older age, anemia, lower left ventricular ejection fraction, and presence of left ventricular hypertrophy were associated with greater odds of having PH. After adjusting for relevant confounding variables, PH was independently associated with higher risk for death (hazard ratio, 1.38; 95% confidence interval, 1.10 to 1.72) and cardiovascular events (hazard ratio, 1.23; 95% confidence interval, 1.00 to 1.52) but not renal events. Similarly, TRV and PASP were associated with death and cardiovascular events but not renal events. In this study of patients with CKD and preserved left ventricular systolic function, we report a high prevalence of PH. PH and higher TRV and PASP (echocardiographic measures of PH) are associated with adverse outcomes in CKD. Future studies may explain the mechanisms that underlie these findings.

Pulmonary Hypertension an Independent Risk Factor for Death in Intensive Care Unit: Correlation of Hemodynamic Factors with Mortality.

OBJECTIVE: Critically ill patients with pulmonary hypertension (PH) pose additional challenges due to the existence of right ventricular (RV) dysfunction. The purpose of this study was to assess the impact of hemodynamic factors on the outcome. METHODS: We reviewed the records of patients with a diagnosis of PH admitted to the intensive care unit. In addition to evaluating traditional hemodynamic parameters, we defined severe PH as right atrial pressure >20 mmHg, mean pulmonary artery pressure >55 mmHg, or cardiac index (CI) <2 L/min/m(2). We also defined the RV functional index (RFI) as pulmonary artery systolic pressure (PASP) adjusted for CI as PASP/CI; increasing values reflect RV dysfunction. RESULTS: Fifty-three patients (mean age 60 years, 72% women, 79% Blacks), were included in the study. Severe PH was present in 68% of patients who had higher Sequential Organ Failure Assessment (SOFA) score (6.8 ± 3.3 vs 3.8 ± 1.6; P = 0.001) and overall in-hospital mortality (36% vs 6%; P = 0.02) compared to nonsevere patients, although Acute Physiology and Chronic Health Evaluation (APACHE) II scores (19.9 ± 7.5 vs 18.5 ± 6.04; P = 0.52) were similar and sepsis was more frequent among nonsevere PH patients (31 vs 64%; P = 0.02). Severe PH (P = 0.04), lower mean arterial pressure (P = 0.04), and CI (P = 0.01); need for invasive ventilation (P = 0.02) and vasopressors (P = 0.03); and higher SOFA (P = 0.001), APACHE II (P = 0.03), pulmonary vascular resistance index (PVRI) (P = 0.01), and RFI (P = 0.004) were associated with increased mortality. In a multivariate model, SOFA [OR = 1.45, 95% confidence interval (C.I.) = 1.09-1.93; P = 0.01], PVRI (OR = 1.12, 95% C.I. = 1.02-1.24; P = 0.02), and increasing RFI (OR = 1.06, 95% C.I. = 1.01-1.11; P = 0.01) were independently associated with mortality. CONCLUSION: PH is an independent risk factor for mortality in critically ill patients. Composite factors rather than individual hemodynamic parameters are better predictors of outcome. Monitoring of RV function using composite hemodynamic factors resulting in specific interventions is likely to improve survival and needs to be studied further.