Polyserositis as a Unique Presentation of Isolated Myeloid Sarcoma: A Case Report.

BACKGROUND: Myeloid Sarcoma (MS) are tumors containing myeloid blasts occurring in a location other than the bone marrow, including lymph nodes, skin, and soft tissues. MS presenting as polyserositis however is very rare, with only a few cases in the literature. CASE REPORT: A 20-year-old male presented with cough, shortness of breath and was found to have left upper lobe consolidation, left pleural effusion, pericardial effusion, and a large anterior mediastinal mass. A transthoracic echocardiogram showed pericardial effusion with tamponade physiology. He underwent emergent pericardiocentesis and thoracentesis. The fluid studies showed flow cytometry findings consistent with MS/ acute myeloid leukemia (AML) phenotype. A bone marrow aspirate and biopsy were unremarkable and showed no immunophenotypic findings diagnostic of acute leukemia or a lymphoproliferative disorder. Cytogenetics was negative for AML abnormalities per FISH analysis. Videoassisted thoracoscopy surgery (VATS) with biopsy of the mediastinal mass, pericardium, and left upper lobe of the lung was consistent with MS. He was treated with induction cytarabine and idarubicin, and a follow up PET-CT scan showed complete remission. He is currently day 200 + post stem cell transplant with no evidence of disease recurrence. CONCLUSION: To the best of our knowledge, this is the first case of isolated myeloid sarcoma presenting as polyserositis, without prior leukemia/ bone marrow involvement. Hence, fluid studies should involve cytometry analysis and MS should be entertained as a differential for polyserositis, even without a history of prior leukemia. Timely diagnosis can expedite aggressive chemotherapy required for a potentially life-threatening disease.

Feasibility of Extracting Meaningful Patient Centered Outcomes From the Electronic Health Record Following Critical Illness in the Elderly.

Background: Meaningful patient centered outcomes of critical illness such as functional status, cognition and mental health are studied using validated measurement tools that may often be impractical outside the research setting. The Electronic health record (EHR) contains a plethora of information pertaining to these domains. We sought to determine how feasible and reliable it is to assess meaningful patient centered outcomes from the EHR. Methods: Two independent investigators reviewed EHR of a random sample of ICU patients looking at documented assessments of trajectory of functional status, cognition, and mental health. Cohen's kappa was used to measure agreement between 2 reviewers. Post ICU health in these domains 12 month after admission was compared to pre- ICU health in the 12 months prior to assess qualitatively whether a patient's condition was "better," "unchanged" or "worse." Days alive and out of hospital/health care facility was a secondary outcome. Results: Thirty six of the 41 randomly selected patients (88%) survived critical illness. EHR contained sufficient information to determine the difference in health status before and after critical illness in most survivors (86%). Decline in functional status (36%), cognition (11%), and mental health (11%) following ICU admission was observed compared to premorbid baseline. Agreement between reviewers was excellent (kappa ranging from 0.966 to 1). Eighteen patients (44%) remained home after discharge from hospital and rehabilitation during the 12- month follow up. Conclusion: We demonstrated the feasibility and reliability of assessing the trajectory of changes in functional status, cognition, and selected mental health outcomes from EHR of critically ill patients. If validated in a larger, representative sample, these outcomes could be used alongside survival in quality improvement studies and pragmatic clinical trials.

Incidence of Post-Heart Transplant Chronic Thyroiditis and Its Association With Pretransplant Amiodarone Use.

BACKGROUND: Chronic thyroiditis (CT) is a common cause of thyroid dysfunction and could therefore adversely affect outcomes in patients undergoing heart transplant (HT). The incidence of post-HT CT and whether amiodarone, a commonly used anti-arrhythmic drug in patients with heart failure during pre-HT period, is associated with the development of post-HT CT are unknown. METHODS: A retrospective review of HT recipients from February 2, 2010 to October 16, 2018 was performed. Patients who lacked relevant pre-/post-HT records, underwent thyroidectomy, had pre-HT thyroid dysfunction or thyroiditis within 15 days post-HT, and those on amiodarone during the post-HT period were excluded, yielding a final cohort of 75 patients. RESULTS: Patients had a mean age of 63.3 ± 1.4 years and were predominantly male (90.7%) and white (80%). The incidence of post-HT CT was 32% with the majority (83.3%) manifesting as hypothyroidism. Median time to diagnosis of CT after transplant was 10.2 months (interquartile range, 4-27.4). Additionally, the CT group had higher pre-HT use of amiodarone (non-CT vs CT: 21.6% vs 50%, P = .01), higher prevalence of atrial fibrillation (non-CT vs CT: 23.5% vs 45.8%; P = .05), and more stage IV/V chronic kidney disease (non-CT vs CT: 2% vs 16.7%, P = .02). On multivariate analysis, pre-HT amiodarone use was associated with the development of post-HT CT after adjustment for age, sex, and chronic kidney disease (odds ratio, 3.65; 95% CI, 1.17-11.44; P = .03). CONCLUSION: The incidence of post-HT CT is high and is strongly associated with pre-HT amiodarone use underpinning the importance of closely following the post-HT thyroid profile in these patients.

Characteristics and Outcomes of COVID-19 Patients Admitted to Intensive Care Units in a Large Health System in Western Pennsylvania.

Importance Despite growing literature, there is still limited understanding of factors that can predict outcomes in coronavirus disease 2019 (COVID-19) patients who require intensive care. Objective To evaluate the characteristics of COVID-19 patients admitted to the intensive care unit (ICU) and identify their associations with outcomes. Background There are limited data on the outcomes in COVID-19 patients in Pennsylvania. Design Retrospective study Setting Intensive care units in an academic health system in Western Pennsylvania. Participants Patients with reverse transcriptase-polymerase chain reaction (RT-PCR)-confirmed COVID-19 admitted to ICUs as direct admission or transfers from regular floors between March 1, 2020, and April 30, 2020. Main outcome(s) and measure(s) The primary outcome was inpatient mortality. Secondary outcomes included complications during ICU stay, hospital length of stay, discharge disposition, and the need for oxygen at discharge. Categorical variables are described as frequencies and continuous variables as median with interquartile range (IQR). Regression modeling was used to identify the predictors of inpatient mortality in these patients. P-value <0.05 was considered statistically significant. Analysis was performed using Stata version 15.1 (StataCorp, College Station, Texas). Results The cohort included 58 consecutive patients, with a median age of 62 years (IQR 54-73), 63.8% of which were male. On presentation, constitutional symptoms were the most common (91.4%), followed by lower respiratory tract symptoms (87.9%). Tachypnea (65.5%) and hypoxia (67.2%) were the most common abnormal vital signs at presentation. Common comorbidities were cardiovascular disease (74.1%), obesity (53.5%), and diabetes (39.7%). The median Acute Physiology and Chronic Health Evaluation (APACHE) score on admission to ICU was 11 (IQR 8.5-17.5). The major complications included acute respiratory distress syndrome (ARDS) 50.0%, shock 41.4%, and acute kidney injury 41.4%. The proportion of patients who underwent mechanical ventilation, required vasopressors, or were on renal replacement therapy were 58.6%, 41.4%, and 10.3%, respectively. Overall mortality was 32.8%. Age, Charlson-comorbidity index, tachypnea, lymphopenia at presentation, high APACHE score, shock, ARDS, mechanical ventilation, and steroid use were significantly associated with mortality. Of the patients who survived their ICU stay, 63.2% were discharged home and 44.7% had a new oxygen requirement at discharge. Conclusion and relevance Our study reports high mortality in COVID-19 patients requiring ICU care in Western Pennsylvania. Identifying factors associated with poor prognosis could help risk-stratify these patients. Prospective studies are needed to assess whether early risk stratification and triaging result in improved outcomes.

Reducing Broad-Spectrum Antimicrobial Use in Extracorporeal Membrane Oxygenation: Reduce AMMO Study.

BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. There are currently no guidelines for antimicrobial prophylaxis. We analyzed 7 years of prophylactic antimicrobial use across 3 time series for patients on ECMO at our institution in the development, improvement, and streamlining of our ECMO antimicrobial prophylaxis protocol. METHODS: In this quasi-experimental interrupted time series analysis, we evaluated the impact of an initial ECMO antimicrobial prophylaxis protocol, implemented in 2014, on antimicrobial use and National Healthcare Safety Network-reportable infection rates. Then, following a revision and streamlining of the protocol in November 2018, we reevaluated the same metrics. RESULTS: Our study population included 338 intensive care unit patients who received ECMO between July 2011 and November 2019. After implementation of the first version of the protocol, we did not observe significant changes in antimicrobial use or infection rates in these patients; however, following revision and streamlining of the protocol, we demonstrated a significant reduction in broad-spectrum antimicrobial use for prophylaxis in patients on ECMO without any evidence of a compensatory increase in infection rates. CONCLUSIONS: Our final protocol significantly reduces broad-spectrum antimicrobial use for prophylaxis in patients on ECMO. We propose a standard antimicrobial prophylaxis regimen for patients on ECMO based on current evidence and our experience.Summary: There are no guidelines for antimicrobial prophylaxis in patients on extracorporeal membrane oxygenation (ECMO). A rational approach employing concepts of antimicrobial stewardship can drive logical antimicrobial selection for prophylaxis in patients on ECMO without adversely impacting outcomes.

Critical care practice in India: Results of the intensive care unit need assessment survey (ININ2018).

BACKGROUND: A diverse country like India may have variable intensive care units (ICUs) practices at state and city levels. AIM: To gain insight into clinical services and processes of care in ICUs in India, this would help plan for potential educational and quality improvement interventions. METHODS: The Indian ICU needs assessment research group of diverse-skilled individuals was formed. A pan- India survey "Indian National ICU Needs" assessment (ININ 2018-I) was designed on google forms and deployed from July 23rd-August 25th, 2018. The survey was sent to select distribution lists of ICU providers from all 29 states and 7 union territories (UTs). In addition to emails and phone calls, social medial applications-WhatsApp™, Facebook™ and LinkedIn™ were used to remind and motivate providers. By completing and submitting the survey, providers gave their consent for research purposes. This study was deemed eligible for category-2 Institutional Review Board exempt status. RESULTS: There were total 134 adult/adult-pediatrics ICU responses from 24 (83% out of 29) states, and two (28% out of 7) UTs in 61 cities. They had median (IQR) 16 (10-25) beds and most, were mixed medical-surgical, 111(83%), with 108(81%) being adult-only ICUs. Representative responders were young, median (IQR), 38 (32-44) years age and majority, n = 108 (81%) were males. The consultants were, n = 101 (75%). A total of 77 (57%) reported to have 24 h in-house intensivist. A total of 68 (51%) ICUs reported to have either 2:1 or 2≥:1 patient:nurse ratio. More than 80% of the ICUs were open, and mixed type. Protocols followed regularly by the ICUs included sepsis care, ventilator- associated pneumonia (83% each); nutrition (82%), deep vein thrombosis prophylaxis (87%), stress ulcer prophylaxis (88%) and glycemic control (92%). Digital infrastructure was found to be poor, with only 46 % of the ICUs reporting high-speed internet availability. CONCLUSION: In this large, national, semi-structured, need-assessment survey, the need for improved manpower including; in-house intensivists, and decreasing patient-to-nurse ratios was evident. Sepsis was the most common diagnosis and quality and research initiatives to decrease sepsis mortality and ICU length of stay could be prioritized. Additionally, subsequent surveys can focus on digital infrastructure for standardized care and efficient resource utilization and enhancing compliance with existing protocols.