Time dependency and unique etiology of barotrauma in COVID-19: A retrospective cohort study with landmark analysis and pathological approach.

BACKGROUND: Barotrauma frequently occurs in coronavirus disease 2019. Previous studies have reported barotrauma to be a mortality-risk factor; however, its time-dependent nature and pathophysiology are not elucidated. To investigate the time-dependent characteristics and the etiology of coronavirus disease 2019-related-barotrauma. METHODS AND FINDINGS: We retrospectively reviewed intubated patients with coronavirus disease 2019 from March 2020 to May 2021. We compared the 90-day survival between the barotrauma and non-barotrauma groups and performed landmark analyses on days 7, 14, 21, and 28. Barotrauma within seven days before the landmark was defined as the exposure. Additionally, we evaluated surgically treated cases of coronavirus disease 2019-related pneumothorax. We included 192 patients. Barotrauma developed in 44 patients (22.9%). The barotrauma group's 90-day survival rate was significantly worse (47.7% vs. 82.4%, p < 0.001). In the 7-day landmark analysis, there was no significant difference (75.0% vs. 75.7%, p = 0.79). Contrastingly, in the 14-, 21-, and 28-day landmark analyses, the barotrauma group's survival rates were significantly worse (14-day: 41.7% vs. 69.1%, p = 0.044; 21-day: 16.7% vs. 62.5%, p = 0.014; 28-day: 20.0% vs. 66.7%, p = 0.018). Pathological examination revealed a subpleural hematoma and pulmonary cyst with heterogenous lung inflammation. CONCLUSIONS: Barotrauma was a poor prognostic factor for coronavirus disease 2019, especially in the late phase. Heterogenous inflammation may be a key finding in its mechanism. Barotrauma is a potentially important sign of lung destruction.

Association between ICU admission during off-hours and in-hospital mortality: a multicenter registry in Japan.

BACKGROUND: The effect of ICU admission time on patient outcomes has been shown to be controversial in several studies from a number of countries. The imbalance between ICU staffing and medical resources during off-hours possibly influences the outcome for critically ill or injured patients. Here, we aimed to evaluate the association between ICU admission during off-hours and in-hospital mortality in Japan. METHODS: This study was an observational study using a multicenter registry (Japanese Intensive care PAtient Database). From the registry, we enrolled adult patients admitted to ICUs from April 2015 to March 2019. Patients with elective surgery, readmission to ICUs, or ICU admissions only for medical procedures were excluded. We compared in-hospital mortalities between ICU patients admitted during off-hours and office-hours, using a multilevel logistic regression model which allows for the random effect of each hospital. RESULTS: A total of 28,200 patients were enrolled with a median age of 71 years (interquartile range [IQR], 59 to 80). The median APACHE II score was 18 (IQR, 13 to 24) with no significant difference between patients admitted during off-hours and those admitted during office-hours. The in-hospital mortality was 3399/20,403 (16.7%) when admitted during off-hours and 1604/7797 (20.6%) when admitted during office-hours. Thus, off-hours ICU admission was associated with lower in-hospital mortality (adjusted odds ratio 0.91, [95% confidence interval, 0.84-0.99]). CONCLUSIONS: ICU admissions during off-hours were associated with lower in-hospital mortality in Japan. These results were against our expectations and raised some concerns for a possible imbalance between ICU staffing and workload during office-hours. Further studies with a sufficient dataset required for comparing with other countries are warranted in the future.

Longer term hemodialysis-dependent chronic renal failure increases the risk of post-cardiac surgery vasoplegic syndrome.

PURPOSE: We evaluated whether longer term hemodialysis (HD) is associated with a higher incidence of vasoplegic syndrome (VS) after cardiac surgery. METHODS: This retrospective, single-center cohort study included 562 consecutive patients who underwent cardiac surgery in a tertiary hospital from January 2015 to December 2016. We assessed VS occurrence and its relationship with HD duration and other risk factors. To assess the effect of the HD duration on VS occurrence, we constructed ordinal variables: HD = 0 (non-HD), 0 < HD ≤ 5 (HD ≤ 5 years), 5 < HD ≤ 10, and 10 < HD. RESULTS: The overall mean (± standard deviation) age of patients was (73 ± 11) years, and there were 60.9% men. Forty-one patients (7.3%) were HD dependent. Cardiac surgeries included all coronary artery bypass graft procedures, all valvular procedures, and aortic surgery involving cardiopulmonary bypass (CPB). Sixty-six patients (10%) developed VS. Most preoperative patient characteristics were comparable between the VS and no-VS groups; a chronic HD status and a total CPB time of > 180 min were significantly more common in the VS group (P < 0.0001 and P = 0.02, respectively). Longer term HD significantly correlated with VS incidence (P < 0.0001). Ordinal variables for the HD duration and age and known risk factors for VS (preoperative use of angiotensin-converting enzyme inhibitors and beta-blockers, low left-ventricular ejection fraction, and CPB time > 180 min) were subjected to multivariate regression analysis. Long-term HD was identified as an independent predictor of VS (odds ratio, 2.29, 95% confidence interval, 1.66-3.18). CONCLUSIONS: Longer term HD may be associated with a higher VS incidence after cardiac surgery. VS should be given attention after cardiac surgery in chronic HD-dependent patients.

Pneumatosis cystoides intestinalis associated with toxic epidermal necrolysis: A case report.

Toxic epidermal necrolysis (TEN) is a severe adverse drug reaction, which is characterized by erythema, blisters, and/or erosions of the mucous membranes and skin, but intestinal involvement is rare. In contrast, pneumatosis cystoides intestinalis (PCI) is a rare condition associated with a wide variety of underlying diseases, but to date no patient has presented with PCI associated with TEN. A 55-year-old man was admitted to intensive care unit for treatment of TEN caused by phenobarbital. On day 8 after admission, he presented with progressive abdominal distention and hypotension. Computed tomography (CT) showed gas in the superior mesenteric vein and air filled cysts in the walls of the small intestine. He was suspected of having septic shock due to PCI. As there were no indications of bowel ischemia or necrosis, the patient was managed conservatively with antibiotics and oxygen therapy. On day 10 after admission, he was weaned off catecholamines, with CT on day 11 showing complete resolution of gas in the superior mesenteric vein and air filled cysts. To our knowledge, this article describes the first patient presenting with PCI associated with TEN.

Fulminant hepatitis following crizotinib administration for ALK-positive non-small-cell lung carcinoma.

We herein report a case of fatal fulminant hepatitis secondary to crizotinib administration. The patient was 54-year-old female with a history of Hepatitis C infection (not current), dermatomyositis and steroid-induced diabetes mellitus. She was diagnosed with advanced lung adenocarcinoma with anaplastic lymphoma kinase rearrangement. We began 400 mg of crizotinib as first-line therapy. No adverse effects were seen until Day 16. On Day 29, she was admitted to hospital with elevated liver enzymes (aspartate aminotransferase 3236 IU/l, alanine aminotransferase 5201 IU/l) and coagulopathy (prothrombin time <10%), and was diagnosed with crizotinib-induced fulminant hepatitis. We started intensive care, using plasma exchange, continuous hemodiafiltration and high-dose steroid therapy. Unfortunately, she did not respond to therapies, and died on Day 36. The mechanism and risk factors of crizotinib-induced hepatotoxicity are uncertain. Physicians should be aware of possible adverse effects of crizotinib. A systemic survey is imperative to identify possible risk factors of crizotinib-related hepatotoxicity.

[Investigation of the outcomes and complications in right thoracotomy approach for mitral valve reoperation].

BACKGROUND: Right thoracotomy is an alternative surgical technique for mitral valve reoperation. The purpose of this study is to determine whether right thoracotomy for mitral valve reoperation affects its perioperative outcomes and complications. METHODS: We investigated the perioperative events in consecutive mitral valve reoperations between January 2006 and November 2009. Demographic, intraoperative and postoperative data were collected and analyzed retrospectively. RESULTS: Five right thoracotomy cases and 22 repeated sternotomy cases were included. Thoracotomy group needed more platelet transfusion (median, 20 units in thoracotomy; 10 units in sternotomy; P=0.047). We had a higher frequency of adrenaline administration (60% in thoracotomy; 4.6% in sternotomy; P=0.005) and needed more doses of dobutamine in thoracotomy group (median, 16.0 microg x kg(-1) x min(-1) in thoracotomy ; 7.5 microg x kg(-1) x min(-1) in sternotomy; P=0.037) to wean them from cardiopulmonary bypass. Right thoracotomy did not reduce cardiopulmonary bypass time (median, 265 min in thoracotomy ; 199 min in sternotomy; P=0.126). We experienced two serious complications requiring reoperation in thoracotomy group, but diagnosed them with intraoperative transesophageal echocardiography. CONCLUSIONS: When we choose right thoracotomy for mitral valve reoperation, we should prepare more blood products and inotropic agents and should evaluate cardiac function by using intraoperative transesophageal echocardiography.

[Remifentanil prevents hyperglycemia and reduces insulin use during cardiopulmonary bypass in adult cardiac surgery].

BACKGROUND: Remifentanil may be beneficial in patients undergoing cardiac surgery, by attenuating the neurohumoral stress response to surgical stimulation and inflammation evoked by cardiopulmonary bypass (CPB). METHODS: We retrospectively examined blood glucose monitored every 30 minutes during CPB and insulin dose in patients during CPB under remifentanil anesthesia (remifentanil group) and those under low dose fentanyl anesthesia (fentanyl group) in adult cardiac surgery. Furthermore we also investigated incidence of atrial fibrillation within 72 hours after surgery in both groups. RESULTS: There were 35 patients in remifentanil group and 22 patients in fentanyl group. Although blood glucose at the beginning and the end of CPB in both groups were not different, remifentanil group showed lower maximum blood glucose (median 172 mg x dl(-1), interquatile range 156-205 mg x dl(-1)) during CPB than in fentanyl group (197 mg x dl(-1), 176-219 mg x dl(-1); P = 0.009). Significantly less insulin was administered during CPB in remifentanil group than in fentanyl group. Incidence of postoperative atrial fibrillation was similar between the groups. CONCLUSIONS: Maximum blood glucose was lower and less insulin was administered during CPB in remifentanil group. These data may suggest that remifentanil reduce stress response to surgical stimulation in cardiac surgery.

[A case of lung cancer combined with pregnancy; dramatically deteriorating condition after caesarian section].

A 34-year-old pregnant woman was diagnosed with pneumonia at another hospital in her 26th week of pregnancy. Antibiotics were administered, but they were not effective. She was then introduced and admitted to our hospital. Lung cancer was suspected from her chest-CT scan on admission. Caesarian section was performed on the day after admission at 33 weeks of gestation. Adenocarcinoma of the lung was diagnosed based on the results of a right-axillary lymph node biopsy performed simultaneously with the caesarian section. On the 8th day after admission, we began to administer gefitinib. We expected positive results from gefitinib, because the patient fitted the optimal profile: female, never smoker, adenocarcinoma histology. Her respiratory condition had worsened dramatically after her caesarian section, so she was given noninvasive positive pressure ventilation from the 13th day after admission. Disseminated intravascular coagulation progressed, and her chest X-ray showed bilateral extensive infiltration. Moreover, tests showed that her tumor was negative for epidermal growth factor recepter mutation, so we judged that gefitinib was not effective for her. Although her performance status was very poor, she and her family strongly desired further chemotherapy. We thus began to administer gemcitabine, but her respiratory condition deteriorated further, and she died on the 17th day after admission. Lung cancer combined with pregnancy is a very rare situation, so we report this case with some references.

[An autopsy case of racemose hemangioma of bronchial arteries associated with neovascularization from the chest wall after ligation and frequent embolizations].

We report an autopsied 33 year old pregnant woman with racemose hemangioma of the bronchial arteries. She was first given a diagnosis of racemose hemangioma of the bronchial arteries at age 19 and underwent surgical ligation. Nevertheless, she had to be admitted to the hospital for bronchial artery embolizations every time hemoptysis recurred. In her 21st gestational week, she was admitted to our hospital because of her 9th recurrent massive hemoptysis and dyspnea. Bronchial artery embolizations were repeatedly performed under intubation to ventilate the healthy left lung separately. We succeeded in temporarily stopping the hemoptysis, but her case was complicated by bacterial pneumonia and septic shock. Her baby was born dead on day 11 and she died on day 12. The autopsy revealed abnormal convoluted and dilated arteries branching from the right intercostal and subclavian arteries and intruding into the lung parenchyma through adhesion caused by her previous thoracostomy. The connections of these abnormal arteries with pulmonary arteries and veins, which had been shown by angiography, were confirmed by autopsy. The autopsy findings suggest that temporal surgical procedures with thoracostomy in this condition can induce abnormal neovascularization via pleural adhesion.

Systemic lupus erythematosus complicated by cytomegalovirus-induced hemophagocytic syndrome and pneumonia.

A 58-year-old female with systemic lupus erythematosus (SLE) and anti-phospholipid syndrome (APS) was referred and admitted to our hospital because of fever and pancytopenia. She had been taking small dose of prednisolone and azathiprine since 2003 with stable SLE and APS. Two weeks before the admission, she developed fever and common cold-like symptoms and was admitted to a hospital. Antibiotics were ineffective and thrombocytopenia manifested. Under a diagnosis of progressive SLE, bolus methylprednisolone was administrated. However, she became pancytopenic and was transferred to our hospital. A bone marrow aspirate showed the hemophagocytosis and chest CT scanning revealed interstitial pneumonia. Cytomegalovirus (CMV) antigenemia test gave a positive result. A diagnosis of CMV-induced hemophagocytic syndrome (HPS) and CMV pneumonia was made. Gancyclovir resolved the pancytopenia, pneumonia, and fever. There have been only 3 reported cases of CMV-related HPS in collagen disease.