The Impact of Chronic Medical Conditions on Mortality in Acute Respiratory Distress Syndrome.

PURPOSE: To examine the impact of chronic comorbidities on mortality in Acute Respiratory Distress Syndrome (ARDS). MATERIALS AND METHODS: Retrospective cohort study of adults with ARDS (ICD-10-CM code J80) from the National Inpatient Sample between January, 2016 and December, 2018. For the primary outcome of mortality, we conducted weighted logistic regression adjusting for factors identified on univariate analysis as potentially significant or differing between the two groups at baseline. We used negative binomial regression adjusting for the same comorbidities to identify risk factors for longer length of stay (LOS) among ARDS survivors. RESULTS: After exclusions, 1046 records were analyzed (3355 ARDS survivors and 1875 non-survivors.) The comorbidities examined included hypertension, diabetes mellitus, obesity, hypothyroidism, alcohol and drug use, chronic kidney disease (CKD), cardiovascular disease, chronic liver disease, chronic pulmonary disease and malignancy. In multivariate analysis, we found that malignancy (OR 2.26, 95% CI 1.84-2.78, p < 0.001), cardiovascular disease (OR 1.54, 95% CI 1.23-1.92, p < 0.001), and CKD (OR 1.75, 95% CI 1.22-2.50, p = 0.002) increased the risk of death. In interaction analyses, cardiovascular disease combined with either malignancy or CKD conferred higher odds of death compared to either risk factor alone. CONCLUSIONS: The comorbidity of malignancy confers the most reliable risk of poor outcomes in ARDS with higher odds of hospital death and a simultaneous association with longer hospital LOS among survivors.

Differences in Utilization of Life Support and End-of-Life Care for Medical ICU Patients With Versus Without Cancer.

OBJECTIVES: To explore differences in the utilization of life support and end-of-life care between patients dying in the medical ICU with cancer compared with those without cancer. DESIGN: Retrospective review of 403 deaths or hospice transfers in the medical ICU from January 1, 2012, to June 30, 2013. SETTING: Urban tertiary care university hospital. PATIENTS: Consecutive medical ICU deaths or hospice transfers over an 18-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred eighty-two patients (45%) had a diagnosis of active cancer and 221 (55%) did not. Despite similar severity of illness, there were significant differences in the use of life support and end-of-life care. Patients without cancer had longer medical ICU length of stay (median, 5 vs 4 d; p = 0.0495), used mechanical ventilation more often and for longer (83.7% vs 70.9%, p = 0.002; 4 vs 3 d, p = 0.017), and initiated dialysis more frequently (26.7% vs 14.8%; p = 0.0038). Patients without active cancer had family meetings later (median, 3 vs 2 d; p = 0.001), less frequent palliative care consultation (17.6% vs 32.4%; p = 0.0006), and took longer to transition to do not resuscitate or comfort care (median, 4 vs 3 d; p = 0.048). CONCLUSIONS: Among patients dying in the medical ICU, the diagnosis of active cancer influences the intensity of life support utilization and the quality of end-of-life care. Patients with active cancer use less life support and may receive better end-of-life care than similar patients without cancer. These differences are likely due to biases or misunderstandings about the trajectory of advanced nonmalignant disease among patients, families, and perhaps providers.

Tuberculous Peritonitis.

Tuberculous peritonitis is rare in the United States but continues to be reported to occur in certain high-risk populations, which include patients with AIDS or cirrhosis, patients on continuous ambulatory peritoneal dialysis, recent immigrants from areas of high endemicity, and those who are immunosuppressed. The diagnosis of this disease requires a high clinical index of suspicion and should be considered in the differential of ascites with a lymphocyte predominance and serum-ascitic albumin gradient of <1.1 mg/dl. Microbiological or pathological confirmation remains the gold standard for diagnosis. Ascitic fluid cultures have low yield, but peritoneoscopy with biopsy or cultures frequently confirms the diagnosis. Newer techniques with future application include determination of adenosine deaminase and interferon gamma levels in ascitic fluid. Ultrasound and computed tomography are frequently used to guide fluid aspiration and biopsies. Six months of treatment with antituberculosis therapy is adequate except in cases of drug-resistant tuberculosis. The role of steroids remains controversial. Surgical approaches may be required to deal with complications including bowel perforation, intestinal obstruction from adhesions, fistula formation, or bleeding.

Chemo killed the small-talk gene.

Urvashi Vaid is a community organizer and writer active in the lesbian, gay, bisexual, and transgender (LGBT) and social justice movements for over three decades. She is currently Director of the Engaging Tradition Project at the Center for Gender and Sexuality Law at Columbia University Law School. She is founder of LPAC, the first lesbian political action committee, and sits on the Board of Directors of the Gill Foundation. Vaid's past positions include Executive Director of the Arcus Foundation, Deputy Director of Governance and Civil Society Unit for the Ford Foundation, Executive Director of the National Gay and Lesbian Task Force, and staff attorney for the ACLU National Prison Project. She is author of the books Irresistible Revolution: Confronting Race, Class and The Assumptions of Lesbian, Gay, Bisexual, and Transgender Politics, and Virtual Equality: The Mainstreaming of Gay & Lesbian Liberation, and co-editor of the book Creating Change: Public Policy, Sexuality and Civil Rights. Urvashi has had thyroid cancer and stage III breast cancer.

Thrombolytic therapy in a patient with suspected pulmonary embolism despite a negative computed tomography pulmonary angiogram.

We report a case of a 62-year-old male who presented to our intensive care unit with hypoxemia 6 hours after retinal surgery. He had a negative computed tomography (CT) pulmonary angiogram, but an emergency echocardiogram revealed the McConnell sign. He was thrombolysed and had rapid improvement in oxygenation and hemodynamics. Thrombolysis in hemodynamically unstable pulmonary embolism is not controversial, but most algorithms require confirmation of the diagnosis. Our patient had a negative CT pulmonary angiogram but was thrombolysed based on the clinical picture. Autopsy confirmed the diagnosis of multiple pulmonary emboli and unexpectedly discovered a patent foramen ovale that explained paradoxical embolism to the brain.