COVID-19 presenting as stroke.

OBJECTIVE: Acute stroke remains a medical emergency even during the COVID-19 pandemic. Most patients with COVID-19 infection present with constitutional and respiratory symptoms; while others present with atypical gastrointestinal, cardiovascular, or neurological manifestations. Here we present a series of four patients with COVID-19 that presented with acute stroke. METHODS: We searched the hospital databases for patients that presented with acute stroke and concomitant features of suspected COVID-19 infection. All patients who had radiographic evidence of stroke and PCR-confirmed COVID-19 infection were included in the study. Patients admitted to the hospital with PCR- confirmed COVID-19 disease whose hospital course was complicated with acute stroke while inpatient were excluded from the study. Retrospective patient data were obtained from electronic medical records. Informed consent was obtained. RESULTS: We identified four patients who presented with radiographic confirmation of acute stroke and PCR-confirmed SARS-CoV-2 infection. We elucidate the clinical characteristics, imaging findings, and the clinical course. CONCLUSIONS: Timely assessment and hyperacute treatment is the key to minimize mortality and morbidity of patients with acute stroke. Stroke teams should be wary of the fact that COVID-19 patients can present with cerebrovascular accidents and should dawn appropriate personal protective equipment in every suspected patient. Further studies are urgently needed to improve current understandings of neurological pathology in the setting of COVID-19 infection.

Spectrum of neuropsychiatric manifestations in COVID-19.

Corona Virus Disease 2019 (COVID-19) emerged in December 2019 from Wuhan, China. It typically presents with mild upper respiratory tract infection symptoms and may have life threatening complications, including acute respiratory distress syndrome, acute stroke, myocardial infarction, kidney failure, shock, and even death. Coronavirus infections are known to have neuroinvasive potential with consequent neuropsychiatric manifestations. We analyzed COVID-19 adult patients in the TriNetX database, which is a global health collaborative clinical research platform collecting real-time electronic medical records data from a network of health care organizations (HCOs) from January 20, 2020 to June 10th, 2020. 40,469 patients were diagnosed with COVID-19 among whom 9086 (22.5%) patients had neuropsychiatric manifestations. The most common neurologic manifestations included headache (3.7%) and sleep disorders (3.4%), Encephalopathy (2.3%), Stroke and transient ischemic attack (TIA) (1.0%) and 0.6% had seizures. Most common psychiatric manifestations included anxiety and other related disorders (4.6%), mood disorders (3.8%), while 0.2% patients had suicidal ideation. Early recognition and prompt management of neuropsychiatric manifestations in these patients have a potential to decrease overall morbidity and mortality.

Industry payments to hospitalist physicians: a 5-year analysis of the Open Payments programme from 2014 to 2018.

We analysed Open Payments programme data (https://openpaymentsdata.cms.gov) on industry-to-physician payments to hospitalists for the years 2014 to 2018. Payments to hospitalists increased by 106.5% from 2014 to 2018 with food and beverage (38.5%) and compensation for services other than consulting (24.3%) being the highest-paid categories. Industry payment to hospitalists was highly skewed with top 10 hospitalists receiving more than 30% of the total payments during the study period. The most common drugs associated with payments were anticoagulant medications (apixaban and rivaroxaban). Industry seems to be spending a significant amount of money to increase awareness of medications among hospitalists. Identification of these trends and potential motives of industry spending is critical to address any potential physician bias.

Seizure and COVID-19: Association and review of potential mechanism.

Since the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Wuhan, China, this highly transmissible virus has since spread rapidly around the world. Though respiratory complication is the primarily reported manifestation though rare, yet serious neurological complications are being frequently reported in the literature. In selected coronavirus disease-2019 (COVID-19) cases neurologic complications may manifest as seizures. In this paper, we have reviewed current literature on seizures linked with SARS- COV 2 infection including published or pre-print original articles, review articles, and case reports. We have discussed the electroencephalogram (EEG), imaging, and Cerebrospinal fluid (CSF) findings in patients with COVID-19 presenting with seizure. We will be concluding the paper by briefly discussing the three mechanisms by which seizures can develop in patients infected with SARS- COV 2 - (a) Direct Mechanism (b) Indirect Mechanism and (c) Exacerbation of Seizure in Patients with Epilepsy (PWE). Our aim is to update the physicians working with COVID-19 patients about this potential complication and hope that understanding of these proposed mechanisms can provide an opportunity for the physicians for early diagnosis or even better, help prevent this complication.

Cystic bronchiectasis in sarcoidosis.

Pulmonary sarcoidosis can manifest in different radiologic patterns. Typical manifestations in high-resolution computed tomography are bilateral perihilar lymphadenopathy, micronodules, and fibrotic changes. Atypical manifestations are mass-like or alveolar opacities, honeycomb-like cysts, miliary opacities, tracheobronchial involvement, and pleural disease. Cystic bronchiectasis in pulmonary sarcoidosis is rare, with only a few reported cases in the literature. We present another case of cystic bronchiectasis with a honeycomb-like pattern in pulmonary sarcoidosis and with cardiac involvement. This case was presented as an abstract poster at the American Thoracic Society conference in 2022.

Indwelling Pleural Catheter (IPC) for the Management of Hepatic Hydrothorax: The Known and the Unknown.

BACKGROUND: Hepatic hydrothorax (HH) is described as pleural effusion secondary to liver cirrhosis after ruling out other etiologies. We aim to assess the efficacy of an indwelling pleural catheter (IPC) placement in refractory HH in this systematic review and meta-analysis. METHODS: A comprehensive search of literature was performed from inception to December 2020. The authors reviewed, selected, and abstracted the data from eligible studies into Covidence, a systematic review software. Cochrane criteria was used to rate each study for the risk of bias. The data abstracted were described using a random-effects model. Heterogeneity was evaluated using the I2 test. RESULTS: Ten studies involving a total of 269 patients were included. The studies were analyzed for the proportion of pleurodesis achieved, the average time to pleurodesis, total complication rate, pleural infection rate, and mortality. A proportion of 47% of the total subjects included achieved spontaneous pleurodesis in an average duration of 104.3 days. The frequency of total complication rate was noted to be 30.36%. The incidence of pleural cavity infection was described to be 12.4% and death resulting from complications of IPC was 3.35%. CONCLUSION: The current management options for the refractory pleural effusion in HH include repeated thoracenteses, transjugular intrahepatic portosystemic shunt, surgical repair of defects in the diaphragm, and liver transplantation. However, the cost, eligibility, and availability can be some of the major concerns with these treatment modalities. With this meta-analysis, we conclude that IPCs can provide an alternative therapeutic option for spontaneous pleurodesis.

A case of hemothorax secondary to intrapleural fibrinolytic therapy: Considerations for use of fibrinolytics in high-risk patients.

Indwelling Pleural Catheters (IPC) are increasingly being used for management of recurrent pleural effusions (RPEs). Use of IPC for management of both malignant and non-malignant recurrent pleural effusions has been associated with complications such as dysfunctional or nonfunctioning IPCs. Alteplase, a tissue plasminogen activator (tPA) is often used to restore flow of non-draining IPC in symptomatic patients. We present a case of a sixty-eight-year old patient with life-threatening pleural hemorrhage following intrapleural catheter instillation of tPA that was managed successfully by thoracotomy. Our case describe the importance of individualizing the fibrinolytic dose, frequency and the indwelling time in high risk patients. We have reviewed the current literature and recommendations for use of fibrinolytic therapy for IPC in high risk patients on anticoagulation.

Esophageal Food Impaction: A Retrospective Chart Review.

BACKGROUND: Esophageal food impaction (EFI) is the third most common non-biliary emergency in gastroenterology, with an annual incidence rate of 13 episodes per 100,000 person-years and 1,500 deaths per year. Patients presenting with food impaction often have underlying esophageal pathology. We evaluated the possible risk factors for EFI in our study. METHODS: We performed a retrospective chart review of 455 patients at Staten Island University Hospital (SIUH) that presented with symptoms of food impaction from 1999 to 2017. We analyzed relevant clinical data such as age, risk factors, type of food bolus, location, administration of glucagon, endoscopic technique and complications. RESULTS: Overall, 174 patients had endoscopically confirmed EFI. The majority were males 102/174 (58.6%). Esophageal pathological findings included esophagitis in 58/174 (33.3%), strictures in 43/174 (24.7%), hiatal hernias in 29/174 (16.6%) and Schatzki's rings in 15/174 (8.6%). Thirty-two out of 174 (18.3%) had normal endoscopic findings. Diabetes mellitus (DM) was reported in 20/174 (11.4%) patients. The type of food impacted was mostly meat in 73/174 (41.9%) cases. The location of EFI was mainly in the lower one-third of the esophagus in 94/174 (54%). The endoscopic push technique was used in 95/174 (54.5%) patients and the pull technique in 83/174 (47.7%) cases. The endoscopic therapeutic intervention was successful as a first attempt in 165/175 (94.8%) patients. Complications were reported in only 5/174 (2.8%), and these mostly comprised of perforations and tears. Glucagon was given to 74/174 (42.5%) patients. The median door-to-scope time (time of presentation at the emergency department to endoscopic intervention) was 7 h (range 1.5 - 24 h) in patients who had received glucagon as opposed to 7 h (range 1 - 24 h) in patients who did not receive it. CONCLUSION: EFI is more common in males. Esophageal strictures and hiatal hernias were the most common pathologies found in endoscopy. Esophagitis was evident in 33.3% of patients, but if it was the cause or consequence of EFI is not clearly understood. DM was associated with food impaction in only 11.4% of patients, but more studies are needed to determine if DM has a stronger association with EFI. The door-to-scope time was shorter in patients who had received glucagon. Endoscopy is a safe and effective therapeutic intervention for EFI, and complications reported were minimal.