Direct Peritoneal Resuscitation (DPR) Improves Acute Physiology and Chronic Health Evaluation (APACHE) IV and Acute Physiology Score When Used in Damage Control Laparotomies: Prospective Cohort Study on 37 Patients.

INTRODUCTION: Using direct peritoneal resuscitation (DPR) as an adjunct when managing patients undergoing damage control laparotomy (DCL) shows promising results. We report our initial experience in utilizing DPR when managing patients who underwent DCL for emergent surgery at the index operation. MATERIALS AND METHODS: We prospectively collected data on 37 patients between August 2020 to October 2021 who underwent DCL with open abdomens after the index operation and utilized DPR. DPR was performed using peritoneal lavage with DIANEAL PD-2-D 2.5% Ca 3.5 mEq/L at a rate of 400ml/hour. Patients' physiological scores and clinical outcomes were evaluated. RESULTS: 86% required DCL and DPR due to septic abdomen/bowel ischemia. The median (interquartile range [IQR]) age was 62 years (53-70); 62% were male, and median (IQR) body mass index was 30.0kg/m2 (25.5-38.4). On DPR initiation, median (IQR) APACHE-IV score was 48 (33-64) and median (IQR) Acute Physiology Score (APS) was 31 (18-54). After initiation, median (IQR) APACHE-IV score and median (IQR) APS were 39 (21-62) and 19 (11-56), respectively, and both showed significant improvement in survivors (p<0.05). Median (IQR) DPR duration was four days (2-8) and primary abdominal closure was achieved in 30 patients (81%). There were eight mortalities (21.6%) within 30 days postoperatively, of which seven were within 3-24 days due to uncontrolled sepsis/multiple organ failure. The most frequent complication was surgical-site infection recorded in 12 patients (32%). Twenty-four patients (67%) were discharged home/transferred to a rehab center/nursing home. CONCLUSION: DPR application showed significant improvement of APACHE-IV score and APS in patients with peritonitis/septic abdomen.

Tofacitinib for the treatment of refractory immune checkpoint inhibitor-associated immune nephritis.

Immune checkpoint inhibitor (ICI)-associated immune nephritis or acute interstitial nephritis (AIN) is one of the rare but known complication of ICI therapy. Guidelines recommend treatment of ICI-associated AIN with steroids, then TNF-alpha inhibitor infliximab. However, some cases are refractory to these therapies, potentially due to insufficient cytokine blockade. This is the first case where a 65-year-old female with metastatic lung adenocarcinoma, requiring high maintenance doses of steroids for immune nephritis was treated with tofacitinib, an oral Janus kinase (JAK) inhibitor. Tofacitinib enabled successful steroid tapering and might be a therapy option for refractory immune nephritis.

Steal and strain: A case of coronary artery fistula presenting with coronary steal syndrome and underlying bronchiectasis.

BACKGROUND: Coronary artery fistula is a relatively rare disorder with an incidence rate of 0.05-0.9%, and the majority of fistulae are detected incidentally. Most coronary artery fistulae are congenital, and the acquired variant is very rare. Herein, we present a possible acquired coronary artery to pulmonary artery fistula, most likely secondary to bronchiectasis in the adjacent lung. We will analyze the hemodynamic significance of the fistula in this case and also seek to understand the outcomes of various treatment modalities. CASE PRESENTATION: A 56-year-old male patient presented with hypoxemia secondary to acute pulmonary edema during a hypertensive emergency. He developed myocardial ischemia after treatment with diuretics and nitroglycerin, due to shunting of blood from the right coronary artery to the right lower lobe branch of the right pulmonary artery, via the fistula. This resulted in coronary steal syndrome. Coronary angiogram confirmed the fistula connecting the right coronary artery to the right lower lobe branch of the right pulmonary artery. An attempt at coil embolization was unsuccessful due to the inability to advance the microcatheter beyond the fistula. DISCUSSION: The majority of coronary artery fistulae are asymptomatic as they are hemodynamically not significant and are incidentally detected by coronary angiography, CT angiogram, echocardiogram or multi-detector row computed tomography (MDCT) with 3D reconstruction. The development of congenital fistula can be explained by the Hackensellner involution-persistence hypothesis, but the anatomy in this case and the bronchiectasis in the part of the lung adjacent to the fistula makes an acquired cause very likely due to local inflammation and the age of patient at initial diagnosis. An initial diagnosis of bronchiectasis was made at age 51, which was 5 years prior to the detection of the coronary artery fistula in this patient. Symptoms have been described mostly in the elderly and include chest pain, dyspnea, fatigue, syncope, and palpitations. Such symptomatic fistula should be treated either by percutaneous transluminal embolization or surgical ligation. CONCLUSION: This is a unique case of acquired coronary to pulmonary artery fistula in the setting of bronchiectasis in a patient in which PTE was attempted and failed. More research is required to understand the pathophysiology of acquired fistula. The decision regarding the method of closure should be individualized and decided on a case by case basis.

The Association Between Anemia of Chronic Inflammation and Alzheimer's Disease and Related Dementias.

BACKGROUND: Dementia is a spectrum of neurological diseases characterized by memory impairment and cognitive decline with the pathogenesis and effective management remaining elusive. Several studies have identified a correlation between anemia and Alzheimer's disease and related dementias (ADRD); however, anemia subtypes and association with ADRD have yet to be studied conclusively. OBJECTIVE: To study an association between ADRD and anemia of chronic inflammation. METHODS: We conducted a retrospective case-control study of the patients, diagnosed with ADRD at Brookdale Hospital. Pair-wise comparisons between means of controls and cases in terms of iron studies and laboratory results were performed using a Mann-Whitney U test. Pair-wise comparisons between anemia subgroups (moderate and severe) were performed using a Two Sample proportion Z-Test, where for each couple of normally distributed population. RESULTS: There was a total of 4,517 (1,274 ADRD group; 3,243 Control group) patients. There was significant difference in hemoglobin 10.15 versus 11.04 [p-value <0.001]. Iron studies showed a significant difference in ferritin 395±488.18 versus 263±1023.4 [p < 0.001], total iron binding capacity 225±84.08 versus 266±82.30 [p < 0.001] and serum iron level 64±39.34 versus 53±41.83 [p < 0.001]. Folic acid and vitamin B12 levels were normal in both groups. Severe and moderate anemia in the ADRD group were respectively 6.2% [95% CI: 4.2-8.4] and 13% [95% CI: 9.8-16.2] higher. Overall, incidence of moderate-to-severe anemia was found to be 19% higher in ADRD group [95% CI: 15.8-22.1]. CONCLUSION: We demonstrated an association between ADRD and anemia of chronic inflammation independent of age, renal function, and HgbA1C levels.

Cavitary Pulmonary Infarction in a Case of Pulmonary Embolism After Successful Vascular Recanalization.

Cavity formation after pulmonary embolism can be a result of infarction; however, the data available on the incidence rate were obtained from the cases of patients treated with anticoagulation without recanalization. It is yet unknown if interventions like catheter-directed alteplase or thrombectomy reduce the risk of cavity formation. We present an interesting case of a patient who developed pulmonary cavity and possible secondary infection after successful vascular recanalization with catheter-directed alteplase and thrombectomy.

A Study to Assess the Factors Affecting Adherence to Exercise in the Indian Population.

Introduction As proven by many previous studies, physical inactivity is associated with many diseases, including heart conditions and cancer. The elimination of physical inactivity helps increase life expectancy and reduce morbidity. Nonadherence to exercise is a common problem faced by many people. The goal of this study was to determine the percentage of people in the Indian population who regularly exercise. We also assessed factors for nonadherence, motivating factors, and the intensity of exercise usually performed and explored any association between adherence to exercise and demographic factors. Materials and methods We conducted an anonymous questionnaire-based, cross-sectional study in an adult Indian population (participants were older than 18 years) from rural and urban areas having no contraindication to at least some form of voluntary exercise. Data were collected via email by sending a questionnaire, and an appropriate statistical methodology was used to derive the results. Results This study included 220 individuals older than 18 years, and most participants were aged 25 to 30 years (35.5%). Most participants (67.3%) were women, and 32.7% were men. Forty-one percent of the total population reported suffering from some medical condition. Nearly half (51.8%) of the subjects were involved in physical activity, and 48.2% were not involved in physical activity. The most common reason for not exercising was a lack of time followed by a lack of motivation. Maintenance of good health was the main reported benefit of physical exercise, with self-motivation being the main motivator. Low-intensity exercise was the preferred form of exercise for most of the participants; high-intensity exercise was preferred by younger participants, though less commonly than low-intensity exercise. Older participants (i.e., those aged > 40 years) preferred moderate-intensity exercise. Only half the study population were educated regarding physical activity by a healthcare professional. We found no statistically significant association between the presence of a medical condition, body mass index (BMI), or healthcare education and adherence to exercise. Conclusion The inclusion of exercise in a daily routine is one of the more important lifestyle changes advised for all ailments and for improvements in patient quality of life. Nearly half the Indian population does not exercise daily. Because we found no statistical significance between demographic factors, health conditions, BMI, or general healthcare education, an individualized education and exercise plan may help improve exercise adherence.