Case Report: Three cases of clinically suspected viral myocarditis with recovery of left ventricular dysfunction.

Viral myocarditis is an important cause of non-ischemic cardiomyopathy. Multiple clinical manifestations have been reported, including acute heart failure, cardiogenic shock, and ventricular arrhythmias. We present three patients with clinically suspected viral myocarditis causing acute heart failure. Serum coxsackievirus B antibodies were positive in all three patients. Each case resulted in significant clinical improvement with hemodynamic support and acute recovery of left ventricular ejection fraction. Despite an initial critical presentation concerning for cardiogenic shock, we highlight three cases of clinically suspected coxsackie myocarditis with an excellent short-term prognosis.

Coronary Air Embolism Secondary to Percutaneous Lung Biopsy: A Systematic Review.

To determine mortality and morbidity associated with coronary air embolism (CAE) secondary to complications of percutaneous lung biopsy (PLB) and illicit-specific risk factor associated with this complication and overall mortality, we searched PubMed to identify reported cases of CAE secondary to PLB. After assessing inclusion eligibility, a total of 31 cases from 26 publications were included in our study. Data were analyzed using Fisher's exact test. In 31 reported cases, cardiac arrest was more common after left lower lobe (LLL) biopsies (n=4, 80%, p=0.001). Of these patients who suffered from cardiac arrest, CAE was found more frequently in the right coronary artery (RCA) than other locations but did not reach statistical significance (n=5, 62%, p=0.39). At the same time, intervention in the LLL was significantly associated with patient mortality (n=3, 60%, p=0.010). Of the patients who died, CAE was more likely to have occurred in the RCA, but this association was not statistically significant (n=4, 57%, p=0.33). LLL biopsies have a statistically significant correlation with cardiac arrest and patient death. More research is needed to examine the effect of the air location in the RCA on patient morbidity and mortality.

A Comparison of ICU Mortality Scoring Systems Applied to COVID-19.

Background Over the past three years, COVID-19 has been a major source of mortality in intensive care units around the world. Many scoring systems have been developed to estimate mortality in critically ill patients. Our intent with this study was to compare the efficacy of these systems when applied to COVID-19. Methods The was a multicenter, retrospective cohort study of critically ill patients with COVID-19 admitted to 16 hospitals in Texas from February 2020 to March 2022. The Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA) score, and 4C Mortality scores were calculated on the initial day of ICU admission. Primary endpoints were all-cause mortality, ICU length of stay, and hospital length of stay. Results Initially, 62,881 patient encounters were assessed, and the cohort of 292 was selected based on the inclusion of the requisite values for each of the scoring systems. The median age was 56 +/- 14.93 years and 61% of patients were male. Mortality was defined as patients who expired or were discharged to hospice and was 78%. The different scoring systems were compared using logistic regression, receiver operating characteristic (ROC) curve, and area under the ROC curve (AUC) analysis to compare the accuracy of prediction of the mortality and length of stay. The multivariate analysis showed that SOFA, APACHE II, SAPS II, and 4C scores were all significant predictors of mortality. The SOFA score had the highest AUC, though the confidence intervals for all of the models overlap therefore one model could not be considered superior to any of the others. Linear regression was performed to evaluate the models' ability to predict ICU and hospital length of stay, and none of the tested systems were found to be significant predictors of length of stay. Conclusion The SOFA, APACHE II, ISARIC 4-C, and SAPS II scores all accurately predicted mortality in critically ill patients with COVID-19. The SOFA score trended to perform the best.

A Case of Vanishing Bronchus Syndrome in a Non-lung Transplant Patient.

Vanishing bronchus syndrome (VBS) is the most severe form of bronchial stenosis. It has been described as a complication following a lung transplant (LT). We present a case of VBS in a patient with non-Hodgkin lymphoma in remission status post chemotherapy and radiation therapy and no history of a lung transplant.

Aspirin use is associated with decreased inpatient mortality in patients with COVID-19: A meta-analysis.

Thromboembolism is a major cause of death in patients who suffer from COVID-19. Studies examining the effects of aspirin (ASA) on mortality relating to this phenomenon have showed conflicting results with varying degrees and certainties of evidence. We performed an aggregate data meta-analysis of fourteen studies encompassing 164,539 COVID-19 patients, which showed a reduced risk of in-hospital mortality associated with ASA use in eight studies that reported risk ratios (RR 0.90; 95 % CI 0.82-0.98; I2 = 27.33 %, P = 0.01), six studies that reported hazard ratios (HR 0.56; 95 % CI 0.41-0.76, P ≤ 0.01; I2 = 85.92 %) and pooled effect size (0.71; 95 % CI 0.59-0.85, P = 0.00, I2 = 91.51 %). The objective of this study is to report the association between low dose ASA and a reduced risk of in-hospital mortality in patients with COVID-19.

Parvovirus Reactivation in COVID-19.

Anemia is a diagnostic challenge in patients with coronavirus disease 2019 (COVID-19). This is due to the broad differential of etiologies for anemia, which includes bleeding, bone marrow suppression secondary to sepsis, and hemolytic anemia. Here, we present a first-ever case of otherwise unexplained anemia in a patient receiving treatment for COVID-19 secondary to parvovirus B19 reactivation. While parvovirus infections often present as acute states of anemia, this patient developed a case of reactivation secondary to immunosuppression from COVID-19 treatment. This case indicates the importance of assessing for parvovirus infections in COVID-19 patients with otherwise unexplained anemia.

Systemic Inflammation-Related Bradycardia in COVID-19.

Systemic inflammation-related sinus bradycardia in COVID-19 infection has not been well described yet. This six-patient case series excludes common causes of bradycardia. As bradycardia may be a sequela of COVID-19 infection, we recommend closely monitoring hemodynamics and stopping medications that can exacerbate bradycardia in these patients.

Ceftaroline-Associated Encephalopathy: A Rare Adverse Effect.

In this case report, we present a patient who suffered ceftaroline-associated encephalopathy, while receiving ceftaroline for acute bacterial skin and skin structure infections (aBSSSIs) that resolved after cessation of the suspected agent. We recommend close monitoring for encephalopathy in patients with creatinine clearance (CrCl) of <50 mL/min receiving ceftaroline.

A 78-Year-Old Man with a Pulmonary Embolism Who Developed Skin Necrosis 7 Days After Treatment with the Direct Oral Anticoagulant Factor Xa Inhibitor Apixaban.

BACKGROUND Apixaban is one of the newer direct oral anticoagulants (DOACs) being used to manage venous thrombosis. Skin toxicities are recognized adverse effects of the new DOACs, but are rare and usually associated with vasculitis. This report is of a 78-year-old man admitted to the hospital with pulmonary thromboembolism, who developed severe and extensive skin necrosis of both forearms 7 days after treatment with apixaban. CASE REPORT A 78-year-old man was admitted for pulmonary embolism and congestive heart failure exacerbation. He was started on therapeutic enoxaparin and diuresis. Later on, enoxaparin was substituted with apixaban. Seven days after starting apixaban, he suddenly developed skin changes that developed into skin necrosis on both forearms and the abdominal wall. A skin biopsy was not performed due to the high risk of bleeding. Skin necrosis was diagnosed based on clinical findings. A review of clinical data and the patient's medication profile did not reveal any other possible etiology or culprit medication. Clinical presentation and lab values were not consistent with infections or autoimmune etiologies. Apixaban was discontinued as it was perceived to be the likely cause of skin necrosis. The skin changes gradually improved within 1 week with supportive wound care, and the patient did not require a skin graft. The patient was discharged safely with subcutaneous low-molecular-weight heparin therapy. CONCLUSIONS This report shows that skin toxicity can be associated with apixaban and that with the increasing use of these newer DOACs, clinicians should be aware of these potential adverse effects.

Comparative Transcriptional Analyses of Francisella tularensis and Francisella novicida.

Francisella tularensis is composed of a number of subspecies with varied geographic distribution, host ranges, and virulence. In view of these marked differences, comparative functional genomics may elucidate some of the molecular mechanism(s) behind these differences. In this study a shared probe microarray was designed that could be used to compare the transcriptomes of Francisella tularensis subsp. tularensis Schu S4 (Ftt), Francisella tularensis subsp. holarctica OR960246 (Fth), Francisella tularensis subsp. holarctica LVS (LVS), and Francisella novicida U112 (Fn). To gain insight into expression differences that may be related to the differences in virulence of these subspecies, transcriptomes were measured from each strain grown in vitro under identical conditions, utilizing a shared probe microarray. The human avirulent Fn strain exhibited high levels of transcription of genes involved in general metabolism, which are pseudogenes in the human virulent Ftt and Fth strains, consistent with the process of genome decay in the virulent strains. Genes encoding an efflux system (emrA2 cluster of genes), siderophore (fsl operon), acid phosphatase, LPS synthesis, polyamine synthesis, and citrulline ureidase were all highly expressed in Ftt when compared to Fn, suggesting that some of these may contribute to the relative high virulence of Ftt. Genes expressed at a higher level in Ftt when compared to the relatively less virulent Fth included genes encoding isochorismatases, cholylglycine hydrolase, polyamine synthesis, citrulline ureidase, Type IV pilus subunit, and the Francisella Pathogenicity Island protein PdpD. Fth and LVS had very few expression differences, consistent with the derivation of LVS from Fth. This study demonstrated that a shared probe microarray designed to detect transcripts in multiple species/subspecies of Francisella enabled comparative transcriptional analyses that may highlight critical differences that underlie the relative pathogenesis of these strains for humans. This strategy could be extended to other closely-related bacterial species for inter-strain and inter-species analyses.

Efficacy and safety of long-acting ß-agonist/long-acting muscarinic antagonist combinations in COPD: a network meta-analysis.

BACKGROUND: The place of long-acting ß agonist/long-acting muscarinic antagonist (LABA/LAMA) combinations in stable patients with COPD is not well defined. The purpose of this study was to systematically review the efficacy and safety of LABA/LAMA combinations. METHODS: Several databases and manufacturers' websites were searched for relevant clinical trials. Randomised control trials, at least 12 weeks duration, comparing a LABA/LAMA combination with placebo and/or monotherapy were included. The data were pooled using a network as well as a traditional direct comparison meta-analysis. RESULTS: Twenty-three trials with a total of 27 172 patients were included in the analysis. LABA/LAMA combinations were associated with a greater improvement in lung function, St. George's Respiratory Questionnaire (SGRQ) score, and Transitional Dyspnoea Index (TDI) than monotherapies. LABA/LAMA combinations were associated with a significantly greater proportion of SGRQ and TDI responders than monotherapies (OR 1.23 (95% credible interval (CrI) 1.06-1.39), OR 1.34 (95% CrI 1.19-1.50) versus LABAs and OR 1.24 (95% CrI 1.11-1.36), OR 1.31 (95% CrI 1.18-1.46) versus LAMAs, respectively) and fewer moderate-to-severe exacerbations compared with LABAs (HR 0.82 (95% CrI 0.73-0.93)), but not when compared with LAMAs (HR 0.92 (95% CrI 0.84-1.00)). There were no statistically significant differences associated with LABA/LAMA combinations compared with monotherapies in safety outcomes as well as in severe exacerbations. CONCLUSIONS: The combination therapy was the most effective strategy in improving lung function, quality of life, symptom scores and moderate-to-severe exacerbation rates, and had similar effects on safety outcomes and severe exacerbations as compared with monotherapies.

Psychiatric disorder does not preclude adequate continuous positive airway pressure titration.

Obstructive sleep apnea (OSA) is a highly prevalent disorder associated with significant morbidity and multiple complications. A large proportion of patients with OSA also have a coexisting primary psychiatric disorder. The effect of psychiatric disorders on the ability to tolerate continuous positive airway pressure (CPAP) titration is not known. In this study, whether the presence of psychiatric disorders precludes the patients' ability to tolerate CPAP titration for OSA was investigated. A retrospective chart review on a sample of 284 patients who underwent sleep studies in a single-center, university-based Veterans Affairs hospital was performed. A total of 143 patients with OSA who underwent titration of CPAP therapy were identified. The prevalence of psychiatric disorders between patients who tolerated titration and those who did not tolerate it was compared using the χ² test. The percentages of patients with psychiatric disorders who tolerated and did not tolerate CPAP were 33.6% and 33.3%, respectively. No statistically significant difference between the 2 groups (χ² = 0.051 with 1 degree of freedom; P = 0.82) was found. The predominantly male patient population, exclusion of mild OSA, lack of data about the level of control of the psychiatric symptoms and the sleep technicians not being blinded to the patients' psychiatric diagnoses were some of the limitations of this study. No significant difference existed in the prevalence of psychiatric disorders between patients intolerant to CPAP titration and those who tolerated CPAP for OSA.

Lung scedosporiosis in human immunodeficiency virus/acquired immunodeficiency syndrome.

A 31-year-old African American woman with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (recent CD4 count of 66/mm) presented to the emergency room with a tension pneumothorax that required an emergent chest tube placement. Computed tomography scan showed fungus balls in multiple lung cavities and surrounding infiltrates. The patient showed remarkable improvement with voriconazole suggesting aspergillosis. However, the patient was serologically negative for Aspergillus and other common fungal infections. Because of a persistent air leak, surgical intervention was needed. The histological finding was consistent with invasive mycosis, and cultures were positive for Scedosporium apiospermum. Literature review showed that, among patients with HIV/AIDS, Scedosporium can present from focal localized to systemic disease, is resistant to traditional antifungal agents, and may respond to prompt management with voriconazole.

Proteome cataloging and relative quantification of Francisella tularensis tularensis strain Schu4 in 2D PAGE using preparative isoelectric focusing.

The protein complement of whole cell extract of the bacterium Francisella tularensis tularensis was analyzed using two-dimensional electrophoresis with preparative isoelectric focusing in the first dimension. The format allows the quantification of relative protein abundance by linear densitometry and extends the potential dynamic range of protein detection by as much as an order of magnitude. The relative abundance and rank order of 136 unique proteins identified in F. tularensis tularensis were established. It is estimated that 16% of the moderately to highly expressed proteins and 8% of all predicted non-pseudogenes were identified by comparing this proteome information with the relative abundance of mRNA as measured by microarray. This rank-ordered proteome list provides an important resource for understanding the pathogenesis of F. tularensis and is a tool for the selection and design of synthetic vaccines. This method represents a useful additional technique to improve whole proteome analyses of simple organisms.

High-throughput proteomics processing of proteins in polyacrylamide in a multiwell format.

Processing multiple protein samples from polyacrylamide at significant sensitivity represents a major chokepoint for raising the success rate in high-volume protein identification projects. A multiwell filterplate method for processing proteins in polyacrylamide was optimized for sensitivity using a protein standard. The results demonstrate this process to be a reliable and reproducible method over a range of gel loadings and suitable for the identification of proteins near the threshold of silver stain. This high-throughput manual method requires a minimum of specialized equipment, and can be performed disconnected from a proteomics infrastructure for the preparation of mass spectrometry-ready samples.