Plasma exchange for the management of digoxin toxicity in an individual with an acute kidney injury: A case report.

Digoxin toxicity can be life-threatening. Digoxin-specific antibody (DSA) fragments are used in severe digoxin toxicity, binding to serum-free digoxin and enabling increased renal excretion. In severe renal impairment, clearance of these complexes is prolonged, leading to rebound toxicity. Digoxin and DSA complexes are not dialysable. We present a case of a gentleman with severe digoxin toxicity and acute kidney injury (AKI). Despite receiving DSA doses, his digoxin levels rebounded and symptoms persisted. Based on published case reports, plasma exchange (PEX) after further dosing was arranged. PEX facilitated the removal of digoxin-DSA complexes, bypassing renal excretion. During PEX, clinical signs improved and were sustained. He did not require further dialysis or PEX, renal function recovered and he was discharged. This case highlights challenges in the management of severe digoxin toxicity in patients with a concurrent AKI. The use of PEX enabled digoxin-DSA complex removal and should be considered in these circumstances.

Influence of vitamin D status on respiratory infection incidence and immune function during 4 months of winter training in endurance sport athletes.

The purpose of this study was to examine the influence of vitamin D status on mucosal and systemic immunity and the incidence, severity and duration of upper respiratory tract illness (URTI) episodes in endurance athletes during a 16-week winter training period. Blood was collected from 225 subjects at the start of the study and plasma was analysed for total 25-hydroxy vitamin D (25(OH)D) and cathelicidin concentration. Blood was also collected at the end of the study and analysed for 25(OH)D and antigen-stimulated cytokine production. Unstimulated saliva samples were obtained at the start and at 4-week intervals during the study period. Saliva samples were analysed for salivary antimicrobial peptides and proteins (AMPs). Weekly training and daily illness logs were kept. At the start and end of the study 38% and 55%, respectively, of the athlete cohort had inadequate (plasma 25(OH)D 30-50 nmol/L) or deficient (plasma 25(OH)D < 30 nmol/L) vitamin D status. There was a significantly higher proportion of subjects who presented with symptoms of URTI in the vitamin D deficient status group (initial plasma 25(OH)D < 30 nmol/L) during the study period than in the optimal vitamin D group (> 120 nmol/L) and the total number of URTI symptom days and the median symptom-severity score in the vitamin D deficient group was signifi- cantly higher than in the other groups. The plasma cathelicidin concentration positively correlated with the plasma 25(OH)D concentration and the saliva secretory immunoglobulin A (SIgA) secretion rate in the optimal vitamin D status group was significantly higher than in the other groups. Low vitamin D status was associated with lower pro-inflammatory cytokine production by monocytes and lymphocytes. Low vitamin D status could be an important determinant of URTI risk in endurance athletes and mucosal as well as systemic immunity may be modified via vitamin D-dependent mechanisms.

Point-of-care echocardiography and thoracic ultrasound in the management of critically ill patients with COVID-19 infection: Experience in three regional UK intensive care units.

Introduction: Point-of-care ultrasound (POCUS) has an established role in the management of the critically ill. Information and experience of its use in those with COVID-19 disease is still evolving. We undertook a review of cardiac and thoracic ultrasound examinations in patients with COVID-19 on the intensive care unit (ICU). Our aim was to report key findings and their impact on patient management. Methods: A retrospective evaluation of critically ill patients with COVID-19 was undertaken in three adult ICUs, who received point-of-care cardiac and/or thoracic ultrasound during the 2019-2020 COVID-19 pandemic. We recorded baseline demographic data, principal findings, change in clinical management and outcome data. Results: A total of 55 transthoracic echocardiographic examinations scans were performed on 35 patients. 35/55 (64%) echocardiograms identified an abnormality, most commonly a dilated or impaired right ventricle (RV) and 39/55 (70%) scans resulted in a change in management. Nine patients (26%) were found to have pulmonary arterial thrombosis on CTPA or post-mortem. More than 50% of these patients showed evidence of right ventricular dilatation or impairment. Of the patients who were known to have pulmonary arterial thrombosis and died, 83% had evidence of right ventricular dilatation or impairment. 32 thoracic ultrasound scans were performed on 23 patients. Lung sliding and pleural thickening were present bilaterally in all studies. Multiple B-lines were present in all studies, and sub-pleural consolidation was present bilaterally in 72%. Conclusion: POCUS is able to provide useful and clinically relevant information in those critically ill with COVID-19 infection, resulting in change in management in a high proportion of patients. Common findings in this group are RV dysfunction, multiple B-lines and sub-pleural consolidation.

Capture and inactivation of viral particles from bioaerosols by electrostatic precipitation.

Infectious viral particles in bioaerosols generated during laparoscopic surgery place staff and patients at significant risk of infection and contributed to the postponement of countless surgical procedures during the COVID-19 pandemic causing excess deaths. The implementation of devices that inactivate viral particles from bioaerosols aid in preventing nosocomial viral spread. We evaluated whether electrostatic precipitation (EP) is effective in capturing and inactivating aerosolized enveloped and non-enveloped viruses. Using a closed-system model mimicking release of bioaerosols during laparoscopic surgery, known concentrations of each virus were aerosolized, exposed to EP and collected for analysis. We demonstrate that both enveloped and non-enveloped viral particles were efficiently captured and inactivated by EP, which was enhanced by increasing the voltage to 10 kV or using two discharge electrodes together at 8 kV. This study highlights EP as an effective means for capturing and inactivating viral particles in bioaerosols, which may enable continued surgical procedures during future pandemics.

Tocilizumab for the treatment of giant cell arteritis in Scotland: a report on behalf of the Scottish Society for Rheumatology standards subgroup.

Objectives: The aim was to describe a modern National Health Service (NHS) Scotland cohort of patients with GCA over 12 months of care to include clinical presentation, practices relating to assessment and treatment, and specifically, the use of tocilizumab. Methods: A multicentre audit of patients newly diagnosed with GCA between November 2019 and October 2021 was established on behalf of the Scottish Society for Rheumatology. Clinical data were collected retrospectively by rheumatology teams at participating NHS centres using electronic patient records. An extended cohort of patients from NHS Lothian was examined to investigate outcomes of tocilizumab use for >1 year. Results: Sixty-three patients from three NHS Scotland health boards were included, with analysis of data from 216 clinic episodes. Mean follow-up was 371 days. Mean age was 71 years; 62% were female. The most common presenting features were headache (93.6%), scalp tenderness (82.5%) and ocular symptoms (24%). At baseline, 63% of patients had at least one existing risk factor for adverse outcomes from high-dose CS use, namely hypertension (57.1%), diabetes (24%) and osteoporosis (11%). Thirty per cent of all patients (19 of 63) received tocilizumab, with only 11% (7 of 63) receiving tocilizumab owing to glucocorticoid risk factors at baseline. One-quarter of all patients (16 of 63) experienced relapse of GCA during follow-up, of whom six were subsequently treated with tocilizumab. Conclusion: This multicentre audit demonstrates that despite its availability for patients with risk factors for CS adversity and those who suffer relapse of GCA, tocilizumab is used in less than one-quarter of patients who might benefit. The reasons for this require further exploration.

Improving VTE risk assessment and prophylaxis prescribing rate in medical patients: integrating risk assessment tool into the workflow.

Medical inpatients often have important risk factors for venous thromboembolism (VTE). In our institution, VTE prophylaxis in this group was underused. The main barriers identified were inattention to VTE prophylaxis, competing priorities and lack of confidence in the decision-making. We aimed to improve the rate of VTE prophylaxis use by introducing a paper-based risk assessment tool, with actionable management recommendations within the prescription chart. The rationale was that an assessment tool at the point of prescribing can reduce steps between decision-making and prescribing process, thus promoting confidence and acting as a reminder. A total of 552 prescription charts completed over a period of 29 weeks were examined during the baseline period. In the postintervention period, 871 charts completed over 40 weeks period were examined. The risk assessment tool was completed in 51% of the cases examined in the postintervention period. The introduction of the risk assessment tool was associated with a significant change in the pattern of VTE pharmacological prophylaxis use. The change occurred when the form was made highly visible and enclosed in the prescription chart. The pharmacological prophylaxis use was higher with a completed assessment form than without (mean (SD) 97.5% (7.6%) vs 70.1% (19.4%); p<0.0001). The rate of appropriate prophylaxis decision was 98.2% (SD 5.2%) with a completed assessment form, and 80.7% (SD 17.9%) when it was not used. The qualitative interviews revealed positive themes; many users found it useful, easy and convenient to use. Our data have shown that a paper-based VTE risk assessment tool placed within the prescription chart could substantially improve the rate of appropriate assessment and VTE prophylaxis implementation. This suggests that tool clearly needs to be a seamless integration into the workflow to capture users' attention and mitigate the influence of time perception.

A description of echocardiography in life support use during cardiac arrest in an Emergency Department before and after a training programme.

OBJECTIVES: To investigate echocardiography in life support (ELS) use in Emergency Department (ED) cardiac arrest patients before and after a training day. METHODS: A prospective before and after cohort study. Data was collated over a 24-month period before and after an ELS training day from our ED ultrasound database [Registry of Emergency Based Ultrasound Scanning (REBUS)], ED electronic patient records and from stored digital ELS scans. RESULTS: In the year before ELS training, eight of 187 cardiac arrest patients had ELS performed (4.3%). In the year after training, 46 of 232 cardiac arrest patients had ELS performed (19.8%; P<0.001). This increase has persisted with 40 of 129 (31%) patients undergoing ELS in the 6 months poststudy period. ELS aided management in six of eight pretraining cases and 32 of 46 post-training cases. CONCLUSION: Use of ELS significantly increased after the training day most commonly supporting a decision to stop resuscitation. This change in practice has been maintained.