Clinical significance of BPI-ANCA in patients with cystic fibrosis: a single center prospective study.

Recurrent pulmonary exacerbation due to infection and inflammation remain the major cause of mortality and morbidity in patients with cystic fibrosis (CF). Increased levels of BPI-ANCA have been linked to Pseudomonas colonization and pulmonary exacerbations in patients with CF. The majority of these studies were done in Europe, and it is unclear whether similar findings are true in CF patients who lives in United States. In our single center study of 47 patients with CF, the prevalence of BPI-ANCA was 19% at baseline and 15% at annual follow-up visit. Overall, there were no statistical differences noted in FEV1 and frequency of pulmonary exacerbations in CF patients who were positive for BPI-ANCA compared to those who were negative for BPI-ANCA. The role of BPI-ANCA in patients with CF still remains unclear.

Characteristics and outcomes of patients with sepsis who had cortisol level measurements or received hydrocortisone during their intensive care unit management: A retrospective single center study.

Objectives: The current guidelines for managing patients with sepsis include the early cultures, administration of antibiotics, and fluid resuscitation. Several clinical trials have tried to determine whether or not the administration of corticosteroids improves outcomes in these patients. This study analyzed the characteristics of a large group of critically ill patients who either had cortisol levels drawn during their intensive care unit management or had hydrocortisone administered during their management. Methods: A list of patients who had cortisol levels measured or who had hydrocortisone administered empirically for the treatment of sepsis was identified by the medical record department at University Medical Center in Lubbock, Texas. The primary outcome was in-hospital mortality. Secondary outcomes included the need for mechanical ventilation, the need for renal replacement therapy, the need for vasopressors, length of stay, and the development of nosocomial infections. Results: This study included 351 patients, including 194 women (55.3%). The mean age was 62.9 ± 16.1 years. The mean admission SOFA score was 9.3 ± 3.63, the mean APACHE 2 score was 18.15 ± 7.7, and the mean lactic acid level was 3.8 ± 4.0 mmol/L. One hundred sixty-two patients required intubation, 262 required vasopressors, 215 developed acute kidney injury, and 319 had cortisol levels measured. The mean length of stay was 11.5 ± 13.7 days; the mortality rate was 32.2%. Multiple variable analysis demonstrated that higher cortisol levels were associated with increased mortality (44.1% if cortisol ⩾20 µg/dL versus 17.5% if cortisol <20 µg/dL). One hundred forty-five patients received corticosteroids, and multivariable analysis demonstrated that these patients had increased mortality (40.0% versus 26.7%). Conclusion: In this study, higher cortisol levels were associated with increased mortality. The administration of hydrocortisone was associated with increased mortality possibly reflecting the use of this medication in patients who had a higher likelihood of poor outcomes.

Acute Myocardial Injury Following COVID-19 Vaccination: A Case Report and Review of Current Evidence from Vaccine Adverse Events Reporting System Database.

COVID-19 vaccination related adverse events is an evolving field. Here we present a case of acute myocardial injury that developed as a result of an acute immune response following the second dose of COVID-19 vaccination (Moderna) in a 67-year-old man who presented in acute congestive heart failure. His clinical course improved over 3 days. Review of the Vaccine Adverse Events Reporting System (VAERS) in the Centers for Disease Control and Prevention websites identified 37 vaccine recipients who developed myocarditis as an adverse event following COVID-19 vaccination. With the mass expansion of COVID-19 vaccine administration, physicians need to be vigilant about the possibility of new adverse events.

Super-refractory status epilepticus in a 29-year-old pregnant female.

Super-refractory status epilepticus is a rare medical and neurological emergency due to the high mortality and morbidity associated with this condition. Furthermore, there is very little data regarding its incidence, etiology, and management in the pregnant population with super-refractory status epilepticus. The treatment of super-refractory status epilepticus during pregnancy is specifically a major challenge as there are limited available therapeutic options due to the well-established teratogenicity of most antiepileptic drugs and the unknown safety profile of some of the anesthetics commonly used for seizure control. We report a case of successfully treated super-refractory status epilepticus in a 29-year-old, 26 weeks pregnant female who after an emergent delivery and prolonged exposure to multiple antiepileptic drugs recovered full neurological function.

Macrophage Activation Syndrome in Adults: A Retrospective Case Series.

Macrophage activation syndrome (MAS) is a form of hemophagocytic lymphohistocytosis that occurs in patients with a variety of inflammatory rheumatologic conditions. Traditionally, it is noted in pediatric patients with systemic juvenile idiopathic arthritis and systemic lupus erythematous. It is a rapidly progressive and life-threatening syndrome of excess immune activation with an estimated mortality rate of 40% in children. It has become clear recently that MAS occurs in adult patients with underlying rheumatic inflammatory diseases. In this article, we describe 6 adult patients with likely underlying MAS. This case series will outline factors related to diagnosis, pathophysiology, and review present therapeutic strategies.

Age-Adjusted D-Dimer in the Prediction of Pulmonary Embolism: Systematic Review and Meta-analysis.

BACKGROUND: Pulmonary embolism (PE), depending on the severity, carries a high mortality and morbidity. Proper evaluation, especially in patients with low probability for PE, is important to avoid unnecessary diagnostic testing. OBJECTIVE: To review the diagnostic utility of conventional versus age-adjusted D-dimer cutoff values in patients 50 years and older with suspected pulmonary embolism. METHODS: Systematic review with univariant and bivariant meta-analysis. DATA SOURCES: We searched PubMed, MEDLINE, and EBSCO for studies published before September 20th, 2020. We cross checked the reference list of relevant studies that compares conventional versus age-adjusted D-dimer cutoff values in patients with suspected pulmonary embolism. STUDY SELECTION: We included primary published studies that compared both conventional (500 µg/L) and age-adjusted (age × 10 µg/L) cutoff values in patients with non-high clinical probability for pulmonary embolism. RESULTS: Nine cohorts that included 47 720 patients with non-high clinical probability were included in the meta-analysis. Both Age-adjusted D-dimer and conventional D-dimer have high sensitivity. However, conventional D-dimer has higher false positive rate than age-adjusted D-dimer. CONCLUSION: Age-adjusted D-dimer cutoffs combined with low risk clinical probability assessment ruled out PE diagnosis in suspected patients with a decreased rate of false positive tests.

Prevalence of Coronavirus Antibody Among First Responders in Lubbock, Texas.

BACKGROUND: The ongoing coronavirus disease (COVID-19) pandemic has a major impact on first responders. Scarce personal protective equipment (PPE) has forced them to conserve and reuse some of their PPE. The efficacy of these practices in preventing transmission of COVID-19 from patients to first responders is unclear. There are limited data on the prevalence of antibodies specific for COVID-19 exposure in these front-line workers. AIM: Our objective was to determine the prevalence of positive immunoglobulin G antibody specific to COVID-19 among first responders in Lubbock, Texas. METHODS: Blood samples were collected on 683 asymptomatic first responders who work in Lubbock, Texas and the surrounding area, after informed consents were signed. IgG antibody to SARS-CoV-2 was measured using Abbott's SARS-CoV-2 IgG Reagent Kit in combination with the SARS-CoV-2 IgG Calibrator Kit on the Abbott's ARCHITECT i1000SR analyzer. RESULTS: The prevalence of IgG specific antibodies to COVID-19 was 0.73%, five of the 683 participants tested positive. Four of those who tested positive had no known prior SARS-CoV-2 infection or exposure without adequate PPE. CONCLUSIONS: The prevalence of IgG specific antibodies to COVID-19 was much lower than expected in our study population despite high sensitivity and specificity of the test reagent. The most likely explanations for this finding include limited exposure, inadequate time for a IgG response, possible clearance of COVID-19 infection locally by the respiratory tract IgA defense system without eliciting a systemic IgG response, and short persistence of IgG antibodies in mild or asymptomatic cases.

High prevalence of non-thyroidal illness syndrome in patients at long-term care facilities.

PURPOSE: Patients in acute care hospitals are often transferred to long-term care (LTC) when there is an expectation for a lengthy recovery. Prolonged non-thyroidal illness syndrome (NTIS) creates a state of hypothyroidism. We aimed to investigate the prevalence of NTIS in patients at LTC facilities. METHODS: A cross-sectional study at University Hospitals and Rehabilitation and Skilled Nursing facility was performed. Four groups: control (n:33), intensive care unit (ICU) (n:34), long-term care hospital (LTCH) (n:50), and long-term care on chronic ventilatory support (LTCVS) (n:30). Serum levels of TSH, free T4 (FT4), free T3 (FT3), and interleukin 6 (IL6) measured at admission day in controls, within 48 h of admission in the intensive care group, between days 31 and 120 in the LTC hospital group and days 31 and 6 years in the LTC on chronic ventilatory support group. RESULTS: Serum FT3 levels were lower in groups intensive care unit ICU, LTCH, and LTCVS than control. Low serum FT3 levels were observed in 80% ICU, 54% LTCH, 37% LTCVS, and 6% control patients. Low serum FT4 levels were observed in 32% ICU, 16% LTCH, and 20% LTCVS patients. Both low serum FT4 and FT3 levels were observed in 32% ICU, 16% LTCH, and 13% LTCVS patients. Serum IL6 and FT3 levels showed a negative correlation. CONCLUSIONS: NTIS is highly prevalent in patients in LTC, creating a state of persistent hypothyroidism. The effects of thyroid hormone replacement in patients at LTC with non-thyroidal illness deserve further investigation.

Prevalence of Bactericidal/Permeability-Increasing Protein Autoantibodies in Cystic Fibrosis Patients: Systematic Review and Meta-Analysis.

Background: There have been varying reports on the prevalence of antineutrophil cytoplasmic antibodies with bactericidal/permeability-increasing protein (BPI-ANCA) specificity in cystic fibrosis (CF) patients. These autoantibodies are believed to develop in response to infection and colonization, especially with Pseudomonas aeruginosa. The aim of this review was to estimate the overall prevalence of BPI-ANCA in CF patients. Methods: We searched PubMed, Scopus, and Embase databases for studies reporting the prevalence of BPI-ANCA in CF patients. We also searched the Journal of Cystic Fibrosis and our institution's library for relevant studies on BPI-ANCA. We calculated the proportion with a 95% confidence interval (CI) to assess the prevalence of BPI-ANCA in the individual studies and then pooled the results using a random effects model. Publication bias was assessed using graphical and statistical methods. Finally, we assessed statistical heterogeneity using the I 2 test. Results: Our search yielded 12 eligible studies published between 1996 and 2015. The prevalence of BPI-ANCA in patients with CF varied from 17.9% to 83% with a pooled prevalence of 49.45% (95% CI 35.53-63.42). No evidence of bias was found. However, there was evidence of statistically significant variation in the prevalence estimate due to heterogeneity (I 2 = 93.4%, P < 0.01). Conclusions: Given the highly varying prevalence of BPI-ANCA in patients with CF, more well-designed prospective clinical studies are needed to determine its true prevalence and clinical relevance.

Acute necrotizing esophagitis presenting with severe lactic acidosis and shock.

Acute necrotizing esophagitis, also known as "black esophagus," is typically characterized by a circumferential, friable black mucosal surface and preferentially involves the distal esophagus. It predominantly affects elderly men and presents as an upper gastrointestinal bleed. We describe a 60-year-old man with an acute upper gastrointestinal bleed and sepsis and subsequently acute necrotizing esophagitis.