A Giant Right-Heart Thrombus-in-Transit in a Patient with COVID-19 Pneumonia.

BACKGROUND Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread to more than 200 countries across the world. Studies have shown that patients with COVID-19 are prone to thrombotic disease resulting in increased mortality. We present a case of COVID-19 pneumonia in a warehouse worker with a giant thrombus-in-transit involving the right ventricle and tricuspid valve. We also describe the associated diagnostic and therapeutic challenges. CASE REPORT A 54-year-old man with recent COVID-19 exposure presented with fever, cough, dyspnea, and syncope and was found to be in hypoxic respiratory failure requiring supplemental oxygen. The clinical course deteriorated with worsening respiratory failure and septic shock, requiring mechanical ventilation and pressor support. Further evaluation revealed a positive nasopharyngeal swab for SARS-CoV-2 and an S1Q3T3 pattern on electrocardiogram. A bedside transthoracic echocardiogram was performed due to clinical deterioration and hemodynamic instability, which showed a large thrombus-in-transit through the tricuspid valve into the right ventricle. The patient was treated with low-molecular-weight heparin, hydroxychloroquine, azithromycin, and supportive care. A repeat echocardiogram after 1 week did not show any thrombus. The patient slowly improved over the following weeks but required tracheostomy due to prolonged mechanical ventilation. He was discharged on oral anticoagulation. CONCLUSIONS This case highlights the presence of significant COVID-19-related hemostatic disturbances and the importance of associated diagnostic and therapeutic challenges. A bedside echocardiogram can provide valuable information in patients with suspected high-risk pulmonary embolism and hemodynamic instability. Early diagnosis by keeping a high index of suspicion and prompt treatment is vital to avoid adverse outcomes and increased mortality.

Research Needs on Respiratory Health in Migrant and Refugee Populations. An Official American Thoracic Society and European Respiratory Society Workshop Report.

Migrants represent a diverse population comprising workers, students, undocumented individuals, and refugees. Worldwide, approximately 1 billion people were considered migrants in 2016. Notably, about 65 million of these migrants were forcibly displaced from their homes, and 20 million were considered refugees. While the geopolitical consequences of such migration continue to be considered, less is known about the impact of these events on the respiratory health of migrants and refugees. In recognition of this knowledge gap, the American Thoracic Society and the European Respiratory Society brought together investigators with diverse and relevant expertise to participate in a workshop and develop a consensus on research needs on the respiratory health of migrants and refugees. The workshop focused on environmental and occupational hazards, chronic noninfectious diseases, and respiratory infectious diseases, which were presented by experts in three distinct sessions, each culminating with panel discussions. A writing committee collected summaries prepared by speakers and other participants, and the information was collated into a single document. Recommendations were formulated, and differences were resolved by discussion and consensus. The group identified important areas of research need, while emphasizing that reducing the burden of pulmonary, critical care, and sleep disorders in migrants and refugees will require a concerted effort by all stakeholders. Using best research practices, considering how research impacts policies affecting migrant and refugee populations, and developing new approaches to engage and fund trainees, clinical investigators, and public health practitioners to conduct high-quality research on respiratory health of migrants and refugees is essential.

An Expectorated "Stent": An Unexpected Complication of EBUS-TBNA.

Endobronchial ultrasound-guided transbronchial needle aspiration has a low complication rate and is a cost-effective procedure for mediastinal staging and diagnosis when compared with the more invasive mediastinoscopy. There are increasing case reports of unexpected complications including equipment failures with and without significant medical consequences. Knowledge of complications, including those that are rare, is essential for the physician performing this minimally invasive procedure. We report a case of a retained foreign body from the unexpected separation of a distal spring/coil mechanism from the Olympus ViziShot Aspiration needle following early needle deployment within the working channel of the bronchoscope.

Rapid Deployment of International Tele-Intensive Care Unit Services in War-Torn Syria.

The conflict in Syria has created the largest humanitarian emergency of the twenty-first century. The 4-year Syrian conflict has destroyed hospitals and severely reduced the capacity of intensive care units (ICUs) and on-site intensivists. The crisis has triggered attempts from abroad to support the medical care of severely injured and acutely ill civilians inside Syria, including application of telemedicine. Within the United States, tele-ICU programs have been operating for more than a decade, albeit with high start-up costs and generally long development times. With the benefit of lessons drawn from those domestic models, the Syria Tele-ICU program was launched in December 2012 to manage the care of ICU patients in parts of Syria by using inexpensive, off-the-shelf video cameras, free social media applications, and a volunteer network of Arabic-speaking intensivists in North America and Europe. Within 1 year, 90 patients per month in three ICUs were receiving tele-ICU services. At the end of 2015, a network of approximately 20 participating intensivists was providing clinical decision support 24 hours per day to five civilian ICUs in Syria. The volunteer clinicians manage patients at a distance of more than 6,000 miles, separated by seven or eight time zones between North America and Syria. The program is implementing a cloud-based electronic medical record for physician documentation and a medication administration record for nurses. There are virtual chat rooms for patient rounds, radiology review, and trainee teaching. The early success of the program shows how a small number of committed physicians can use inexpensive equipment spawned by the Internet revolution to support from afar civilian health care delivery in a high-conflict country.