The impact of fever as a testing indication on the detection rate of deep vein thrombosis in neurocritically ill patients.

Aim: Deep vein thrombosis (DVT) is considered a possible source of non-infectious, non-central fever in the intensive care unit (ICU). In the neurocritically ill, it is unknown whether lower extremity venous Doppler ultrasonography (LEVDUS) for DVT in the setting of fever leads to a higher detection rate than the baseline detection rate of DVT in this population. The aim of this study was to compare the DVT detection rate of LEVDUS performed for the indication of fever to LEVDUS performed for other indications in a neurosciences ICU. Methods: Requisition forms for all LEVDUS performed in a referral neurosciences ICU were reviewed and separated into those with "fever" as the stated reason for request and those with other stated reasons. The DVT detection rate was compared between these two categories of indications. Results: Five hundred eleven LEVDUS were analyzed, of which 422 had been ordered for indications other than fever. Sixteen of these tests were positive, a detection rate of 3.8%. The remaining 89 LEVDUS had "fever" as the ordering indication. Six of these tests were positive for DVT, a detection rate of 6.7%. The likelihood of positivity of a test obtained as part of fever evaluation relative to one obtained for non-fever indications was not significantly different (OR, 1.83; 95% CI, 0.570-5.11; P = 0.246). Conclusion: LEVDUS triggered by fever detected DVT at a numerically, but not statistically significantly higher rate than did LEVDUS performed for other indications in a neurocritically ill population. More rigorous investigation of this question is needed.

Early tracheostomy in patients undergoing mechanical thrombectomy for acute ischemic stroke.

PURPOSE: Respiratory failure following mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is a known complication, and requirement of tracheostomy is associated with worse outcomes. Our objective is to evaluate characteristics associated with tracheostomy timing in AIS patients treated with MT. METHODS: The National Inpatient Sample was queried for adult patients treated with MT for AIS from 2016 to 2019. Baseline demographic characteristics, comorbidities, and inpatient outcomes were analyzed for associations in patients who received tracheostomy. Timing of early tracheostomy (ETR) was defined as placement before day 8 of hospital stay. RESULTS: Of 3505 AIS-MT patients who received tracheostomy, 915 (26.1%) underwent ETR. Patients who underwent ETR had shorter length of stay (LOS) (25.39 days vs 32.43 days, p < 0.001) and lower total hospital charges ($483,472.07 vs $612,362.86, p < 0.001). ETR did not confer a mortality benefit but was associated with less acute kidney injury (OR, 0.697; p = 0.013), pneumonia (OR, 0.449; p < 0.001), and sepsis (OR, 0.536; p = 0.002). CONCLUSION: An expected increase in complications and healthcare resource utilization is seen in AIS-MT patients receiving tracheostomy, likely reflecting the severity of patients' post-stroke neurologic injury. Among these high-risk patients, ETR was predictive of shorter LOS and fewer complications.

Significant Mortality Associated With COVID-19 and Comorbid Cerebrovascular Disease: A Quantitative Systematic Review.

We report the first quantitative systematic review of cerebrovascular disease in coronavirus disease 2019 (COVID-19) to provide occurrence rates and associated mortality. Through a comprehensive search of PubMed we identified 8 cohort studies, 5 case series, and 2 case reports of acute cerebrovascular disease in patients with confirmed COVID-19 diagnosis. Our first meta-analysis utilizing the identified publications focused on comorbid cerebrovascular disease in recovered and deceased patients with COVID-19. We performed 3 additional meta-analyses of proportions to produce point estimates of the mortality and incidence of acute cerebrovascular disease in COVID-19 patients. Patient's with COVID-19 who died were 12.6 times more likely to have a history of cerebrovascular disease. We estimated an occurrence rate of 2.6% (95% confidence interval, 1.2-5.4%) for acute cerebrovascular disease among consecutively admitted patients with COVID-19. While for those with severe COVID-19' we estimated an occurrence rate of 6.5% (95% confidence interval, 4.4-9.6%). Our analysis estimated a rate of 35.5% for in-hospital mortality among COVID-19 patients with concomitant acute cerebrovascular disease. This was consistent with a mortality rate of 34.0% which we obtained through an individual patient analysis of 47 patients derived from all available case reports and case series. COVID-19 patients with either acute or chronic cerebrovascular disease have a high mortality rate with higher occurrence of cerebrovascular disease in patients with severe COVID-19.

Extracorporeal membrane oxygenation in COVID-19 compared to other etiologies of acute respiratory failure: A single-center experience.

BACKGROUND: The COVID-19 pandemic has led to a boom in the use of V-V ECMO for ARDS secondary to COVID. Comparisons of outcomes of ECMO for COVID to ECMO for influenza have emerged. Very few comparisons of ECMO for COVID to ECMO for ARDS of all etiologies are available. OBJECTIVES: To compare clinically important outcome measures in recipients of ECMO for COVID to those observed in recipients of ECMO for ARDS of other etiologies. METHODS: V-V ECMO recipients between March 2020 and March 2022 consisted exclusively of COVID patients and formed the COVID ECMO group. All patients who underwent V-V ECMO for ARDS between January 2014 and March 2020 were eligible for analysis as the non-COVID ECMO comparator group. The primary outcome was survival to hospital discharge. Secondary outcomes included ECMO decannulation, ECMO duration >30 days, and serious complications. RESULTS: Thirty-six patients comprised the COVID ECMO group and were compared to 18 non-COVID ECMO patients. Survival to hospital discharge was not significantly different between the two groups (33% in COVID vs. 50% in non-COVID; p = 0.255) nor was there a significant difference in the rate of non-palliative ECMO decannulation. The proportion of patients connected to ECMO for >30 days was significantly higher in the COVID ECMO group: 69% vs. 17%; p = 0.001. There was no significant difference in serious complications. CONCLUSION: This study could not identify a statistically significant difference in hospital survival and rate of successful ECMO decannulation between COVID ECMO and non-COVID ECMO patients. Prolonged ECMO may be more common in COVID. Complications were not significantly different.

Impact of jet lag on free throw shooting in the National Basketball Association.

Jet lag can impair a variety of physical and mental functions. The impact of jet lag on athletic performance has been assumed but difficult to prove methodologically. The challenges have involved eliminating the impact of the quality of the opponent and the difficulties determining when an athlete actually traveled across time zones. Analyzing free throw (FT) shooting in the National Basketball Association allowed these challenges to be overcome. 48,309 games across 19 consecutive seasons were examined of which 675 games involved a team that met our definition of jet lag. In these games, players on the jet lagged teams made 12,154 of 16,286 (74.6%) FTs that were attempted while in the remaining games of that season, the same players on these teams made 993,962 of 1,318,188 (75.4%) FTs attempted, X2 (1, N = 1,334,474) = 5.21, p = .02. There was no significant impact of jet lag on the players who took the most number of FTs in these jet lagged games. However, the remaining players on the team made 7,394 of 10,016 (73.8%) FTs attempted in jet lagged games while the same players made 794,009 of 1,056,587 (75.1%) FTs in other games that season, X2 (1, N = 1,066,603) = 9.35, p = .002. When subcategorized further, the impact on the players on jet lagged teams was only seen when they traveled from east to west but not when travel was from west to east. Our analysis reveals that jet lag does negatively influence athletic performance, primarily through circadian rhythm disruption. However, elite athletes appear to be able to overcome this impact if they are given enough opportunities to do so.

Comparison of pulse-dose and high-dose corticosteroids with no corticosteroid treatment for COVID-19 pneumonia in the intensive care unit.

Corticosteroid dosing in the range of 0.5-2 mg/kg/day of methylprednisolone equivalents has become a standard part of the management of intensive care unit (ICU) patients with COVID-19 pneumonia based on positive results of randomized trials and a meta-analysis. Alongside such conventional dosing, administration of 1 gm of methylprednisolone daily (pulse dosing) has also been reported in the literature with claims of favorable outcomes. Comparisons between such disparate approaches to corticosteroids for Coronavirus disease 2019 (COVID-19) pneumonia are lacking. In this retrospective study of patients admitted to the ICU with COVID-19 pneumonia, we compared patients treated with 0.5-2 mg/kg/day in methylprednisolone equivalents (high-dose corticosteroids) and patients treated with 1 gm of methylprednisolone (pulse-dose corticosteroids) to those who did not receive any corticosteroids. The endpoints of interest were hospital mortality, ICU-free days at Day 28, and complications potentially attributable to corticosteroids. Pulse-dose corticosteroid therapy was associated with a significant increase in ICU-free days at Day 28 compared to no receipt: adjusted relative risk (aRR): 1.45 (95% confidence interval [CI]: 1.05-2.02; p = 0.03) and compared with high-dose corticosteroid administration (p = 0.003). Nonetheless, receipt of high-dose corticosteroids-but not of pulse-dose corticosteroids-significantly reduced the odds of hospital mortality compared to no receipt: adjusted Odds ratio (aOR) 0.31 (95% CI: 0.12-0.77; p = 0.01). High-dose corticosteroids reduced mortality compared to pulse-dose corticosteroids (p = 0.04). Pulse-dose corticosteroids-but not high-dose corticosteroids-significantly increased the odds of acute kidney injury requiring renal replacement therapy compared to no receipt: aOR 3.53 (95% CI: 1.27-9.82; p = 0.02). The odds of this complication were also significantly higher in the pulse-dose group when compared to the high-dose group (p = 0.05 for the comparison). In this single-center study, pulse-dose corticosteroid therapy for COVID-19 pneumonia in the ICU was associated with an increase in ICU-free days but failed to impact hospital mortality, perhaps because of its association with development of severe renal failure. In line with existing trial data, the effect of high-dose corticosteroids on mortality was favorable.

Clinical and Laboratory Profile of COVID-19 Pneumonia Patients With a Complicated Post-Intensive Care Unit Hospital Course.

BACKGROUND: Characteristics of intensive care unit (ICU) downgrades who experience a complicated post-ICU ward course (ICU return or floor death) and the incidence of this phenomenon have not been examined in ICU survivors of coronavirus disease 2019 (COVID-19) pneumonia. The aim of the present study was to establish the rate of a complicated post-ICU ward course among survivors of COVID-19 pneumonia and describe the associated patient, ICU management, and serum biomarker characteristics. An additional aim was to compare these parameters between those who experienced a complicated post-ICU course and those who did not. METHODS: This was a retrospective study of patients who were admitted to the ICU with COVID-19 pneumonia and were downgraded to a hospital floor at the end of their initial ICU stay. Patients were divided based on a complicated or uncomplicated post-ICU course. Groups were compared with respect to relevant clinical variables. Serum biomarker levels were compared on day of ICU exit and were trended in the days preceding the downgrade. Ward stay of patients who had a complicated course was examined for notable floor events surrounding their decompensation. RESULTS: Eighteen out of 99 downgraded patients (18%) experienced a complicated post-ICU course, among them there were 14 returns (14%) and four deaths (4%). They had higher Charlson Comorbidity Index, higher Acute Physiology and Chronic Health Evaluation (APACHE) IV score, as well as higher D-dimer and C-reactive protein (CRP) at ICU departure. They were less likely to have received therapeutic anticoagulation and convalescent plasma during their ICU stay. On multivariable analysis, these parameters except D-dimer remained independently associated with a complicated course. Review of biomarker trends preceding ICU exit demonstrated an upward trajectory of D-dimer, CRP, and lactate dehydrogenase (LDH) in the complicated course group not mirrored by the uncomplicated course group. Examination of notable floor events leading up to decompensation revealed that in 50% the ward course was characterized by new cardiac disturbances. CONCLUSIONS: Our rate of ward death among ICU downgrades was similar to pre-COVID data, but the rate of ICU return was higher. Complicated post-ICU course patients were exhibiting upward biomarker trends at ICU exit, and their ward stay was punctuated by acute cardiac abnormalities.

Obstructive sleep apnoea and cardiovascular disease: a literature review.

As obesity becomes more common worldwide, the prevalence of obstructive sleep apnoea (OSA) continues to rise. Obstructive sleep apnoea is a well-known disorder that causes chronic intermittent hypoxia (CIH), which is considered a risk factor for atherosclerosis directly and indirectly. Ischaemic heart disease remains the leading cause of death. Most risk factors for atherosclerosis are well understood. However, other factors such as CIH are less well understood. Several studies have investigated the pathophysiology of CIH, attempting to uncover its link to atherosclerosis and to determine whether OSA treatment can be a therapeutic modality to modify the risk for atherosclerosis. In this article, we will review the pathophysiology of OSA as an independent risk factor for cardiovascular disease and discuss the most common markers that have been studied. We will also examine the potential impact of OSA management as a risk factor modifier on the reversibility of atherosclerosis.

Stroke in critical COVID-19 patients: a cautionary tale from the frontlines.

INTRODUCTION: Although Coronavirus Disease 2019 (COVID-19) is primarily a disease of the respiratory system in its transmission and clinical manifestations, physicians have also reported a tropism toward the nervous system. METHODS: Neurological symptoms can occur as one of many systemic manifestations of a critical form of the disease or in isolation as the predominant presenting complaint. RESULTS: We report a series of 6 patients who suffered significant cerebrovascular accidents while being treated for critical COVID-19 in the intensive care units of a quaternary care hospital in New York's Hudson valley. CONCLUSIONS: This series demonstrates how a relatively rare but catastrophic neurological complication can occur in patients with COVID-19 while they are being managed for their more common problems such as respiratory and renal failure.

Postobstructive pneumonia in lung cancer.

Postobstructive pneumonia can complicate lung cancer, particularly in more advanced stages of the disease, producing significant clinical decline and a poorer prognosis. It can lead to complications such as empyema, lung abscess and fistula formation. Postobstructive pneumonia can also be the first manifestation of an underlying malignancy. There are multiple challenges in the management of these patients. Recognition and treatment of this entity can be complex and includes the use of imaging, administration of broad-spectrum antibiotics to cover the wide variety of microorganisms involved and the use of different interventional modalities to relieve the obstruction. Existing literature on postobstructive pneumonia is scarce. In this article, we review the pathophysiology, different diagnostic methods and the therapeutic options to treat this condition. The utility and efficacy of the various modalities that are currently available in clinical practice to the interventional pulmonologist are described in some detail.

Intracranial Administration of Nicardipine After Aneurysmal Subarachnoid Hemorrhage: A Review of the Literature.

BACKGROUND: Intrathecal (IT), intraventricular (IVt), and intracisternal administration of nicardipine deliver treatment directly into the central nervous system. This route of drug delivery is being investigated as a potential treatment of vasospasm following aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE: The authors reviewed the existing literature regarding the direct administration of nicardipine into the intracranial space for the treatment of vasospasm following aSAH. METHODS: An electronic search of literature published between 1994 and 2018 was performed using PubMed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. A variety of combinations of the search terms "intrathecal nicardipine," "intraventricular nicardipine," and "nicardipine prolonged-release" were used. RESULTS: A total of 17 studies were included in this systematic review, 3 of which were studies in animals. The studies consistently demonstrated that IT nicardipine successfully reverses vasospasm, but the effect, as shown in some studies, was limited to the immediate vicinity of drug release. The data regarding long-term clinical outcomes are variable, with some studies demonstrating marked improvement whereas others fail to demonstrate improved outcomes when compared with patients who receive standard of care. Although adverse sequalae were uncommon, IT and IVt administration and therapy were associated with adverse effects including headache, meningitis, and hydrocephalus. CONCLUSIONS: Given the findings presented in these studies, IT, IVt, and intracisternal (pellet) nicardipine administration can be useful treatment adjuncts for vasospasm following aSAH, especially in cases refractory to conventional forms of treatment. However, larger, controlled clinical trials are warranted.

Low Risk Monitoring in Neurocritical Care.

Background/Rationale: Patients are admitted to Intensive care units (ICUs) either because they need close monitoring despite a low risk of hospital mortality (LRM group) or to receive ICU specific active treatments (AT group). The characteristics and differential outcomes of LRM patients vs. AT patients in Neurocritical Care Units are poorly understood. Methods: We classified 1,702 patients admitted to our tertiary and quaternary care center Neuroscience-ICU in 2016 and 2017 into LRM vs. AT groups. We compared demographics, admission diagnosis, goal of care status, readmission rates and managing attending specialty extracted from the medical record between groups. Acute Physiology, Age and Chronic Health Evaluation (APACHE) IVa risk predictive modeling was used to assess comparative risks for ICU and hospital mortality and length of stay between groups. Results: 56.9% of patients admitted to our Neuroscience-ICU in 2016 and 2017 were classified as LRM, whereas 43.1% of patients were classified as AT. While demographically similar, the groups differed significantly in all risk predictive outcome measures [APACHE IVa scores, actual and predicted ICU and hospital mortality (p < 0.0001 for all metrics)]. The most common admitting diagnosis overall, cerebrovascular accident/stroke, was represented in the LRM and AT groups with similar frequency [24.3 vs. 21.3%, respectively (p = 0.15)], illustrating that further differentiating factors like symptom duration, neurologic status and its dynamic changes and neuro-imaging characteristics determine the indication for active treatment vs. observation. Patients with intracranial hemorrhage/hematoma were significantly more likely to receive active treatments as opposed to having a primary focus on monitoring [13.6 vs. 9.8%, respectively (p = 0.017)]. Conclusion: The majority of patients admitted to our Neuroscience ICU (56.9%) had <10% hospital mortality risk and a focus on monitoring, whereas the remaining 43.1% of patients received active treatments in their first ICU day. LRM Patients exhibited significantly lower APACHE IVa scores, ICU and hospital mortality rates compared to AT patients. Observed-over-expected ICU and hospital mortality ratios were better than predicted by APACHE IVa for low risk monitored patients and close to prediction for actively treated patients, suggesting that at least a subset of LRM patients may safely and more cost effectively be cared for in intermediate level care settings.

Diagnostic and therapeutic challenges in managing persistent air leaks.

Persistent air leak (PAL) is a common and challenging condition associated with increased morbidity and mortality, intensive care unit admission, and prolonged hospital stay. Multiple medical and surgical approaches have been developed to manage PAL. Depending on the etiology of PAL, surgical management may be effective and usually performed using video-assisted thoracoscopic surgery (VATS). Medical management is less invasive and consists of pleural or bronchoscopic methods. The non-surgical techniques for the management of PAL have not been investigated in large prospective studies, and so their use is mostly guided by observational data. Specifically, the role of intrabronchial valve (IBV) placement for PAL has been the subject of an ever-increasing number of case reports and series documenting successful deployment of IBVs for both surgical and medical PAL. In this case-based discussion, we describe three patients with non-surgical PAL who were managed using multiple modalities, including both surgical and medical approaches. These cases illustrate the challenges in identifying the location of the air leak and in the application of various therapeutic options.

Milestones: a rapid assessment method for the Clinical Competency Committee.

INTRODUCTION: Educational milestones are now used to assess the developmental progress of all U.S. graduate medical residents during training. Twice annually, each program's Clinical Competency Committee (CCC) makes these determinations and reports its findings to the Accreditation Council for Graduate Medical Education (ACGME). The ideal way to conduct the CCC is not known. After finding that deliberations reliant upon the new milestones were time intensive, our internal medicine residency program tested an approach designed to produce rapid but accurate assessments. MATERIAL AND METHODS: For this study, we modified our usual CCC process to include pre-meeting faculty ratings of resident milestones progress with in-meeting reconciliation of their ratings. Data were considered largely via standard report and presented in a pre-arranged pattern. Participants were surveyed regarding their perceptions of data management strategies and use of milestones. Reliability of competence assessments was estimated by comparing pre-/post-intervention class rank lists produced by individual committee members with a master class rank list produced by the collective CCC after full deliberation. RESULTS: Use of the study CCC approach reduced committee deliberation time from 25 min to 9 min per resident (p < 0.001). Committee members believed milestones improved their ability to identify and assess expected elements of competency development (p = 0.026). Individual committee member assessments of trainee progress agreed well with collective CCC assessments. CONCLUSIONS: Modification of the clinical competency process to include pre-meeting competence ratings with in-meeting reconciliation of these ratings led to shorter deliberation times, improved evaluator satisfaction and resulted in reliable milestone assessments.

Pulmonary sarcoidosis: an update.

Sarcoidosis is a multisystem disease characterized by the presence of noncaseating granulomas, the exact etiology of which is yet to be determined. Pulmonary involvement occurs in the majority of patients and its severity ranges from asymptomatic involvement of mediastinal lymph nodes to progressive pulmonary fibrosis and chronic respiratory failure that is insensitive to treatment. Diagnosis of pulmonary sarcoidosis requires a compatible clinical picture supported by radiologic and pathologic data. A recent development in establishing the diagnosis of pulmonary sarcoidosis is endobronchial ultrasound that increases the yield of transbronchial needle aspiration of hilar and/or mediastinal lymph nodes. Fluorodeoxyglucose positron emission tomography (FDG-PET) is highly sensitive in detecting occult sites of disease and is of value in guiding biopsies of these sites. A combined imaging modality using both FDG-PET and CT scan is more sensitive than PET alone and is now the standard of care in patients requiring biopsies of active lesions. Biologic agents like anti-tumor necrosis factor antibodies are being used as second line treatment in those patients dependent on steroids or in cases of refractory sarcoidosis. Lung transplantation is the final option in suitable patients with end-stage pulmonary sarcoidosis.

Role of extracorporeal membrane oxygenation in adult respiratory failure: an overview.

Extracorporeal membrane oxygenation (ECMO) provides complete or partial support of the heart and lungs. Ever since its inception in the 1960s, it has been used across all age groups in the management of refractory respiratory failure and cardiogenic shock. While it has gained widespread acceptance in the neonatal and pediatric physician community, ECMO remains a controversial therapy for Acute Respiratory Distress Syndrome (ARDS) in adults. Its popularity was revived during the swine flu (H1N1) pandemic and advancements in technology have contributed to its increasing usage. ARDS continues to be a potentially devastating condition with significant mortality rates. Despite gaining more insights into this entity over the years, mechanical ventilation remains the only life-saving, yet potentially harmful intervention available for ARDS. ECMO shows promise in this regard by offering less dependence on mechanical ventilation, thereby potentially reducing ventilator-induced injury. However, the lack of rigorous clinical data has prevented ECMO from becoming the standard of care in the management of ARDS. Therefore, the results of two large ongoing randomized trials, which will hopefully throw more light on the role of ECMO in the management of this disease entity, are keenly awaited. In this article we will provide a basic overview of the development of ECMO, the types of ECMO, the pathogenesis of ARDS, different ventilation strategies for ARDS, the role of ECMO in ARDS and the role of ECMO as a bridge to lung transplantation.

Pulmonary nodule: a comprehensive review and update.

The incidental detection of solitary pulmonary nodules and ground-glass nodules has increased substantially with the use of computed tomography as a diagnostic modality and is expected to rise exponentially as lung cancer screening guidelines are more widely implemented by primary care physicians. The lesions should then be classified as low, indeterminate, or high risk for malignancy, depending on the clinical and radiological characteristics. Once classified, these lesions should be evaluated and managed as per expert consensus-based recommendations for performing follow-up computed tomography scans and tissue sampling depending on the pretest probability. When weighing the risks and benefits of further investigations, patient preference and suitability for surgery should be taken into consideration as well.