Predictors and outcomes of acute pulmonary embolism in COVID-19; insights from US National COVID cohort collaborative.

OBJECTIVES: To investigate whether COVID-19 patients with pulmonary embolism had higher mortality and assess the utility of D-dimer in predicting acute pulmonary embolism. PATIENTS AND METHODS: Using the National Collaborative COVID-19 retrospective cohort, a cohort of hospitalized COVID-19 patients was studied to compare 90-day mortality and intubation outcomes in patients with and without pulmonary embolism in a multivariable cox regression analysis. The secondary measured outcomes in 1:4 propensity score-matched analysis included length of stay, chest pain incidence, heart rate, history of pulmonary embolism or DVT, and admission laboratory parameters. RESULTS: Among 31,500 hospitalized COVID-19 patients, 1117 (3.5%) patients were diagnosed with acute pulmonary embolism. Patients with acute pulmonary embolism were noted to have higher mortality (23.6% vs.12.8%; adjusted Hazard Ratio (aHR) = 1.36, 95% CI [1.20-1.55]), and intubation rates (17.6% vs. 9.3%, aHR = 1.38[1.18-1.61]). Pulmonary embolism patients had higher admission D-dimer FEU (Odds Ratio(OR) = 1.13; 95%CI [1.1-1.15]). As the D-dimer value increased, the specificity, positive predictive value, and accuracy of the test increased; however, sensitivity decreased (AUC 0.70). At cut-off D-dimer FEU 1.8 mcg/ml, the test had clinical utility (accuracy 70%) in predicting pulmonary embolism. Patients with acute pulmonary embolism had a higher incidence of chest pain and history of pulmonary embolism or deep vein thrombosis. CONCLUSIONS: Acute pulmonary embolism is associated with worse mortality and morbidity outcomes in COVID-19. We present D-dimer as a predictive risk tool in the form of a clinical calculator for the diagnosis of acute pulmonary embolism in COVID-19.

Cardiopulmonary disease as sequelae of long-term COVID-19: Current perspectives and challenges.

COVID-19 infection primarily targets the lungs, which in severe cases progresses to cytokine storm, acute respiratory distress syndrome, multiorgan dysfunction, and shock. Survivors are now presenting evidence of cardiopulmonary sequelae such as persistent right ventricular dysfunction, chronic thrombosis, lung fibrosis, and pulmonary hypertension. This review will summarize the current knowledge on long-term cardiopulmonary sequelae of COVID-19 and provide a framework for approaching the diagnosis and management of these entities. We will also identify research priorities to address areas of uncertainty and improve the quality of care provided to these patients.

Ineffective CPAP Treatment After Effective CPAP Titration.

CASE PRESENTATION: A 67-year-old woman was evaluated for snoring, frequent awakenings, excessive sleepiness, nocturia, headaches, witnessed apneas, and choking and gasping from sleep. Medical history included OSA, hypertension, type 2 diabetes, depression in remission, and mild intermittent asthma. Epworth sleepiness scale score was 22 (abnormal is ≥10, maximum score is 24; increasing scores represent increasing sleepiness). She had been prescribed CPAP therapy. She reported initial nasal mask discomfort (ResMed AirFit N20 nasal mask), which improved with change to an oronasal mask. Patient used nightly, with acceptable tolerance. Sleep onset and wake times remained consistent, with an average total sleep time of 7 hours. She denied alcohol intake, sedative medication use, or changes in weight.

Loop-mediated Isothermal Amplification (LAMP) for Identification of Pythium insidiosum.

OBJECTIVE: Pythium insidiosum causes a life-threatening condition called pythiosis. High morbidity and mortality of pythiosis are consequences of delayed diagnosis. We aimed to develop a loop-mediated isothermal amplification (LAMP) assay for the rapid detection of P. insidiosum for use in remote areas, where pythiosis is prevalent. METHODS: We designed four LAMP primers to amplify the rDNA sequence. A side-by-side comparison evaluated performances of LAMP and the previously-established multiplex PCR (M-PCR), using gDNA samples extracted from colonies of P. insidiosum (n = 28) and other fungi (n = 54), and tissues of animals with (n = 16) or without (n = 13) pythiosis. RESULTS: LAMP demonstrated a 50% shorter assay duration (1.5 h) and a 10-fold lower limit of detection (10-4 ng) than did M-PCR. Based on colony-extracted gDNAs, LAMP and M-PCR correctly reported P. insidiosum in all 28 samples, providing 100% sensitivity. While M-PCR did not amplify all fungal controls (100% specificity), LAMP falsely detected one organism (98% specificity). Based on the clinical samples, LAMP and M-PCR provided an equivalently-high specificity (100%). However, LAMP showed a markedly-higher sensitivity than that of M-PCR (88% vs. 56%). CONCLUSIONS: LAMP is a simple, useful, efficient assay for the detection of P. insidiosum in clinical specimens and pure cultures in resource-limited laboratories.

Role of Morphological and Hemodynamic Factors in Predicting Intracranial Aneurysm Rupture: A Review.

Intracranial aneurysms (IAs) carry the risk of rupture, which will lead to subarachnoid hemorrhage, which has a high mortality and morbidity risk. However, the treatment of IA's carries mortality and morbidity risks too. There are well-known risk factors for the rupture of IAs like age, size, and site. However, choosing patients with unruptured IAs for treatment is still a big challenge. This review article aimed to find out the relationship between morphological and hemodynamic characters of IAs with their rupture and incorporate these factors with well-known factors to yield an accurate module for predicting the rupture of IAs and decision-making in the treatment of unruptured IAs. We searched in PubMed and Medline databases by using the following keywords: IAs, subarachnoid hemorrhage, and risk of rupture, morphology, and hemodynamic "mesh." A total of 19 studies with 7269 patients and 9167 IAs, of which 1701 had ruptured, were reviewed thoroughly. Some modules like population, hypertension, age, size, earlier subarachnoid hemorrhage, and site (PHASES) score that involve well-known risk factors can be used to assess the risk of rupture of IAs. However, decision making for treating unruptured IA needs more detailed and more accurate modules. Studying morphological and hemodynamic factors and incorporation of them with well-known risk factors to yield a more comprehensive module will be very helpful in treating unruptured IA. Among morphological factors, aspect ratio (AR), size ratio (SR), aneurysm height, and bottle-neck factor showed significant effects on the growth and rupture of IA. Besides, wall shear stress (WSS), oscillatory shear index (OSI), and low wall shear stress area (LSA) as hemodynamic factors could have a substantial impact on the formation, shape, growth, and rupture of unruptured IA.

The Effect of Anemia and the Goal of Optimal HbA1c Control in Diabetes and Non-Diabetes.

Hemoglobin A1c (HbA1c) is the gold standard for the diagnosis of diabetes; however, many clinical conditions affect the HbA1c level, including anemia. And, the most common causes of anemia worldwide include iron deficiency anemia (IDA). We performed a systematic search using different combinations of MeSH words from the electronic database for the last 10 years (2011 to 2020). Articles included in the study were observational, randomized controlled trial (RCT), and review/systematic review. A total of 18 articles were included in the study. The majority of the studies showed the association between hemoglobin (Hb) and HbA1c. Large-scale studies showed that the HbA1c level increases in IDA and some studies showed its correction after the treatment with oral iron supplementation. Our study indicates the need for screening for anemia in patients before commencing the treatment of diabetes diagnosed via the HbA1c level. Furthermore, anemia should be corrected before setting the treatment goal of optimal HbA1c control, especially when the level is in the diagnostic threshold. Also, the purpose of strict HbA1c control is not recommended in the anemic patient before it is corrected. However, further large-scale interventional studies are needed to know precisely the goal of optimal HbA1c control in diabetic and non-diabetic individuals.

Inhaled Corticosteroids as an Associated Risk Factor for Asthmatic Pneumonia: A Literature Review.

Asthma patients have commonly been prescribed inhaled corticosteroids (ICSs) as the first line of control therapy. ICSs are associated with an increased risk of pneumonia in chronic obstructive airway disease (COPD) patients. However, the evidence remains controversial in asthma patients. Several observational studies reported an increased risk of pneumonia; however, COPD patients were not excluded clearly in these studies. In observational studies that excluded COPD patients and in randomized controlled trials, ICS use was not found to be associated with the risk of pneumonia. Hence, COPD patients should be excluded in future studies, and the currently available evidence demonstrates that ICS use is not associated with an increased risk of pneumonia in asthma patients.

Future of Bariatric Embolization: A Review of Up-to-date Clinical Trials.

Obesity is a significant health issue with an overall rise in mortality; it has multiple risk factors, including hormonal effects, which play a significant role in the balance of food intake and weight gain. Ghrelin is an anabolic hormone secreted from stomach fundus and plays a significant role in this regulation. Management of obesity involves multiple interventions, including lifestyle adjustment, pharmacotherapy, and bariatric surgery. Bariatric embolization is a relatively new procedure; several animal studies show that embolization of the left gastric artery reduces serum ghrelin and induces weight loss.  Also, several clinical studies were conducted in the past ten years which have shown bariatric embolization's effectiveness in inducing weight loss: a meta-analysis of 47 patients included in six different clinical studies of left gastric artery embolization resulted in 8% total weight loss from baseline body weight. Many studies also show this procedure's effect on lowering the HgA1C level and lipid profile. Clinical studies mostly reported minor adverse effects such as transient abdominal discomfort, nausea and vomiting, gastric ulcers, and major adverse effects were uncommon, suggesting the procedure is well tolerated. It may be an alternative line of management in patients who are not suitable candidates for bariatric surgery. Although future clinical studies will provide an answer to several questions like the exact effects of the procedure on diabetes and metabolic syndrome, future studies are also needed to establish particular guidelines to match different patient characteristics with their optimal procedural techniques and pre- and post-procedure evaluation tests.

Potential specific therapies in COVID-19.

COVID-19 has grown into a global pandemic that has strained healthcare throughout the world. There is a sense of urgency in finding a cure for this deadly virus. In this study, we reviewed the empiric options used in common practice for COVID-19, based on the literature available online, with an emphasis on human experiences with these treatments on severe acute respiratory syndrome-associated coronavirus (SARS-COV-1) and other viruses. Convalescent blood products are the most promising potential treatment for use in COVID-19. The use of chloroquine or hydroxychloroquine (HCQ), remdesivir, and tocilizumab are some of the other promising potential therapies; however, they are yet to be tested in randomized clinical trials (RCTs). The use of lopinavir-ritonavir did not prove beneficial in a large RCT. The use of corticosteroids should be avoided in COVID-19 pneumonia unless used for other indications, based on the suggestion of harm in patients with SARS-COV-1 and Middle Eastern Respiratory Syndrome (MERS) infection. The reviews of this paper are available via the supplemental material section.

A Rare Thermophilic Bug in Complicated Diverticular Abscess.

Actinomycosis is a form of painful abscess in the gastrointestinal tract or in deep tissue caused by actinomyces species. They are one of the commensal bacteria in the oral cavity and gastrointestinal tract of humans but can opportunistically cause infection in immunosuppressive hosts through invasion of breached mucosa or necrotic tissue while mimicking malignancy, gastrointestinal tuberculosis, and inflammatory bowel disease. Actinomyces israelii is, by far, the major and most common human pathogen throughout literatures. By virtue of rarity and diagnostic confusion with masquerading malignancies, only 10% of the cases have been diagnosed preoperatively, so as to be able to verge patients from undergoing unnecessary surgical intervention. Herein, we present a rare case of complicated diverticular abscess manifested by Actinomyces meyeri after postoperative tissue diagnosis.