Impact of concomitant gastroesophageal reflux disease symptomology on prognosis and pulmonary function of chronic hypersensitivity pneumonitis.

Background and Objectives: Comorbid risk factors in chronic hypersensitivity pneumonitis (CHP) are poorly characterised. Gastroesophageal reflux disease (GERD) is linked to interstitial lung diseases like idiopathic pulmonary fibrosis (IPF), but its association and treatment in CHP is less understood. This study aims to understand the role and prevalence of GERD in CHP, plus the effect of GERD treatment on lung function and mortality. Methods: A tertiary referral centre panel was retrospectively reviewed for 214 patients diagnosed with CHP based on clinical history, bronchoalveolar lavage fluid analysis, imaging and histopathology. GERD diagnostic criteria included symptomology, acid suppressive therapy use and diagnostic testing. CHP patients with GERD (n = 89) and without GERD (n = 125) were compared via descriptive statistical analysis. Pulmonary function, GERD diagnosis plus treatment and other comorbidities were evaluated against CHP outcomes. Results: Respective differences between diagnosis and study termination dates in the GERD population versus without GERD for functional vital capacity (FVC) were - 1 L vs - 2.5 L, diffusing capacity of the lungs for carbon monoxide (DLCO) were - 2 mL/min/mmHg versus - 1 mL/min/mmHg, per cent alive at the time of study 88% versus 81%, median date of survival 574.5 versus 850 and supplemental oxygen requirement 41% versus 37%. GERD prevalence was higher in CHP patients relative to the general population. No statistical significance was found between survival curves, oxygen requirement, smoking history, FVC, or DLCO. Conclusions: GERD could be a harmful comorbidity in CHP though may not necessarily affect survival or functional outcomes. This aligns with previous IPF studies, though remains controversial. Further research is needed regarding this association and treatment benefit.

Impact of Pulmonary Hypertension Hemodynamic Phenotype on Incident Atrial Fibrillation.

INTRODUCTION: Atrial fibrillation/flutter (AF) is common among patients with pulmonary hypertension (PH) and is associated with poor clinical outcomes. AF has been shown to occur more commonly among patients with postcapillary PH, although AF also occurs among patients with precapillary PH. The goal of this study was to evaluate the independent impact of PH hemodynamic phenotype on incident AF among patients with PH. METHODS: We retrospectively identified 262 consecutive patients, without a prior diagnosis of atrial arrhythmias, seen at the PH clinic at Mayo Clinic, Florida, between 1997 and 2017, who had right heart catheterization and echocardiography performed, with follow-up for outcomes through 2021. Kaplan-Meier analysis and Cox-proportional hazards regression modeling were used to evaluate the independent effect of PH hemodynamic phenotype on incident AF. RESULTS: Our study population was classified into two broad PH hemodynamic groups: precapillary (64.9%) and postcapillary (35.1%). The median age was 59.5 years (Q1: 48.4, Q3: 68.4), and 72% were female. In crude models, postcapillary PH was significantly associated with incident AF (HR 2.17, 95% CI: 1.26-3.74, p = 0.005). This association was lost following multivariable adjustment, whereas left atrial volume index remained independently associated with incident AF (aHR 1.30, 95% CI: 1.09-1.54, p = 0.003). CONCLUSION: We found PH hemodynamic phenotype was not significantly associated with incident AF in our patient sample; however, echocardiographic evidence of left atrial remodeling appeared to have a greater impact on AF development. Larger studies are needed to validate these findings and identify potential modifiable risk factors for AF in this population.

Overwhelming cryptococcosis complicated by cryptococcal endocarditis.

Cryptococcal species endocarditis is infrequently described, carries high mortality and nearly always occurs in immunocompromised states or on prosthetic valves. We report the case of a man in his 70s with multiple recent hospitalisations for pneumonia, hypercalcaemia and septic tank exposure who presented with intermittent fevers, progressive weakness,and worsening encephalopathy, manifested as confusion and word-finding difficulties for 3 weeks. Workup revealed cryptococcal species on blood serum gram stain, native aortic valve endocarditis and meningitis. Cerebrospinal fluid analysis demonstrated lymphocytosis, ultimately found to be secondary to chronic lymphocytic leukaemia. Surgical valve replacement was deemed medically contraindicated and antifungal therapy was initiated. Though poorly understood with very few documented cases, management of cryptococcal endocarditis relies on prompt diagnosis, early surgery when indicated, long-term antifungal therapy and treatment of underlying immunocompromising states where possible.

Cardiovascular Concerns from COVID-19 in Pilots.

BACKGROUND: Cardiovascular disease, now complicated by the COVID-19 pandemic, remains a leading cause of death and risk for sudden incapacitation for pilots during flight. The capacity for aeromedically significant cardiovascular sequelae with potentially imperceptible clinical symptoms elicits concern both during and following resolution of acute COVID-19 in pilots.OBJECTIVE: We summarize the current state of knowledge regarding COVID-19 cardiovascular implications as applied to the aviation environment to better understand their significance toward flight safety and application toward a focused cardiovascular screening protocol following recovery from infection.METHODS: A narrative review of the cardiovascular implications of COVID-19 infection was performed using the PubMed literature search engine and existing organizational guidelines. In addition, to established medical aviation benchmarks, surrogate populations examined included high performance athletes (as a correlate for high G-forces), and scuba divers (as an environmental work analog). Conditions of primary concern included myocardial injury, proarrhythmic substrates, risk of sudden death, myopericarditis, pulse orthostatic lability in response to vigorous activity, cardiovagal dysfunction, and thromboembolic disease.LITERATURE REVIEW: Cardiovascular screening guideline recommendations post-infection recovery are suggested based on profile stratification: airperson flight class, tactical military, and aerobatic pilots. This provides an approach to inform aeromedical decision making.CONCLUSION: Aviation medical examiners should remain cognizant of the clinically apparent and occult manifestations of cardiovascular dysfunction associated with COVID-19 infection when applying return-to-work screening guidelines. This will ensure high flight safety standards are maintained and sudden incapacitation risk mitigated during and following the ongoing pandemic.Elkhatib W, Herrigel D, Harrison M, Flipse T, Speicher L. Cardiovascular concerns from COVID-19 in pilots. Aerosp Med Hum Perform. 2022; 93(12):855-865.

The Use of an Interleukin-6 Inhibitor in Vasoplegic Shock from Severe Systemic Inflammatory Response Syndrome: A Case Report.

A 66-year-old Caucasian male with a history of chronic myelomonocytic leukemia (CMML) developed fluid-unresponsive hypotension requiring initiation of four different maximum dosed vasopressors, steroids, and broad-spectrum antibiotics 4 hours following four-vessel coronary artery bypass grafting involving a 150-minute cardiac bypass. Placement of a Swanz-Ganz catheter showed a cardiac output of 7 L/minute with systemic vascular resistance of 571 dynes/sec/cm-5. Over 24 hours, three doses of tocilizumab (interleukin-6 inhibitor) every 8 hours were initiated, plus 250 mg methylprednisolone per 6 hours increment, and then daily thereafter. After the initial dose of tocilizumab, it was possible to wean vasoconstrictors. We have shown for the first time that therapy with tocilizumab is effective in reversing the hemodynamic instability associated with the significant systemic inflammatory response from the "double hit" of CMML and coronary artery bypass grafting with cardiopulmonary bypass as has previously been shown in cytokine release syndrome. How to cite this article: Elkhatib WY, Saunders H, Helgeson SA, Moss JE. The Use of an Interleukin-6 Inhibitor in Vasoplegic Shock from Severe Systemic Inflammatory Response Syndrome: A Case Report. Indian J Crit Care Med 2021;25(8):939-941.

Mouse Hind Limb Skeletal Muscle Functional Adaptation in a Simulated Fine Branch Arboreal Habitat.

The musculoskeletal system is remarkably plastic during growth. The purpose of this study was to examine the muscular plasticity in functional and structural properties in a model known to result in significant developmental plasticity of the postcranial skeleton. Fifteen weanling C57BL/6 mice were raised to 16 weeks of age in one of two enclosures: a climbing enclosure that simulates a fine branch arboreal habitat and is traversed by steel wires crossing at 45° relative to horizontal at multiple intersections, and a control enclosure that resembles a parking deck with no wires but the same volume of habitable space. At killing, ex vivo contractility properties of the soleus (SOL) and extensor digitorum longus (EDL) muscles were examined. Our results demonstrate that EDL muscles of climbing mice contracted with higher specific forces and were comprised of muscle fibers with slower myosin heavy chain isoforms. EDL muscles also fatigued at a higher rate in climbing mice compared to controls. SOL muscle function is not affected by the climbing environment. Likewise, mass and architecture of both EDL and SOL muscles were not different between climbing and control mice. Our data demonstrate that functional adaptation does not require concomitant architectural adaptation in order to increase contractile force. Anat Rec, 301:434-440, 2018. © 2018 Wiley Periodicals, Inc.