Development of a brief scoring system to predict any-cause mortality in patients hospitalized with COVID-19 infection.

Patients hospitalized with COVID-19 infection are at a high general risk for in-hospital mortality. A simple and easy-to-use model for predicting mortality based on data readily available to clinicians in the first 24 hours of hospital admission might be useful in directing scarce medical and personnel resources toward those patients at greater risk of dying. With this goal in mind, we evaluated factors predictive of in-hospital mortality in a random sample of 100 patients (derivation cohort) hospitalized for COVID-19 at our institution in April and May, 2020 and created potential models to test in a second random sample of 148 patients (validation cohort) hospitalized for the same disease over the same time period in the same institution. Two models (Model A: two variables, presence of pneumonia and ischemia); (Model B: three variables, age > 65 years, supplemental oxygen ≥ 4 L/min, and C-reactive protein (CRP) > 10 mg/L) were selected and tested in the validation cohort. Model B appeared the better of the two, with an AUC in receiver operating characteristic curve analysis of 0.74 versus 0.65 in Model A, but the AUC differences were not significant (p = 0.24. Model B also appeared to have a more robust separation of mortality between the lowest (none of the three variables present) and highest (all three variables present) scores at 0% and 71%, respectively. These brief scoring systems may prove to be useful to clinicians in assigning mortality risk in hospitalized patients.

Pneumothorax in Mechanically Ventilated Patients with COVID-19 Infection.

Data on patient-related factors associated with pneumothorax among critically ill patients with COVID-19 pneumonia is limited. Reports of spontaneous pneumothorax in patients with coronavirus disease 2019 (COVID-19) suggest that the COVID-19 infection could itself cause pneumothorax in addition to the ventilator-induced trauma among mechanically ventilated patients. Here, we report a case series of five mechanically ventilated patients with COVID-19 infection who developed pneumothorax. Consecutive cases of intubated patients in the intensive care unit with the diagnosis of COVID-19 pneumonia and pneumothorax were included. Data on their demographics, preexisting risk factors, laboratory workup, imaging findings, treatment, and survival were collected retrospectively between March and July 2020. Four out of five patients (4/5; 80%) had a bilateral pneumothorax, while one had a unilateral pneumothorax. Of the four patients with bilateral pneumothorax, three (3/4; 75%) had secondary bacterial pneumonia, two had pneumomediastinum and massive subcutaneous emphysema, and one of these two had an additional pneumoperitoneum. A surgical chest tube or pigtail catheter was placed for the management of pneumothorax. Three out of five patients with pneumothorax died (3/5; 60%), and all of them had bilateral involvement. The data from these cases suggest that pneumothorax is a potentially fatal complication of COVID-19 infection. Large prospective studies are needed to study the incidence of pneumothorax and its sequelae in patients with COVID-19 infection.

Renal cholesterol crystal embolism in the setting of warfarin use.

A 73-year-old man presented for evaluation of weakness and black tarry stools that occurred 1 day prior to admission. His medical history is significant for diabetes mellitus, stage 3 chronic kidney disease and deep vein thrombosis on warfarin. He was admitted to the hospital and was found to have acute kidney injury and gastrointestinal bleeding due to a supratherapeutic International Normalized Ratio. His hospital course was complicated by persistent decline in his renal function. He was given intravenous fluid resuscitation, fresh frozen plasma and packed red blood cells for his acute blood loss anaemia. Urinalysis was consistent with acute tubular necrosis. Given the persistent rise in creatinine, a kidney biopsy was obtained, and was significant for mild inflammatory changes, without evidence of vasculitis or allergic interstitial nephritis. Histopathological examination with tissue fixation revealed cholesterol embolisation. Given that he had no recent endovascular procedure or instrumentation, this atheroembolic event was attributed to his warfarin use.

Return of the old guard: a case of tetanus in an unvaccinated patient.

A 78-year-old woman with no known medical history presented with severe neck pain that began 4 days prior to admission located in the paraspinal cervical region radiating to the shoulders, legs and back. She had associated stiffness of her neck and progression of pain to her jaw and throat with progression to generalised body spasms with lower extremity stiffness and weakness that limited her ability to walk. She quickly developed dysphagia and odynophagia with subsequent generalised spasms and profound hypoxic respiratory failure requiring nasotracheal intubation. The presumptive diagnosis of tetanus was made and she was given tetanus toxoid immune globulin and Tdap vaccine. She was managed in the intensive care unit and after a week of admission, required a tracheostomy and gastrostomy tube placement. She required a prolonged hospitalisation stay of 21 days before being transferred to a long-term vent facility.

The Discontinuation of Antibiotics in Patients with Chronic Obstructive Pulmonary Disease Exacerbation and a Positive Respiratory Viral Assay: A Single-center Retrospective Analysis.

Background The use of antibiotics in chronic obstructive pulmonary disorder (COPD) exacerbations attributed to viral infections is observed in this study. The aim of this analysis is to describe the rate of discontinuation of antibiotics in patients who have an acute exacerbation of COPD (AECOPD) caused by viral infections, in turn encouraging the use of the respiratory viral panel in an effort to improve antibiotic stewardship at our facility. Methods A retrospective chart review was performed. A total of 92 patients were analyzed who had a positive respiratory viral polymerase chain reaction (PCR) (RVP) admitted for COPD exacerbations, of which 20 patients had a bacterial co-infection by a sputum analysis. Patients with a positive infiltrate on chest X-ray (CXR) were excluded. The rate of discontinuation of antibiotics, excluding azithromycin and doxycycline, in patients with a positive RVP with and without a bacterial co-infection were analyzed. Results Of these 92 patients, we found that a bacterial co-infection was detected by sputum culture in 20 patients. The average number of days until discontinuation for patients with no bacterial coinfection was 1.67 days while for those with a bacterial co-infection was 3.20 days. The difference in the number of days was statistically significant (p<0.001). Conclusion In conclusion, patients with an identified viral etiology of COPD exacerbations had antibiotics discontinued significantly sooner than those patients with bacterial coinfections.

Naloxone-Induced Non-Cardiogenic Pulmonary Edema: A Case Report.

A 22-year-old man was admitted for an elective right-shoulder open subacromial decompression and distal clavicle excision. He received a single intravenous dose of fentanyl 50 µg for anesthesia. His procedure was completed without intra-operative complications; however, he developed post-operative respiratory depression in the setting of narcotic administration. He was given naloxone 0.2 mg intravenously once to reverse this effect, which subsequently led to acute hypoxic respiratory failure secondary to pulmonary edema shortly after administration of naloxone. His oxygen saturation was noted to be 50% on room air, he was tachypneic with a respiratory rate of 22, and his heart rate ranged from 89 to 104 beats per minute. His blood pressure remained within normal limits at 128/62. His chest X-ray was notable for patchy bilateral perihilar infiltrates and the patient was intubated postoperatively. An EKG revealed normal sinus rhythm, and cardiac enzymes were negative. He was diagnosed with naloxone-induced non-cardiogenic pulmonary edema supported by the temporal relationship of the causal drug and no other identifiable cause of his clinical picture. He received furosemide and underwent diuresis while intubated, with subsequent improvement in his oxygen requirements. His vitals remained stable and he was extubated 6 h later. A Naranjo assessment score of 6 was obtained, indicating a probable relationship between the patient's symptoms and the suspect drug.

Venous and arterial air embolism: a rare phenomenon with fatal consequences.

Air embolism is often an iatrogenic complication which may occur in venous or arterial circulation depending on the port of entry. We present two cases in which air embolism occurred in venous and arterial circulation after contrast medium injection (CMI) and coronary artery bypass graft (CABG) surgery, respectively. In one case, accumulation of air bubbles was observed in the pulmonary artery after CMI. This was attributed to inadvertent injection of air owing to improper connection of the injector and the catheter. The patient was managed with 100% oxygen in the Trendelenburg and left lateral decubitus position. Repeat imaging demonstrated resorption of the emboli. In another case, air was introduced during CABG in the left atrium and ventricle. Immediate suction of air was attempted however, the patient developed cardiogenic shock requiring vasopressors, and subsequently seizures and coma due to diffuse ischaemic stroke. The patient eventually expired.

Gads-deficient thymocytes are blocked at the transitional single positive CD4+ stage.

Positive selection of T-cell precursors is the process by which a diverse T-cell repertoire is established. Positive selection begins at the CD4(+)CD8(+) double positive (DP) stage of development and involves at least two steps. First, DP thymocytes down-regulate CD8 to become transitional single positive (TSP) CD4(+) thymocytes. Then, cells are selected to become either mature single positive CD4(+) or mature single positive CD8(+) thymocytes. We sought to define the function of Gads during the two steps of positive selection by analyzing a Gads-deficient mouse line. In Gads(+/+) mice, most TSP CD4(+) thymocytes are TCR(hi)Bcl-2(hi)CD69(+), suggesting that essential steps in positive selection occurred in the DP stage. Despite that Gads(-/-) mice could readily generate TSP CD4(+) thymocytes, many Gads(-/-) TSP CD4(+) cells were TCR(lo)Bcl-2(lo)CD69(-), suggesting that Gads(-/-) cells proceeded to the TSP CD4(+) stage prior to being positively selected. These data suggest that positive selection is not a prerequisite for the differentiation of DP thymocytes into TSP CD4(+) thymocytes. We propose a model in which positive selection and differentiation into the TSP CD4(+) stage are separable events and Gads is only required for positive selection.