Modified Radical Mastectomy vs Breast-Conserving Surgery: Current Clinical Practice in Women with Early Stage Breast Cancer at a Corporate Tertiary Cancer Center in India.

Breast cancer is the most common cancer in women in urban India and surgery has one of the definitive roles in treating this cancer. Over the decades, multiple studies have been published and they have shown that BCS followed by radiotherapy has equivalent disease-free survival (DFS) and overall survival (OS) as compared with MRM. The surgeon has the main role in explaining the treatment options to the patient. It is a prospective study conducted at Vedant Cancer and Multispeciality Hospital in a metropolitan city, Thane, India. Patients with stage I or II breast cancer with tumor size less than 5 cm were included in the study. Patients with locally advanced and metastatic breast cancer were excluded from the study. The study population was early breast cancer patients registered and waiting for surgery (n = 86) at Vedant Cancer and Multispeciality Hospital from November 2019 to end of April 2020. The total number of females enrolled in the study were 86 and out of this, 79.1% (n = 68) females opted for MRM and 20.9% (n = 18) females opted for BCS in which 8 patients had changed their decision after re-counseling in the ward from MRM to BCS. The most common reasons selected by patients to undergo MRM were fear of cancer recurrence (30.2%, n = 26), avoidance of side effects of radiation therapy (25.5%, n = 22) and fear of radiation therapy (23.2%, n = 20). Surgeon had decided the surgical option in 79.1% (n = 68) cases. The study shows that the treating surgeon and patient's husband are the principal persons who decide the surgical option and active participation of women during counseling is an important factor. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-021-01457-8.

Exhaled VOCs can discriminate subjects with COVID-19 from healthy controls.

COVID-19 detection currently relies on testing by reverse transcription polymerase chain reaction (RT-PCR) or antigen testing. However, SARS-CoV-2 is expected to cause significant metabolic changes in infected subjects due to both metabolic requirements for rapid viral replication and host immune responses. Analysis of volatile organic compounds (VOCs) from human breath can detect these metabolic changes and is therefore an alternative to RT-PCR or antigen assays. To identify VOC biomarkers of COVID-19, exhaled breath samples were collected from two sample groups into Tedlar bags: negative COVID-19 (n= 12) and positive COVID-19 symptomatic (n= 14). Next, VOCs were analyzed by headspace solid phase microextraction coupled to gas chromatography-mass spectrometry. Subjects with COVID-19 displayed a larger number of VOCs as well as overall higher total concentration of VOCs (p< 0.05). Univariate analyses of qualified endogenous VOCs showed approximately 18% of the VOCs were significantly differentially expressed between the two classes (p< 0.05), with most VOCs upregulated. Machine learning multivariate classification algorithms distinguished COVID-19 subjects with over 95% accuracy. The COVID-19 positive subjects could be differentiated into two distinct subgroups by machine learning classification, but these did not correspond with significant differences in number of symptoms. Next, samples were collected from subjects who had previously donated breath bags while experiencing COVID-19, and subsequently recovered (COVID Recovered subjects (n= 11)). Univariate and multivariate results showed >90% accuracy at identifying these new samples as Control (COVID-19 negative), thereby validating the classification model and demonstrating VOCs dysregulated by COVID are restored to baseline levels upon recovery.

Efficacy of Bivalirudin for Therapeutic Anticoagulation in COVID-19 Patients Requiring ECMO Support.

OBJECTIVES: The Coronavirus Disease 2019 (COVID-19) pandemic has been associated with cases of refractory acute respiratory distress syndrome (ARDS) sometimes requiring support with extracorporeal membrane oxygenation (ECMO). Bivalirudin can be used for anticoagulation in patients on ECMO support, but its efficacy and safety in patients with COVID-19 is unknown. The authors set out to compare the pharmacologic characteristics and dosing requirements of bivalirudin in patients requiring ECMO support for ARDS due to COVID-19 versus ARDS from other etiologies. DESIGN AND SETTING: This retrospective case-control study was performed at Indiana University Health Methodist Hospital in Indianapolis, Indiana. PARTICIPANTS: Patients were included if they were on venovenous ECMO support between June 2019 and June 2020, and divided into two groups: ARDS secondary to COVID-19 and those with ARDS from another etiology (Non-COVID). INTERVENTIONS: Patient demographics, such as age, sex, weight, chronic comorbid conditions, baseline antiplatelet and anticoagulant use, antiplatelet use during ECMO, and need for renal replacement therapy were collected, and compared between groups. Time to activated partial thromboplastin time (aPTT) goal, percentage of time at aPTT goal, bivalirudin rates, total bivalirudin requirements, total duration on bivalirudin, total duration on ECMO, mortality, and complications associated with ECMO were collected and compared between groups. MEASUREMENTS AND MAIN RESULTS: A total of 42 patients met inclusion criteria (n = 19 COVID-19, n = 23 non-COVID). However, percentages of aPTTs at goal were maintained more consistently in patients with COVID-19 versus non-COVID (86% v 74%: p < 0.01). Higher median (IQR) daily rates (3.1 µg/kg/min [2.3-5.2] v 2.4 µg/kg/min [1.7-3.3]: p = 0.05) and higher median (IQR) maximum rates of bivalirudin (5 µg/kg/min [3.7-7.5] v 3.8 µg/kg/min [2.5-5]: p = 0.03) were required in the COVID-19 group versus the non-COVID group. Time to goal aPTT was similar between groups. There were no differences in complications associated with anticoagulation, as demonstrated by similar rates of bleeding and thrombosis between both groups. CONCLUSIONS: Patients on ECMO with ARDS from COVID-19 require more bivalirudin overall and higher rates of bivalirudin to maintain goal aPTTs compared with patients without COVID-19. However, COVID-19 patients more consistently maintain goal aPTT. Future randomized trials are needed to support efficacy and safety of bivalirudin for anticoagulation of COVID-19 patients on ECMO.

Clinical profile, diagnostic challenges, and outcomes in subacute/chronic cerebral sinus venous thrombosis.

PURPOSE: To report clinical profile, diagnostic challenges, and outcomes in cases of subacute/chronic cerebral sinus venous thrombosis (CSVT) presenting to neuro-ophthalmologists/neurologists. METHODS: This was a multicentric, retrospective, observational study. Records of patients with neuroimaging proven subacute/chronic CSVT seen the from January 1, 2016 to March 31, 2020 were analyzed. Data collected included duration of symptoms, diagnosing physician, ophthalmological vs. focal/generalized neurological symptoms, optic disc examination, perimetry, and neuroimaging findings. Statistical analysis was performed using STATA software. RESULTS: Forty-three patients with subacute (30)/chronic (13) CSVT were identified (32 males, 11 females). Median age was 37 (IQR 27-47) years. The presenting complaints were blurred vision 34 (79%), headaches in 25 (58%), vomiting 12 (28%), and diplopia 11 (26%). Eleven patients had associated sixth cranial nerve palsy. All but two patients had either disc edema/optic atrophy; four had unilateral disc edema at presentation. Ophthalmologists and neurologists diagnosed/suspected CSVT correctly in 13/29 (45%) and 11/14 (78.5%) patients, respectively. Most common initial alternate diagnosis was idiopathic intracranial hypertension in 12 (28%). Female gender, age ≤36, unilateral papilledema, not obtaining venogram at initial workup increased chances of initial alternate diagnosis. Median follow-up duration was 21 days. Average visual function remained stable in majority of patients at last follow-up. In total, 47.6% of patients had best-corrected visual acuity ≥20/30 at the final follow-up. CONCLUSION: In our series, subacute or chronic CSVT presented presented primarily with symptoms of intracranial hypertension. Unilateral papilledema, middle-aged patients, female gender, lack of focal/generalized neurological symptoms created diagnostic dilemma. Visual function remained stable in majority of patients.

Extraocular Muscle Transplantation for Primary Treatment of Large-Angle Exotropia.

AIM: To report the feasibility and outcomes of muscle transplantation combined with a unilateral recession-resection procedure for primary large-angle [≥60 Prism Diopters (PD)] exotropia. METHODS: We retrospectively reviewed medical records of patients from three tertiary eye-care institutes who underwent unilateral recess-resect with muscle transplantation for primary treatment of large angle exotropia between August 2017 and July 2020. Motor and restorative success were defined as alignment ≤10PD of orthotropia and ≤12PD of manifest deviation, respectively, at the final follow-up. Patients with at least 3 months of follow-up were included. RESULTS: Ten patients; six males and four females (median age 26 years) met the study criteria. The median follow-up was 12.89 months. The median preoperative exotropia reduced from 65PD (60 to 90PD) to 10PD (0 to 25PD) at final follow-up (p = .0019). The median correction obtained for the entire procedure (recession + resection + muscle transplantation) was 3.05 (1.8 to 4.3) PD/mm. Motor and restorative success was achieved in 60% and 70% of the patients, respectively. The median abduction limitation was -1 (0 to -1) at the final follow-up and there were no palpebral fissure changes beyond 6 weeks postoperatively. CONCLUSIONS: Unilateral muscle transplantation combined with the recession-resection procedure could be a useful alternative for the management of large-angle exotropia.

Comparison of retropupillary fixated iris claw lens versus sclera fixated lens for correction of pediatric aphakia secondary to ectopia lentis.

AIM: To evaluate the postoperative visual acuity and complications in eyes with ectopia lentis in children who underwent lens removal and then implantation of retropupillary fixated iris claw lens versus scleral fixated intraocular lens (SFIOL) implantation. MATERIALS AND METHODS: A retrospective analysis of pediatric cases who presented with lens subluxation secondary to ectopia lentis and who underwent lens extraction (57 eyes of 38 patients) with either retropupillary iris fixated intraocular lens (IOL) implantation (Group A - 36 eyes of 20 patients) and SFIOL implantation (Group B - 21 eyes of 18 patients) was done over a period of 5 years from March 2010 to February 2015. The main outcome measures were preoperative and postoperative best-corrected visual acuity (BCVA) and secondary postoperative complications. RESULTS: The study patients were divided into two groups: Group A patients were implanted with retropupillary iris claw lens whereas Group B patients were implanted with SFIOL. The mean age of presentation was 12 years, the mean follow-up period was of 24 months (range 14-36 months), and the median follow-up period was 26 months in both the groups. An improvement in the mean BCVA (LogMAR) was seen in both the groups. In Group A, the mean BCVA improved from 1.5 ± 0.2 preoperatively to 0.3 ± 0.2 postoperatively, whereas in Group B, the mean BCVA improved from 1.5 ± 0.3 preoperatively to 0.3 ± 0.2 postoperatively (P < 0.001). None of the eyes in either of the groups had any serious complications such as glaucoma, uveitis, cystoid macular edema, or endophthalmitis. CONCLUSION: Retropupillary iris fixation and scleral fixation of IOL are both safe and viable options for the correction of ectopia lentis in pediatric age group.

Obesity, inflammatory and thrombotic markers, and major clinical outcomes in critically ill patients with COVID-19 in the US.

OBJECTIVE: This study aimed to determine whether obesity is independently associated with major adverse clinical outcomes and inflammatory and thrombotic markers in critically ill patients with COVID-19. METHODS: The primary outcome was in-hospital mortality in adults with COVID-19 admitted to intensive care units across the US. Secondary outcomes were acute respiratory distress syndrome (ARDS), acute kidney injury requiring renal replacement therapy (AKI-RRT), thrombotic events, and seven blood markers of inflammation and thrombosis. Unadjusted and multivariable-adjusted models were used. RESULTS: Among the 4,908 study patients, mean (SD) age was 60.9 (14.7) years, 3,095 (62.8%) were male, and 2,552 (52.0%) had obesity. In multivariable models, BMI was not associated with mortality. Higher BMI beginning at 25 kg/m2 was associated with a greater risk of ARDS and AKI-RRT but not thrombosis. There was no clinically significant association between BMI and inflammatory or thrombotic markers. CONCLUSIONS: In critically ill patients with COVID-19, higher BMI was not associated with death or thrombotic events but was associated with a greater risk of ARDS and AKI-RRT. The lack of an association between BMI and circulating biomarkers calls into question the paradigm that obesity contributes to poor outcomes in critically ill patients with COVID-19 by upregulating systemic inflammatory and prothrombotic pathways.

Neglected posterior dislocation of elbow: A review.

Untreated traumatic posterior dislocation of the elbow joint, 3 weeks or older, is defined as "neglected posterior dislocation of the elbow". Around 90% of these are of posterolateral type. These are much more common in the developing and underdeveloped countries. Patients presents with a deformed, stiff and painful elbow with difficulty to perform activities of daily living. The clinical picture looks quite similar to malunited supracondylar fracture of the elbow. Diagnosis is usually confirmed radiographically. CT and MRI scan give additional information and are recommended before embarking on surgery. Treatment is quite challenging due to the significant soft tissue contractures, ligamentous insufficiencies and fibrosis, with possible associated nerve injuries, myositis ossificans, non-compliant patients and the need for long-term postoperative physiotherapy. Goal of surgical treatment is to achieve a painless, stable and mobile elbow with a congruent joint space. We have reviewed the literature and present our view on the prognosis and recommended surgical technique to treat this condition.

Horizontal rectus muscle transplantation for recurrent and residual strabismus.

Purpose: To report outcomes of muscle transplantation for recurrent/residual strabismus. Retrospective, multicentric, observational study.  Methods: We retrospectively reviewed records of all patients operated at three institutes who underwent transplantation of the resected muscle for re-operations for residual/recurrent strabismus from January 1, 2018, to December 31, 2019. Data were collected regarding age, gender, visual acuity, type of strabismus, fixation preference, associated amblyopia, the surgical procedure performed, preoperative and postoperative primary position deviation, limitation of ductions, associated intra-operative and post-operative complications. Surgical success was defined as heterotropia less than or equal to 8 PD, and cosmetic success was defined as manifest deviation ≤12 PD (at 6 weeks follow up). Results: During this period, we identified records of seven patients (5 men: 2 women, median age: 24 years) who underwent muscle transplantation for residual/recurrent strabismus. Six patients underwent extraocular muscle surgery for residual/recurrent exotropia (XT) and one for residual esotropia (ET). In all the patients, median pre-operative primary position deviation reduced from 40 prism diopters (PD) (range: 30 to 55 PD) to 8 PD (range: 6 PD ET to 10 PD XT) at six-weeks follow-up. Four patients had residual exotropia (10-16PD), two had orthotropia and one patient had small-angle esotropia (6PD) at the last follow-up. Excluding two patients who underwent supramaximal re-recession of lateral rectus (≥11 mm from insertion) and re-resection of medial rectus, 3/5 (60%) patients achieved surgical success, and all (100%) achieved cosmetic success at six-weeks-follow-up. There was mild (up to -1) limitation of duction in all patients except one patient (-2 limitation of abduction) who underwent re-recession of lateral rectus to 11 mm from insertion along with medial rectus re-resection and muscle transplant procedure. No intra-operative or post-operative complications were encountered. No patient reported postoperative diplopia. Conclusions: This study describes the feasibility and successful use of muscle transplantation procedure to correct residual/recurrent strabismus, with or without re-recession, especially in patients planned for surgery in one eye. However, larger prospective studies with longer follow-ups will be needed to establish long-term outcomes and correction achieved from this procedure, and comparison with other approaches for reoperations.

Thrombosis, Bleeding, and the Observational Effect of Early Therapeutic Anticoagulation on Survival in Critically Ill Patients With COVID-19.

BACKGROUND: Hypercoagulability may be a key mechanism of death in patients with coronavirus disease 2019 (COVID-19). OBJECTIVE: To evaluate the incidence of venous thromboembolism (VTE) and major bleeding in critically ill patients with COVID-19 and examine the observational effect of early therapeutic anticoagulation on survival. DESIGN: In a multicenter cohort study of 3239 critically ill adults with COVID-19, the incidence of VTE and major bleeding within 14 days after intensive care unit (ICU) admission was evaluated. A target trial emulation in which patients were categorized according to receipt or no receipt of therapeutic anticoagulation in the first 2 days of ICU admission was done to examine the observational effect of early therapeutic anticoagulation on survival. A Cox model with inverse probability weighting to adjust for confounding was used. SETTING: 67 hospitals in the United States. PARTICIPANTS: Adults with COVID-19 admitted to a participating ICU. MEASUREMENTS: Time to death, censored at hospital discharge, or date of last follow-up. RESULTS: Among the 3239 patients included, the median age was 61 years (interquartile range, 53 to 71 years), and 2088 (64.5%) were men. A total of 204 patients (6.3%) developed VTE, and 90 patients (2.8%) developed a major bleeding event. Independent predictors of VTE were male sex and higher D-dimer level on ICU admission. Among the 2809 patients included in the target trial emulation, 384 (11.9%) received early therapeutic anticoagulation. In the primary analysis, during a median follow-up of 27 days, patients who received early therapeutic anticoagulation had a similar risk for death as those who did not (hazard ratio, 1.12 [95% CI, 0.92 to 1.35]). LIMITATION: Observational design. CONCLUSION: Among critically ill adults with COVID-19, early therapeutic anticoagulation did not affect survival in the target trial emulation. PRIMARY FUNDING SOURCE: None.

Clinical and laboratory characteristics of patients with novel coronavirus disease-2019 infection and deep venous thrombosis.

OBJECTIVE: Early reports suggest that patients with novel coronavirus disease-2019 (COVID-19) infection carry a significant risk of altered coagulation with an increased risk for venous thromboembolic events. This report investigates the relationship of significant COVID-19 infection and deep venous thrombosis (DVT) as reflected in the patient clinical and laboratory characteristics. METHODS: We reviewed the demographics, clinical presentation, laboratory and radiologic evaluations, results of venous duplex imaging and mortality of COVID-19-positive patients (18-89 years) admitted to the Indiana University Academic Health Center. Using oxygen saturation, radiologic findings, and need for advanced respiratory therapies, patients were classified into mild, moderate, or severe categories of COVID-19 infection. A descriptive analysis was performed using univariate and bivariate Fisher's exact and Wilcoxon rank-sum tests to examine the distribution of patient characteristics and compare the DVT outcomes. A multivariable logistic regression model was used to estimate the adjusted odds ratio of experiencing DVT and a receiver operating curve analysis to identify the optimal cutoff for d-dimer to predict DVT in this COVID-19 cohort. Time to the diagnosis of DVT from admission was analyzed using log-rank test and Kaplan-Meier plots. RESULTS: Our study included 71 unique COVID-19-positive patients (mean age, 61 years) categorized as having 3% mild, 14% moderate, and 83% severe infection and evaluated with 107 venous duplex studies. DVT was identified in 47.8% of patients (37% of examinations) at an average of 5.9 days after admission. Patients with DVT were predominantly male (67%; P = .032) with proximal venous involvement (29% upper and 39% in the lower extremities with 55% of the latter demonstrating bilateral involvement). Patients with DVT had a significantly higher mean d-dimer of 5447 ± 7032 ng/mL (P = .0101), and alkaline phosphatase of 110 IU/L (P = .0095) than those without DVT. On multivariable analysis, elevated d-dimer (P = .038) and alkaline phosphatase (P = .021) were associated with risk for DVT, whereas age, sex, elevated C-reactive protein, and ferritin levels were not. A receiver operating curve analysis suggests an optimal d-dimer value of 2450 ng/mL cutoff with 70% sensitivity, 59.5% specificity, and 61% positive predictive value, and 68.8% negative predictive value. CONCLUSIONS: This study suggests that males with severe COVID-19 infection requiring hospitalization are at highest risk for developing DVT. Elevated d-dimers and alkaline phosphatase along with our multivariable model can alert the clinician to the increased risk of DVT requiring early evaluation and aggressive treatment.

Isolated Radial Shaft Fracture with Unreducable Posterior Dislocation of the Radial Head in Adult: A Case Report.

INTRODUCTION: Isolated fracture of the radial diaphysis with dislocation of the radial head is a rare injury, which requires careful evaluation. Combined injuries associated with forearm shaft fractures and elbow dislocations are well recognized. CASE REPORT: A 35-year-old male presented to our emergency department with a history of fall in ditch under influence of alcohol with swelling of her right elbow and deformity of right upper limb. Roentgenograms showed oblique fracture of the radial shaft and dislocation of radial head posteriorly. He underwent open reduction and internal fixation of fracture with limited contact dynamic compression plate and reduction of radial head and fixing with radiocapitellar wire. After 4 months, the fracture healed fully and he had complete full range of elbow movements. CONCLUSION: Ipsilateral radial head dislocation and radial shaft fracture are extremely rare injury in a child. A good outcome can be achieved by applying principles of the management of proximal forearm fracture-dislocation. Ipsilateral radial head dislocation and radial shaft fracture is extremely rare injury in a child. A good outcome can be achieved by applying principles of management of proximal forearm fracture-dislocation.

Maintaining Blood Glucose Levels in Range (70-150 mg/dL) is Difficult in COVID-19 Compared to Non-COVID-19 ICU Patients-A Retrospective Analysis.

Beta cell dysfunction is suggested in patients with COVID-19 infections. Poor glycemic control in ICU is associated with poor patient outcomes. This is a single center, retrospective analysis of 562 patients in an intensive care unit from 1 March to 30 April 2020. We review the time in range (70-150 mg/dL) spent by critically ill COVID-19 patients and non-COVID-19 patients, along with the daily insulin use. Ninety-three in the COVID-19 cohort and 469 in the non-COVID-19 cohort were compared for percentage of blood glucose TIR (70-150 mg/dL) and average daily insulin use. The COVID-19 cohort spent significantly less TIR (70-150 mg/dL) compared to the non-COVID-19 cohort (44.4% vs. 68.5%). Daily average insulin use in the COVID-19 cohort was higher (8.37 units versus 6.17 units). ICU COVID-19 patients spent less time in range (70-150 mg/dL) and required higher daily insulin dose. A higher requirement for ventilator and days on ventilator was associated with a lower TIR. Mortality was lower for COVID-19 patients who achieved a higher TIR.

Rapidly progressive vision loss due to fulminant idiopathic intracranial hypertension: a diagnostic and management dilemma.

A 44-year-old obese woman presented with decrease in vision in the right eye (RE) for 3 days. She reported a simultaneous onset of holocranial headache that worsened on bending forward. She denied eye pain, pain on eye movements, and other ocular or neurological complaints. On examination, her distance best-corrected visual acuity was counting fingers at 1 m in the RE and 20/20 in the left eye (LE). Colour vision was subnormal in both eyes (BE). There was grade II relative afferent pupillary defect in the RE. Fundus examination showed disc oedema in BE . Visual fields in the LE showed central scotoma extending nasally. A provisional diagnosis of papillitis was considered. However, contrast-enhanced MRI of the brain and orbits showed evidence of elevated intracranial pressure. Cerebrospinal fluid (CSF) opening pressure was 42 cm H2O while rest of the CSF analysis was normal. Diagnosis was revised to fulminant idiopathic intracranial hypertension. Management with medical therapy and urgent thecoperiteoneal shunt improved visual function in BE.

Impact of Geographical Cohorting in the ICU: An Academic Tertiary Care Center Experience.

ICU is a multifaceted organization where multiple teams care for critically ill patients. In the current era, collaboration between teams and efficient workflows form the backbone of value-based care. Geographical cohorting is a widespread model for hospitalist rounding, but its role in ICUs is unclear. This study evaluates the outcomes of geographical cohorting in a large ICU of an Academic Health Center. DESIGN: This is a retrospective analysis of quality metrics collected 12 months pre- and post-implementation of geographical cohorting. SETTING: A total of 130 bedded ICU at tertiary academic health center in Midwest. PATIENTS: All patients admitted to the ICU. INTERVENTIONS: Our institution piloted the geographical cohorting model for critical care physician rounding on September 1, 2018. MEASUREMENTS: The quality metrics were categorized as ICU harm events and ICU hospital metrics. Team of critical care providers were surveyed 12 months after implementation. MAIN RESULTS: The critical care utilization in the pre- and post-implementation numbers were similar for patient days (pre = 34,839, post = 35,155), central-line days (pre = 17,648, post = 19,224), and Foley catheter days (pre = 18,292, post = 17,364). The ICU length of stay was similar (4.9 d) in both pre- and post-intervention periods. Significant reduction in the incidence of Clostridium difficile infection (relative risk, -0.50; 95% CI, 0.25-0.96; p = 0.039), hospital-acquired pressure injury (relative risk, -0.60; 95% CI, 0.39-0.92; p = 0.020), central line-associated bloodstream infection incidence (relative risk, -0.19; 95% CI, 0.05-0.52; p = 0.008), and catheter-associated urinary tract infection (relative risk, -0.52; 95% CI, 0.29-0.93; p = 0.027). Healthcare providers perceived optimal utilization of their time, reduced interruptions, and improved coordination of care with geographical rounding. CONCLUSIONS: Geographical cohorting improves coordination of care, physician workflow, and critical care quality metrics in very large ICUs.

Neurologic recovery in systemic nontraumatic fat embolism syndrome in an elderly patient with hemoglobin SC disease: A case report.

Cerebral fat embolism syndrome is an under-recognized yet well-known complication of bone marrow necrosis occurring in patients with sickle cell disease. We highlight a case manifested by multisystem organ failure in an elderly patient who attained neurologic recovery with prompt initiation of hematology consultation, RBC exchange, and supportive measures.

Mortality Rates in a Diverse Cohort of Mechanically Ventilated Patients With Novel Coronavirus in the Urban Midwest.

OBJECTIVES: Differences in mortality rates previously reported in critically ill patients with coronavirus disease 2019 have increased the need for additional data on mortality and risk factors for death. We conducted this study to describe length of stay, mortality, and risk factors associated with in-hospital mortality in mechanically ventilated patients with coronavirus disease 2019. DESIGN: Observational study. SETTING: Two urban, academic referral hospitals in Indianapolis, Indiana. PATIENTS OR SUBJECTS: Participants were critically ill patients 18 years old and older, admitted with coronavirus disease 2019 between March 1, 2020, and April 27, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Outcomes included in-hospital mortality, duration of mechanical ventilation, and length of stay. A total of 242 patients were included with mean age of 59.6 years (sd, 15.5 yr), 41.7% female and 45% African American. Mortality in the overall cohort was 19.8% and 20.5% in the mechanically ventilated subset. Patients who died were older compared with those that survived (deceased: mean age, 72.8 yr [sd, 10.6 yr] vs patients discharged alive: 54.3 yr [sd, 14.8 yr]; p < 0.001 vs still hospitalized: 59.5 yr [sd, 14.4 yr]; p < 0.001) and had more comorbidities compared with those that survived (deceased: 2 [0.5-3] vs survived: 1 [interquartile range, 0-1]; p = 0.001 vs still hospitalized: 1 [interquartile range, 0-2]; p = 0.015). Older age and end-stage renal disease were associated with increased hazard of in-hospital mortality: age 65-74 years (hazard ratio, 3.1 yr; 95% CI, 1.2-7.9 yr), age 75+ (hazard ratio, 4.1 yr; 95% CI, 1.6-10.5 yr), and end-stage renal disease (hazard ratio, 5.9 yr; 95% CI, 1.3-26.9 yr). The overall median duration of mechanical ventilation was 9.3 days (interquartile range, 5.7-13.7 d), and median ICU length of stay in those that died was 8.7 days (interquartile range, 4.0-14.9 d), compared with 9.2 days (interquartile range, 4.0-14.0 d) in those discharged alive, and 12.7 days (interquartile range, 7.2-20.3 d) in those still remaining hospitalized.Conclusions:: We found mortality rates in mechanically ventilated patients with coronavirus disease 2019 to be lower than some previously reported with longer lengths of stay.