Safety and efficacy of clot-dissolving therapies for submassive pulmonary embolism: A network meta-analysis of randomized controlled trials.

BACKGROUND: Acute pulmonary embolism (PE) is a serious condition that needs quick and effective treatment. Anticoagulation therapy is the usual care for most PE patients but may not work well for higher-risk ones. Thrombolysis breaks the clot and improves blood flow. It can be given systemically or locally. Ultrasound-assisted catheter-directed thrombolysis (USAT) is a new technique that boosts clot-busting drugs. This network meta-analysis compares death, bleeding, and benefits of four treatments in acute submassive PE. METHODS: We comprehensively searched relevant databases up to July 2023 for RCTs. The outcomes encompassed all-cause mortality, major and minor bleeding, PE recurrence, and hospital stay duration. Bayesian network meta-analysis computed odds ratios (OR) and 95 % CI estimates. RESULTS: In this network meta-analysis of 23 RCTs involving 2521 PE patients, we found that SCDT had the most favorable performance for mortality, as it had the lowest odds ratio (OR) among the four interventions (OR 5.41e-42; 95 % CI, 5.68e-97, 1.37e-07). USAT had the worst performance for major bleeding, as it had the highest OR among the four interventions (OR 4.73e+04; 95 % CI, 1.65, 9.16e+13). SCDT also had the best performance for minor bleeding, as it had the lowest OR among the four interventions (OR 5.68e-11; 95 % CI, 4.97e-25, 0.386). CONCLUSION: Our meta-analysis suggests that SCDT is the most effective treatment intervention in improving the risks of All-cause mortality and bleeding. Thrombolytic therapy helps in improving endpoints including the risk of PE recurrence and the duration of hospital stay.

Coronary Artery Dissection and Myocarditis Caused by Eosinophilic Granulomatosis with Polyangiitis (EGPA): A Case Report.

Eosinophilic granulomatosis with polyangiitis (EGPA) also referred to as Churg-Strauss syndrome is a rare vasculitis of the small to medium vessels. We present a rare case of acute coronary artery dissection brought on by EGPA, which generally has a poor prognosis. A 41-year-old male with history of bronchial asthma presented to the emergency room with a 2-week history of dyspnea, cough with clear phlegm, and fever. For the past eight months he had experienced episodes with similar symptoms relieved by steroids. CT chest showed bilateral upper lobe patchy opacities with extensive workup for infectious etiology being negative. He had peripheral eosinophilia with sinusitis. He had acute coronary syndrome and Coronary angiogram showed Right coronary artery dissection. After making a diagnosis of EGPA based on American college of Rheumatology criteria, he was successfully treated with high dose immunosuppression. Coronary artery dissection is a fatal and uncommon complication of EGPA which is usually diagnosed postmortem. Early recognition of this condition ante mortem and aggressive treatment can be lifesaving as demonstrated in our case.

Sodium-glucose cotransporter-2 inhibitor-associated euglycemic diabetic ketoacidosis in COVID-19-infected patients: A systematic review of case reports.

BACKGROUND: Diabetic ketoacidosis (DKA) manifests as hyperglycemia, metabolic acidosis, and ketosis. However, euglycemic DKA (eu-DKA) conceals severe DKA with glucose levels below 200 mg/dL. Sodium-glucose cotransporter-2 (SGLT2) inhibitors can induce eu-DKA in diabetic patients. Notably, coronavirus disease 2019 (COVID-19) -infected individuals with diabetes using SGLT2 inhibitors face an augmented risk of eu-DKA due to the direct toxic impact of the virus on pancreatic islets. This study aims to comprehensively investigate the association between SGLT2 inhibitors and eu-DKA in COVID-19 patients through meticulous case report analysis. Additionally, we endeavor to examine the outcomes and treatment approaches for COVID-19-infected diabetics receiving SGLT2 inhibitors, providing indispensable insights for healthcare professionals managing this specific patient population. AIM: To investigate the connection between SGLT2 inhibitors and euglycemic DKA in COVID-19 patients through a meticulous analysis of case reports. METHODS: We conducted an exhaustive search across prominent electronic databases, including PubMed, SCOPUS, Web of Science, and Google Scholar. This search encompassed the period from December 2019 to May 2022, incorporating published studies and pre-prints. The search terms employed encompassed "SGLT2 inhibitors", "euglycemic DKA", "COVID-19", and related variations. By incorporating these diverse sources, our objective was to ensure a thorough exploration of the existing literature on this subject, thereby augmenting the validity and robustness of our findings. RESULTS: Our search yielded a total of seven case reports and one case series, collectively comprising a cohort of twelve patients. These reports detailed instances of eu-DKA in individuals with COVID-19. Crucially, all twelve patients were utilizing SGLT2 as their primary anti-diabetic medication. Upon admission, all oral medications were promptly discontinued, and the patients were initiated on intravenous insulin therapy to effectively manage the DKA. Encouragingly, eleven patients demonstrated a favorable outcome, while regrettably, one patient succumbed to the condition. Subsequently, SGLT2 were discontinued for all patients upon their discharge from the hospital. These findings provide valuable insights into the clinical management and outcomes of eu-DKA cases associated with COVID-19 and SGLT2, underscoring the critical importance of prompt intervention and vigilant medication adjustments. CONCLUSION: Our study sheds light on the possibility of diabetic patients developing both drug-related and unrelated DKA, as well as encountering adverse outcomes in the context of COVID-19, despite maintaining satisfactory glycemic control. The relationship between glycemic control and clinical outcomes in COVID-19 remains ambiguous. Consequently, this systematic review proposes that COVID-19-infected diabetic patients using SGLT2 should contemplate alternative treatment protocols until their recovery from the disease.

Effect of fibrinolytic therapy on ST-elevation myocardial infarction clinical outcomes during the COVID-19 pandemic: A systematic review and meta-analysis.

BACKGROUND: ST-elevation myocardial infarction (STEMI) is the result of transmural ischemia of the myocardium and is associated with a high mortality rate. Primary percutaneous coronary intervention (PPCI) is the recommended first-line treatment strategy for patients with STEMI. The timely delivery of PPCI became extremely challenging for STEMI patients during the coronavirus disease 2019 (COVID-19) pandemic, leading to a projected steep rise in mortality. These delays were overcome by the shift from first-line therapy and the development of modern fibrinolytic-based reperfusion. It is unclear whether fibrinolytic-based reperfusion therapy is effective in improving STEMI endpoints. AIM: To determine the incidence of fibrinolytic therapy during the COVID-19 pandemic and its effects on STEMI clinical outcomes. METHODS: PubMed, Google Scholar, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials were queried from January 2020 up to February 2022 to identify studies investigating the effect of fibrinolytic therapy on the prognostic outcome of STEMI patients during the pandemic. Primary outcomes were the incidence of fibrinolysis and the risk of all-cause mortality. Data were meta-analyzed using the random effects model to derive odds ratios (OR) and 95% confidence intervals. Quality assessment was carried out using the Newcastle-Ottawa scale. RESULTS: Fourteen studies including 50136 STEMI patients (n = 15142 in the pandemic arm; n = 34994 in the pre-pandemic arm) were included. The mean age was 61 years; 79% were male, 27% had type 2 diabetes, and 47% were smokers. Compared with the pre-pandemic period, there was a significantly increased overall incidence of fibrinolysis during the pandemic period [OR: 1.80 (1.18 to 2.75); I2= 78%; P = 0.00; GRADE: Very low]. The incidence of fibrinolysis was not associated with the risk of all-cause mortality in any setting. The countries with a low-and middle-income status reported a higher incidence of fibrinolysis [OR: 5.16 (2.18 to 12.22); I2 = 81%; P = 0.00; GRADE: Very low] and an increased risk of all-cause mortality in STEMI patients [OR: 1.16 (1.03 to 1.30); I2 = 0%; P = 0.01; GRADE: Very low]. Meta-regression analysis showed a positive correlation of hyperlipidemia (P = 0.001) and hypertension (P < 0.001) with all-cause mortality. CONCLUSION: There is an increased incidence of fibrinolysis during the pandemic period, but it has no effect on the risk of all-cause mortality. The low- and middle-income status has a significant impact on the all-cause mortality rate and the incidence of fibrinolysis.

COVID-19-associated MRSA infective endocarditis and mitral valve perforation: a case report.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has emerged as a global pandemic, leading to significant morbidity and mortality. The interplay between COVID-19 and other medical conditions can complicate diagnosis and management, necessitating further exploration. CASE PRESENTATION: This case report presents a patient with COVID-19 who developed infective endocarditis (IE) and mitral valve perforation caused by methicillin-resistant Staphylococcus aureus on a native mitral valve. Notably, the patient did not exhibit typical IE risk factors, such as intravenous drug use. However, he did possess risk factors for bacteremia, including a history of diabetes mellitus and recent steroid use due to the COVID-19 infection. The diagnosis of IE was crucially facilitated by transesophageal echocardiography. CONCLUSIONS: This case highlights the potential association between COVID-19 and the development of infective endocarditis. Prompt evaluation using transesophageal echocardiography is vital when there is a high suspicion of IE in COVID-19 patients. Further research is required to elucidate the precise relationship between COVID-19 and IE.

Case Report of Acute Q Fever with Hepatitis Progressing to Chronic Q Fever with Endocarditis.

A 35-year-old male greenhouse worker presented with myalgia, fatigue, and fever. Initially, he was thought to have an unspecified viral infection and was treated with conservative therapy. However, the patient's symptoms persisted, and he reported additional symptoms of mild abdominal pain and headaches. Laboratory evaluation was significant for elevated liver enzymes. Due to concern for acute hepatitis and persistent fever the patient was hospitalized. During his hospital course, no infectious etiology was found to explain his symptoms. After discharge from the hospital, additional testing showed positive serology for Q fever IgG phase II antibody (1:8192) and phase II antibody IgM (>1:2048). He was treated with doxycycline and had a good clinical response. Upon follow-up, he had worsening Phase I IgG serologies. Transesophageal echo demonstrated vegetations consistent with endocarditis.

MINOCA mimic: Type 2 myocardial infarction due to severe aortic stenosis complicated by cardiogenic shock.

Acute myocardial infarction without significant obstructive coronary disease presents a challenging clinical entity that requires timely intervention. The term myocardial infarction with nonobstructive coronary arteries (MINOCA) describes a working diagnosis attributed to varying etiologies in patients with a presumed ischemic cardiac condition. Several overlapping etiologies can be classified as type 2 myocardial infarction (MI). The 2019 AHA statement established diagnostic criteria and clarified the associated confusion, aiding in appropriate diagnosis. In this report, we present a case of demand-ischemia MINOCA and cardiogenic shock in a patient with severe aortic stenosis (AS).

Pseudomonas infection reduction in the ICU: a successful multidisciplinary quality improvement project.

Pseudomonas aeruginosa infection causes high morbidity and mortality, especially in immunocompromised patients. Pseudomonas can develop multidrug resistance. As a result, it can cause serious outbreaks in hospital and intensive care unit (ICU) settings, increasing both length of stay and costs. In the second quarter of 2020, in a community hospital's 15-bed ICU, the P. aeruginosa-positive sputum culture rate was unacceptably high, with a trend of increasing prevalence over the previous 3 quarters. We performed a multidisciplinary quality improvement (QI) initiative to decrease the P. aeruginosa-positive rate in our ICU. We used the Define, Measure, Analyze, Improve, and Control model of Lean Six Sigma for our QI initiative to decrease the P. aeruginosa-positive sputum culture rate by 50% over the following year without affecting the baseline environmental services cleaning time. A Plan-Do-Study-Act approach was used for key interventions, which included use of sterile water for nasogastric and orogastric tubes, adherence to procedure for inline tubing and canister exchanges, replacement of faucet aerators, addition of hopper covers, and periodic water testing. We analyzed and compared positive sputum culture rates quarterly from pre-intervention to post-intervention. The initial P. aeruginosa-positive culture rate of 10.98 infections per 1,000 patient-days in a baseline sample of 820 patients decreased to 3.44 and 2.72 per 1,000 patient-days in the following 2 post-intervention measurements. Environmental services cleaning time remained stable at 34 minutes. Multiple steps involving all stakeholders were implemented to maintain this progress. A combination of multidisciplinary efforts and QI methods was able to prevent a possible ICU P. aeruginosa outbreak.

Intensive care unit adaptations in the COVID-19 pandemic: Lessons learned.

The coronavirus disease 2019 pandemic had deleterious effects on the healthcare systems around the world. To increase intensive care units (ICUs) bed capacities, multiple adaptations had to be made to increase surge capacity. In this editorial, we demonstrate the changes made by an ICU of a midwest community hospital in the United States. These changes included moving patients that used to be managed in the ICU to progressive care units, such as patients requiring non-invasive ventilation and high flow nasal cannula, ST-elevation myocardial infarction patients, and post-neurosurgery patients. Additionally, newer tactics were applied to the processes of assessing oxygen supply and demand, patient care rounds, and post-ICU monitoring.

Ketosis-prone diabetes mellitus: A phenotype that hospitalists need to understand.

Diabetes has been classified mainly into types 1 and 2. Some type 2 diabetes patients, when developing ketosis, have been labeled as having atypical diabetes. Lately, syndromes of ketosis-prone diabetes, primarily in patients who we previously classified as type 2 diabetics, have emerged, and calls are being made to even reclassify diabetes. This mini-review will extensively deal with the historical, molecular, phenotypical, and clinical basis of why ketosis-prone diabetes is different than the traditional principles of type 1 and 2 diabetes and should be classified as such. Clinicians, especially those who are not diabetologists or endocrinologists, as well as hospitalists, intensivists, and primary care providers, will greatly benefit from this review.

Inari large-bore mechanical thrombectomy in intermediate-high risk submassive PE patients: Case series and literature review.

Pulmonary embolism (PE) is one of the most common causes of cardiovascular (CV) mortality worldwide. Owing to the associated morbidity and mortality with other treatment modalities, including systemic thrombolysis, a discernible change in the era of acute pulmonary embolism management has been reported. Catheter-directed thrombectomy using the FlowTriever system (Inari Medical; Irvine, CA, USA) was shown to reduce endpoints of interest in patients with acute intermediate-high risk PE and was associated with rapid hemodynamic improvement. In this report, we describe our experience with three cases of patients presenting with submassive PE, whereby immediate pulmonary artery pressure improvement was evident in all cases after successful mechanical thrombectomy. Our experience supports the use of FlowTriever mechanical thrombectomy for the treatment of submassive PE in clinical practice, with a call for further research to establish associated benefits.

The overestimation of concentric hypertrophy in patients with HFpEF as determined by 2D-echocardiography.

Background: Heart failure with preserved ejection fraction continues to pose multiple challenges in terms of accurate diagnosis, treatment, and associated morbidity. Accurate left ventricular (LV) mass calculation yields essential prognostic information relating to structural heart disease. Two-dimensional (2D) echocardiography-based calculations are solely limited to LV geometric assumptions of symmetry, whereas three-dimensional (3D) echocardiography could overcome these limitations. This study aims to compare the performance of 2D and 3D LV mass calculations. Methods: A prospective review of echocardiography findings at the University of Louisville, Kentucky, was conducted and assessed. Normal ejection fraction (EF) was defined as >=52% in males and >=54% in females. The following calculations were performed: relative wall thickness (RWT) = 2x posterior wall thickness/LV internal diastolic dimension (LVIDd) and 2D LV mass = 0.8{1.04([LVIDd + IVSd +PWd]3 - LVIDd3)} + 0.6. Concentric hypertrophy was RWT >0.42 and LV mass >95 kg/m2 in females or >115 kg/m2 in males. The same cut-offs were used for 2D and 3D echocardiography. Results: Echocardiographic findings for a total number of 154 patients in the study were investigated. There was a weak positive correlation between 2D and 3D LV mass indices (R = 0.534, r2 = 0.286, p = 0.001). Seventy patients had 3D EF >=45% with clinical heart failure (HFpEF). Among HFpEF patients, LV hypertrophy (LVH) was present in 74% of patients by 2D echocardiography and 30% by 3D echocardiography (McNemar test p = 0.001). Using 3D echocardiography as the reference, 68% of normal patients were misdiagnosed with LV hypertrophy by 2D echocardiography. Two-thirds of the patients with concentric remodeling by 3D echocardiography were misclassified as having concentric hypertrophy by 2D echocardiography (p = 0.001). Conclusion: Adapting necropsy-proven LV mass index cutoffs, 2D over-diagnosed LV hypertrophy through overestimation of the mass, compared to 3D echocardiography. In turn, the majority of HFpEF patients showed no structural hypertrophy of the LV on 3D imaging. This suggests that the majority of patients with HFpEF may qualify for pharmacological prevention to prevent further progression to LV remodeling or LVH.

The undesirable communication: A case of cerebral air emboli in the setting of atrio-esophageal fistula following atrial fibrillation catheter ablation.

Atrial-esophageal fistula is an extremely rare condition but is often a deleterious complication following catheter ablation for atrial fibrillation. The associated iatrogenic communication acts as a conduit for air and bacterial translocation, which may lead to cerebral air embolism and polymicrobial sepsis, respectively. Coupled with a history of invasive procedures, the diagnosis is largely based on the accompanying neurological symptoms. In this report, we present the case of a 73-year-old female who presented with neurological deficits attributed to cerebral vascular emboli three weeks after catheter ablation for the treatment of chronic atrial fibrillation.

Overlap of diabetic ketoacidosis and hyperosmolar hyperglycemic state.

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia state (HHS) are two life-threatening metabolic complications of diabetes that significantly increase mortality and morbidity. Despite major advances, reaching a uniform consensus regarding the diagnostic criteria and treatment of both conditions has been challenging. A significant overlap between these two extremes of the hyperglycemic crisis spectrum poses an additional hurdle. It has well been noted that a complete biochemical and clinical patient evaluation with timely diagnosis and treatment is vital for symptom resolution. Worldwide, there is a lack of large-scale studies that help define how hyperglycemic crises should be managed. This article will provide a comprehensive review of the pathophysiology, diagnosis, and management of DKA-HHS overlap.

Idiopathic Systemic Capillary Leak Syndrome: A Rare Cause of Refractory Shock Following Influenza B Infection.

A 68-year-old man presented to the Emergency Department with undifferentiated shock. During the three days prior, he experienced a non-specific viral-like illness. On examination his blood pressure was 70/40 mm Hg with cool, clammy, and mottled extremities and flat neck veins. Laboratory investigations revealed a positive influenza B screen alongside elevated hemoglobin and hematocrit. Following aggressive fluid resuscitation his blood pressure had marginally improved and he was transferred to the intensive care unit (ICU). Vasopressor support with cautious fluid resuscitation continued and at 7- and 10-h following presentation, serum albumin levels were extremely low. Idiopathic systemic capillary leak syndrome triggered by influenza B infection was diagnosed. Following a 9-day ICU stay the patient made a complete recovery and remains stable on intravenous immunoglobulin therapy. This case highlights the importance judicious fluid resuscitation and serum albumin levels when confronted with refractory shock.

A Case of Adult Multisystem Inflammatory Syndrome Following COVID-19 Vaccine.

Multisystem inflammatory syndrome is a life-threatening condition associated with elevated inflammatory markers and multiple organ injury. A diagnosis of exclusion, it has been reported after severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2) in children and adults; recently it has been described in some post-COVID-19 vaccinated individuals. The prognosis with supportive care and immunomodulatory therapy is good, although some individuals may require treatment in the intensive care unit (ICU). Here we report a case of a 58-year-old man who developed multi-organ failure after receiving the second dose of the Moderna mRNA-1273 COVID-19 vaccine. He required critical organ support in the ICU. An extensive workup was done to rule out alternative infectious and inflammatory processes. Following a period of gradual in-hospital convalescence, our patient made a full recovery. To our knowledge, this is the first comprehensively described case of multisystem inflammatory syndrome associated with Moderna mRNA-1273 COVID-19 vaccine in an adult over 50 years of age.

Cardiovascular Complications of Obstructive Sleep Apnea in the Intensive Care Unit and Beyond.

Obstructive sleep apnea (OSA) is a common disease with a high degree of association with and possible etiological factor for several cardiovascular diseases. Patients who are admitted to the Intensive Care Unit (ICU) are incredibly sick, have multiple co-morbidities, and are at substantial risk for mortality. A study of cardiovascular manifestations and disease processes in patients with OSA admitted to the ICU is very intriguing, and its impact is likely significant. Although much is known about these cardiovascular complications associated with OSA, there is still a paucity of high-quality evidence trying to establish causality between the two. Studies exploring the potential impact of therapeutic interventions, such as positive airway pressure therapy (PAP), on cardiovascular complications in ICU patients are also needed and should be encouraged. This study reviewed the literature currently available on this topic and potential future research directions of this clinically significant relationship between OSA and cardiovascular disease processes in the ICU and beyond.

Role of octreotide in small bowel bleeding.

Gastrointestinal bleeding accounts for a drastic negative impact on the quality of the patients' lives as it requires multiple diagnostic and therapeutic interventions to identify the source of the bleeding. Small bowel bleeding is the least common cause of gastrointestinal bleeding. However, it is responsible for the majority of complaints from patients with persisting or recurring bleeding where the primary source of bleeding cannot be identified despite investigation. A somatostatin analog known as octreotide is among the medical treatment modalities currently used to manage small bowel bleeding. This medication helps control symptoms of gastrointestinal bleeding by augmenting platelet aggregation, decreasing splanchnic blood flow, and antagonizing angiogenesis. In this review article, we will highlight the clinical efficacy of octreotide in small bowel bleeding and its subsequent effect on morbidity and mortality.

Subacute necrotizing fasciitis of the posterior neck disguised as a herpes zoster infection: A case report.

Necrotizing fasciitis is a rare soft tissue infection characterized by a rapidly spreading infection of the subcutaneous tissue. Early diagnosis is important as it requires immediate and complete debridement of infected tissues and antibiotic therapy. Necrotizing fasciitis usually involves the extremities, abdomen, and groin, but rarely involves the head and neck. Necrotizing fasciitis has an aggressive course; however, in rare cases, it can present in a subacute indolent form which can be misdiagnosed as other cutaneous diseases. Our case is a unique presentation of subacute necrotizing fasciitis of the posterior neck, which was initially diagnosed as a herpes zoster infection, in a patient with undiagnosed diabetes mellitus, which was complicated with diabetic ketoacidosis and sepsis.

Current Targeted Therapy Options in the Treatment of Cholangiocarcinoma: A Literature Review.

Biliary cancer (BC) is a rare disease. It is formed from the biliary epithelium of the small ducts in the liver periphery (intrahepatic) and the main ducts of the hilum (extrahepatic). The incidence of intrahepatic carcinoma is rising in the western world, and the incidence of gallbladder cancer is declining. Surgical treatment is the primary treatment option for localized forms of these tumors, but only a small group of patients is eligible for it. Palliative therapy is the standard treatment option for those with advanced cases, and it mainly relies on chemotherapy. The advanced form's five-year survival of BC does not exceed 5%. However, targeted therapy aimed at tumors with fusion mutations of the fibroblast growth factor receptor (FGFR), isocitrate dehydrogenase (IDH) 1 and 2, the genes encoding the B-Raf protein (BRAF), breast cancer (BRCA1/2), epidermal growth factor receptor 2 (HER2), and the neurotrophic receptor tyrosine kinase gene (NTRK), is gradually changing the paradigm in the treatment of this disease. This can be seen especially in approaches to treating intrahepatic cholangiocarcinoma, which is associated with a high incidence of mutations. This literature review aims to provide the latest scientific evidence regarding targeted therapy in treating cholangiocarcinoma.