Case report: Disseminated herpes simplex virus 1 infection and hemophagocytic lymphohistiocytosis after immunomodulatory therapy in a patient with coronavirus disease 2019.

Corticosteroids and immunomodulatory therapies are widely used to treat patients with severe coronavirus disease 2019 (COVID-19). Janus kinase (JAK) inhibitors such as tofacitinib have been recently studied as adjuvants in the treatment of COVID-19. Although immunomodulatory therapies may be linked to decreased mortality rates in the acute phase, subsequent severe infectious complications may result from them. We describe a case of a multiorgan system failure secondary to disseminated primary herpes simplex virus 1 (HSV-1) infection and hemophagocytic lymphohistiocytosis (HLH) following treatment with tofacitinib and high-dose dexamethasone therapy for severe COVID-19. Early diagnosis and treatment of these life-threatening conditions may have a significant impact on COVID-19 patients' outcomes.

Effect of intraoperative blood transfusion on Treg and FOXP3 in patients with digestive tract malignancies and different ABO blood types.

BACKGROUND: Blood transfusion can cause immunosuppression and lead to worse outcomes in patients with digestive tract malignancies; however, the specific mechanism behind this is not completely understood. One theory is that increased numbers of regulatory CD3+CD4+CD25+FOXP3+ T cells (Tregs) and forkhead box protein-3 mRNA (FOXP3) expression in the blood after transfusion contribute to these outcomes. The effect of blood transfusion on immune function in patients with different ABO blood types is variable. This study investigates the effect of intraoperative blood transfusion on the number of Tregs and the expression of FOXP3 in the blood of patients with different ABO blood types and digestive tract malignancies. METHODS: Patients with digestive tract malignancies who underwent radical resection and received intraoperative blood transfusion were divided into four groups according to their blood types:blood group A, blood group B, blood group O and blood group AB (n = 20 for each group). Blood was collected from all patients before surgery, immediately after transfusion, 1 day after transfusion, and 5 days after transfusion. The number of Tregs was measured by flow cytometry. The expression of FOXP3 was detected by real time reverse transcription polymerase chain reaction (RT-PCR). RESULTS: There was no significant difference in the number of Tregs or expression of FOXP3 mRNA among patients with different blood types before surgery. However, the number of Tregs and the expression of FOXP3 increased after blood transfusion in all blood type groups. This increase was especially evident and statistically significant on the first day after blood transfusion when compared with measures obtained before the surgery. Measures returned to the preoperative level five days after surgery. There were significant differences in the increase of Tregs and expression of FOXP3 among patients with different blood types. The greatest increase was seen in patients with blood group B and the least in blood group A. CONCLUSIONS: Intraoperative blood transfusion can lead to an increase in blood Tregs and FOXP3 expression in patients with digestive tract malignancies. Increases were greatest on the first day after surgery and differed among patients with different blood types. Increases were greatest in blood type B and least in blood type A.

Mortality and readmission of outcomes after discharge from the surgical intensive care unit to long-term, acute-care hospitals.

BACKGROUND: Patients with prolonged hospitalizations in the surgical intensive care unit often have ongoing medical needs that require further care at long-term, acute-care hospitals upon discharge. Setting expectations for patients and families after protracted operative intensive care unit hospitalization is challenging, and there are limited data to guide these conversations. The purpose of this study was to determine patient survival and readmission rates after discharge from the surgical intensive care unit directly to a long-term, acute-care hospital. METHODS: All patients who were admitted to the surgical intensive care unit at an academic, tertiary care medical center from 2009-2014 and discharged directly to long-term, acute-care hospitals were retrospectively reviewed. Patients represented all surgical subspecialties excluding cardiac and vascular surgery patients. Primary outcomes included 30-day readmission, and 1- and 3-year mortality rates following discharge. RESULTS: In total, 296 patients were discharged directly from the surgical intensive care unit to a long-term, acute-care hospital during the study period. There were 190 men (64%) and mean age was 61 ± 16 years. Mean duration of stay in the surgical intensive care unit was 27 ± 17 days. The most frequent complication was prolonged mechanical ventilation (277, 94%) followed by pneumonia (139, 47%), sepsis (78, 26%), and acute renal failure (32, 11%); 93% of patients required tracheostomy and enteral feeding access prior to discharge, and 19 patients (6%) were newly dependent on hemodialysis. The readmission rate was 20%. There were 86 deaths within 1 year from discharge (29%) with an overall 3-year mortality of 32%. In a multiple logistic regression analysis, a history of end-stage renal disease had a greater odds of readmission (odds ratio 6.07, P = .028). Patients with history of cancer had greater odds of 1- and 3-year mortality (odds ratio = 2.99, P = .028 and odds ratio 2.56, P = .053, respectively), and patients with a neurologic diagnosis had greater odds of 3-year mortality (odds ratio 4.69, P = .031). Readmission significantly increased the odds of 1- and 3-year mortality (odds ratio 3.12, P = .020 and odds ratio 2.90, P = .027, respectively). Patients who had both private insurance and Medicare had greater odds of 1- and 3-year mortality (odds ratio 10.39, P = .005 and odds ratio 10.65, P = .004, respectively). CONCLUSION: Patients who are discharged to long-term, acute-care hospitals have prolonged hospitalizations with high complication rates. These patients have high readmission and 1-year mortality rates. Patients and families should be counseled regarding these outcomes related to post-intensive care unit recovery after discharge to a long-term, acute-care hospital to allow for realistic expectations of survival after prolonged intensive care unit hospitalization.

Methadone analgesia in the critically ill.

PURPOSE: Methadone is increasingly used as an analgesic or a bridge to weaning other analgesics and sedatives in critically ill patients. This review discusses the pharmacology of methadone, summarizes available evidence for its use in the intensive care unit setting, and makes suggestions for appropriate use and monitoring. MATERIALS/METHODS: Articles evaluating the efficacy, safety, and pharmacology of methadone were identified from a PubMed search through June 2015. References from selected articles were reviewed for additional material. Experimental and observational English-language studies that focused on the efficacy, safety, and pharmacology of methadone in critically-ill adults and children were selected. RESULTS: Methadone is a synthetic opioid analgesic with potential advantages over other commonly used opioids. Limited evidence from critically ill pediatric, adult, and burn populations suggests that methadone protocols may expedite weaning opiate infusions, decrease the length of mechanical ventilation, and reduce the incidence of negative outcomes such as opiate withdrawal, delirium, and over-sedation. CONCLUSIONS: Data from current literature supports a role for methadone analgesia in weaning opiates and potentially reducing the duration of mechanical ventilation in critically ill patients. More studies are needed to confirm these benefits and determine criteria for patient selection.

Excessive Dynamic Airway Collapse: An Unexpected Contributor to Respiratory Failure in a Surgical Patient.

Central airway collapse plays a significant, underrecognized role in respiratory failure after extubation of critically ill patients. Historically, airway collapse has been attributed to tracheomalacia (TM), softening of the cartilage in the trachea and other large airways. More recently, excessive dynamic airway collapse (EDAC) has been described as a distinct process unrelated to a loss of cartilaginous airway support. EDAC is caused by the posterior wall of the trachea bulging forward and causing airway obstruction during exhalation. This process is exaggerated when intrathoracic pressure is increased and results in a clinical picture of coughing, difficulty clearing secretions, dyspnea, and stridor. The increased use of computerized tomography and fiberoptic bronchoscopy has identified varying degrees of EDAC and TM in both symptomatic and asymptomatic individuals. This has led to renewed consideration of airway collapse and the different processes that contribute to it. Here we describe a 43-year-old morbidly obese patient who failed repeated attempts at extubation after elective hysterectomy. We will discuss the processes of EDAC and TM, describe how this condition contributed to this patient's respiratory failure, and review diagnosis and management options.

Septic embolism in the intensive care unit.

Septic embolism encompasses a wide range of presentations and clinical considerations. From asymptomatic, incidental finding on advanced imaging to devastating cardiovascular or cerebral events, this important clinico-pathologic entity continues to affect critically ill patients. Septic emboli are challenging because they represent two insults-the early embolic/ischemic insult due to vascular occlusion and the infectious insult from a deep-seated nidus of infection frequently not amenable to adequate source control. Mycotic aneurysms and intravascular or end-organ abscesses can occur. The diagnosis of septic embolism should be considered in any patient with certain risk factors including bacterial endocarditis or infected intravascular devices. Treatment consists of long-term antibiotics and source control when possible. This manuscript provides a much-needed synopsis of the different forms and clinical presentations of septic embolism, basic diagnostic considerations, general clinical approaches, and an overview of potential complications.

Arterial embolism.

Surgical and intensive care patients are at a heightened risk for arterial embolization due to pre-existing conditions such as age, hypercoagulability, cardiac abnormalities and atherosclerotic disease. Most arterial emboli are clots that originate in the heart and travel to distant vascular beds where they cause arterial occlusion, ischemia, and potentially infarction. Other emboli form on the surface of eroded arterial plaque or within its lipid core. Thromboemboli are large clots that dislodge from the surface of athesclerotic lesions and occlude distal arteries causing immediate ischemia. Atheroemboli, which originate from fracturing the lipid core tend to cause a process of organ dysfunction and systemic inflammation, termed cholesterol embolization syndrome. The presentation of arterial emboli depends on the arterial bed that is affected. The most common manifestations are strokes and acute lower limb ischemia. Less frequently, emboli target the upper extremities, mesenteric or renal arteries. Treatment involves rapid diagnosis, which may be aided by precise imaging studies and restoration of blood flow. The type of emboli, duration of presentation, and organ system affected determines the treatment course. Long-term therapy includes supportive medical care, identification of the source of embolism and prevention of additional emboli. Patients who experienced arterial embolism as a result of clots formed in the heart should be anticoagulated. Arterial emboli from atherosclerotic disease of the aorta or other large arteries should prompt treatment to reduce the risk for atherosclerotic progression, such as anti-platelet therapy and the use of statin drugs. The use of anticoagulation and surgical intervention to reduce the risk of arterial embolization from atherosclerotic lesions is still being studied.

An iatrogenic metabolic encephalopathy in a nonagenarian: The dilemma of a critical miss as a possible social dismissal.

Here we posit for discussion the example of a reversible metabolic encephalopthy in a very elderly male that was missed clinically. A metabolic encephalopathy in extrememly elderly patients may be confused with delerium or inattention. A reversible cause of cognative dysfunction in the aged may be missed by practitioners because the aged may be assumed to have some level of impaired cognition; this may lead to a "social dismissal" of mental status changes. We highlight the need for engaged physicians in the care of the aged and vigilance against a professional bias toward the elderly patient that is dismissive.