Streptococcus pneumoniae Coinfection in COVID-19 in the Intensive Care Unit: A Series of Four Cases.

Bacterial coinfections in patients infected with SARS-CoV-2 pneumonia are uncommon, when compared to coinfections with other respiratory viruses. For example, the prevalence of bacterial coinfections in hospitalized seasonal influenza patients can exceed 30%, whereas the prevalence of bacterial coinfections in SARS-CoV-2 infection is less than 4%. Bacterial coinfections increase the severity of respiratory viral infections and have been associated with higher mortality and morbidity. Current literature shows that diagnostic testing and antibiotic therapy for bacterial infections are not necessary upon admission in majority of patients with SARS-CoV-2 patients. It is however important for the clinician to be cognizant of these coinfections since missing the diagnosis may pose a substantial risk to vulnerable COVID-19 patients. In that light, we present four cases of Streptococcus pneumoniae coinfections complicating confirmed SARS-CoV-2 infections.

The tale of the traveling cheese: Shigella in a lung transplant patient.

Shigellae are Gram-negative, nonmotile, facultatively anaerobic, non-spore-forming rods. Shigella is a common cause of gastroenteritis in areas of overcrowding and poor sanitation, but is seen less frequently in the developed world. Infection is mainly acquired through the fecal-oral route, but consumption of unpasteurized dairy remains a high risk for transmission. In the developing world, Shigella is a childhood illness and with adequate hydration is fairly self-limiting. The use of antibiotics depends on the severity of illness, the age of the patient and immune status. In immunocompromised patients, chronic symptomatic or relapsing infection has been described. In this report, we describe a case of a lung transplant patient, one year out of his transplant, on triple immunosuppressive therapy, who presented with septic shock secondary to Shigella gastroenteritis after ingesting unpasteurized cheese brought back from Peru. This case highlights the importance of educating transplant patients on how to reduce certain harmful exposures that may be fatal in immunosuppressed individuals.

Recurrent Silicone Embolism Syndrome requiring VA ECMO.

The illegal use of liquid silicone in injectable procedures has been on the rise for the last few years. While originally thought to be an inert material, today, silicone is associated with several inflammatory complications-including Silicone Embolism Syndrome (SES). SES is the most dreaded complication of unlicensed liquid silicone injections. It is characterized by pneumonitis, diffuse alveolar and silicone pulmonary emboli leading to acute respiratory distress syndrome and cardiopulmonary failure. We present a case of a patient who was diagnosed with SES after she received unlicensed liquid silicone injections for gluteal augmentation. Her disease necessitated treatment with veno-arterial extracorporeal membrane oxygenation. Her neurological status remained poor. Our patient was also treated for SES status-post illicit silicone injections several years prior to the current episode. To our knowledge, this is the only reported instance of the same patient experiencing SES status-post illicit silicone injections on two separate occasions. Our patient's case suggests that robust education is needed for patients and the general public regarding the dangers of illicit body modifications. Given the widespread availability of counterfeit "medical grade" silicone, it is likely that the number of SES cases will continue to increase. Physicians must to be able to recognize the symptoms of SES, and not discount the possibility that patients will continue to receive illicit injections-even if they experienced devastating consequences the first time.

Gastrointestinal Hemorrhage in Patient with Granulomatosis with Polyangitis.

Granulomatosis with polyangitis (GPA) is characterized by a necrotizing granulomatous vasculitis of small arteries and veins. It most commonly affects the upper and lower respiratory tract and kidneys. However, other organs including the gastrointestinal tract can be affected. Gastrointestinal manifestations of GPA are rare and can include ischemia, bowel infarction, and perforation. Hemorrhage is an extremely rare presentation of GPA. We present a case of a woman with GPA and pulmonary renal syndrome on treatment who presents with severe gastrointestinal hemorrhage.

Predicting Mechanical Ventilation and Mortality in COVID-19 Using Radiomics and Deep Learning on Chest Radiographs: A Multi-Institutional Study.

In this study, we aimed to predict mechanical ventilation requirement and mortality using computational modeling of chest radiographs (CXRs) for coronavirus disease 2019 (COVID-19) patients. This two-center, retrospective study analyzed 530 deidentified CXRs from 515 COVID-19 patients treated at Stony Brook University Hospital and Newark Beth Israel Medical Center between March and August 2020. Linear discriminant analysis (LDA), quadratic discriminant analysis (QDA), and random forest (RF) machine learning classifiers to predict mechanical ventilation requirement and mortality were trained and evaluated using radiomic features extracted from patients' CXRs. Deep learning (DL) approaches were also explored for the clinical outcome prediction task and a novel radiomic embedding framework was introduced. All results are compared against radiologist grading of CXRs (zone-wise expert severity scores). Radiomic classification models had mean area under the receiver operating characteristic curve (mAUCs) of 0.78 ± 0.05 (sensitivity = 0.72 ± 0.07, specificity = 0.72 ± 0.06) and 0.78 ± 0.06 (sensitivity = 0.70 ± 0.09, specificity = 0.73 ± 0.09), compared with expert scores mAUCs of 0.75 ± 0.02 (sensitivity = 0.67 ± 0.08, specificity = 0.69 ± 0.07) and 0.79 ± 0.05 (sensitivity = 0.69 ± 0.08, specificity = 0.76 ± 0.08) for mechanical ventilation requirement and mortality prediction, respectively. Classifiers using both expert severity scores and radiomic features for mechanical ventilation (mAUC = 0.79 ± 0.04, sensitivity = 0.71 ± 0.06, specificity = 0.71 ± 0.08) and mortality (mAUC = 0.83 ± 0.04, sensitivity = 0.79 ± 0.07, specificity = 0.74 ± 0.09) demonstrated improvement over either artificial intelligence or radiologist interpretation alone. Our results also suggest instances in which the inclusion of radiomic features in DL improves model predictions over DL alone. The models proposed in this study and the prognostic information they provide might aid physician decision making and efficient resource allocation during the COVID-19 pandemic.

Predicting Clinical Outcomes in COVID-19 using Radiomics and Deep Learning on Chest Radiographs: A Multi-Institutional Study.

We predict mechanical ventilation requirement and mortality using computational modeling of chest radiographs (CXRs) for coronavirus disease 2019 (COVID-19) patients. This two-center, retrospective study analyzed 530 deidentified CXRs from 515 COVID-19 patients treated at Stony Brook University Hospital and Newark Beth Israel Medical Center between March and August 2020. DL and machine learning classifiers to predict mechanical ventilation requirement and mortality were trained and evaluated using patient CXRs. A novel radiomic embedding framework was also explored for outcome prediction. All results are compared against radiologist grading of CXRs (zone-wise expert severity scores). Radiomic and DL classification models had mAUCs of 0.78+/-0.02 and 0.81+/-0.04, compared with expert scores mAUCs of 0.75+/-0.02 and 0.79+/-0.05 for mechanical ventilation requirement and mortality prediction, respectively. Combined classifiers using both radiomics and expert severity scores resulted in mAUCs of 0.79+/-0.04 and 0.83+/-0.04 for each prediction task, demonstrating improvement over either artificial intelligence or radiologist interpretation alone. Our results also suggest instances where inclusion of radiomic features in DL improves model predictions, something that might be explored in other pathologies. The models proposed in this study and the prognostic information they provide might aid physician decision making and resource allocation during the COVID-19 pandemic.

Effects of Prone Ventilation on Oxygenation, Inflammation, and Lung Infiltrates in COVID-19 Related Acute Respiratory Distress Syndrome: A Retrospective Cohort Study.

Patients receiving mechanical ventilation for coronavirus disease 2019 (COVID-19) related, moderate-to-severe acute respiratory distress syndrome (CARDS) have mortality rates between 76-98%. The objective of this retrospective cohort study was to identify differences in prone ventilation effects on oxygenation, pulmonary infiltrates (as observed on chest X-ray (CXR)), and systemic inflammation in CARDS patients by survivorship and to identify baseline characteristics associated with survival after prone ventilation. The study cohort included 23 patients with moderate-to-severe CARDS who received prone ventilation for ≥16 h/day and was segmented by living status: living (n = 6) and deceased (n = 17). Immediately after prone ventilation, PaO2/FiO2 improved by 108% (p < 0.03) for the living and 150% (p < 3 × 10-4) for the deceased. However, the 48 h change in lung infiltrate severity in gravity-dependent lung zones was significantly better for the living than for the deceased (p < 0.02). In CXRs of the lower lungs before prone ventilation, we observed 5 patients with confluent infiltrates bilaterally, 12 patients with ground-glass opacities (GGOs) bilaterally, and 6 patients with mixed infiltrate patterns; 80% of patients with confluent infiltrates were alive vs. 8% of patients with GGOs. In conclusion, our small study indicates that CXRs may offer clinical utility in selecting patients with moderate-to-severe CARDS who will benefit from prone ventilation. Additionally, our study suggests that lung infiltrate severity may be a better indicator of patient disposition after prone ventilation than PaO2/FiO2.

Streptococcus pneumoniae Coinfection in COVID-19: A Series of Three Cases.

Bacterial coinfections are not uncommon with respiratory viral pathogens. These coinfections can add to significant mortality and morbidity. We are currently dealing with the SARS-CoV-2 pandemic, which has affected over 15 million people globally with over half a million deaths. Previous respiratory viral pandemics have taught us that bacterial coinfections can lead to higher mortality and morbidity. However, there is limited literature on the current SARS-CoV-2 pandemic and associated coinfections, which reported infection rates varying between 1% and 8% based on various cross-sectional studies. In one meta-analysis of coinfections in COVID-19, rates of Streptococcus pneumoniae coinfections have been negligible when compared to previous influenza pandemics. Current literature does not favor the use of empiric, broad-spectrum antibiotics in confirmed SARS-CoV-2 infections. We present three cases of confirmed SARS-CoV-2 infections complicated by Streptococcus pneumoniae coinfection. These cases demonstrate the importance of concomitant testing for common pathogens despite the need for antimicrobial stewardship.

Pulmonary Toxoplasmosis Diagnosed on Transbronchial Lung Biopsy in a Mechanically Ventilated Patient.

Toxoplasma gondii is a protozoan parasite that infects up to a third of the world's population. Infection is mainly acquired by ingestion of food or water that is contaminated with oocysts shed by cats or consuming undercooked meat containing tissue cysts. Primary infection is subclinical in immunocompetent hosts. Invasive toxoplasmosis often manifests as cerebral toxoplasmosis in immunosuppressed patients. In persons living with human immunodeficiency virus (HIV), toxoplasmosis occurs when CD4 counts are very low and is considered an acquired immunodeficiency syndrome (AIDS) defining illness. Pulmonary toxoplasmosis is rarely seen in the highly active antiretroviral therapy era. The diagnosis can be challenging due to the nonspecific nature of clinical and radiographic findings. In this report, we present a case of pulmonary toxoplasmosis in a new onset AIDS patient, which was initially clinically misdiagnosed as Pneumocystis jiroveci pneumonia (PJP). Due to a poor response to treatment for PJP, the patient underwent a transbronchial lung biopsy, which led to the diagnosis of pulmonary toxoplasmosis.

Follicular Bronchiolitis: Two Cases with Varying Clinical and Radiological Presentation.

Follicular bronchiolitis (FB) is a rare bronchiolar disorder associated with hyperplasia of the bronchial-associated lymphoid tissue (BALT). It is characterized by the development of lymphoid follicles with germinal centers in the walls of small airways. It falls under the category of lymphoproliferative pulmonary diseases (LPDs) and commonly occurs in relation to connective tissue disease, immunodeficiency, infections, interstitial lung disease (ILD), and inflammatory airway diseases. Computerized tomography (CT) findings include centrilobular nodules with patchy ground glass infiltrate, tree-in-bud findings, and air trapping. It can very rarely present as diffuse cystic lung disease. We present two cases of FB. The first case is associated with Human Immunodeficiency Virus (HIV) infection and asthma with diffuse cystic changes on the CT. The second case is associated with reactive airway disease and gastroesophageal reflux disease (GERD) with the classic centrilobular nodules and ground glass opacities on the CT.

Power and negotiation: review of current evidence and future directions.

This review synthesizes the impact of power on individual and joint negotiation performance. Although power generally has positive effects on negotiators' individual performance (value claiming), recent work suggests that more power is not always beneficial. Taking a dyadic perspective, we also find mixed evidence for how power affects joint performance (value creation); some studies show that equal-power dyads create more value than unequal-power dyads, but others find the opposite. We identify the source of power, power distribution, and competitiveness as critical moderators of this relationship. Finally, we suggest that future research should move beyond studying alternatives in dyadic deal-making, identify strategies to overcome a lack of power,increase empirical realism, and take a more dynamic view of power in negotiations.

Micro-Macro Relationships in the Simulation of Wave Propagation Phenomenon Using the Discrete Element Method.

The present work is aimed to investigate the capability of the discrete element method (DEM) to model properly wave propagation in solid materials, with special focus on the determination of elastic properties through wave velocities. Reference micro-macro relationships for elastic constitutive parameters have been based on the kinematic hypothesis as well as obtained numerically by simulation of a quasistatic uniaxial compression test. The validity of these relationships in the dynamic analysis of the wave propagation has been checked. Propagation of the longitudinal and shear wave pulse in rectangular sample discretized with discs has been analysed. Wave propagation velocities obtained in the analysis have been used to determine elastic properties. Elastic properties obtained in the dynamic analysis have been compared with those determined by simulation of the quasistatic compression test.

Aspirated Almond Masquerading as an Obstructing Endobronchial Mass Suspicious for Lung Cancer.

Foreign body aspiration is relatively rare in adults compared to children. In adults with delayed presentation, a history of choking is often absent, resulting in delayed diagnosis and significant morbidity. Common presenting features in adults include nonresolving cough with or without fever, hemoptysis, or wheezing and may mimic infectious, inflammatory, or neoplastic disorders. We present a case of a 64-year-old man with 80-pack-year smoking history who had a nonresolving left lower lobe infiltrate on chest radiograph after treatment for community-acquired pneumonia. His insidious-onset symptoms included cough, decreased exercise tolerance, and localized wheezing. Computed tomography of the chest showed a left lower lobe consolidation, with narrowing of the bronchus. Flexible bronchoscopy revealed a fleshy endobronchial mass, prompting endobronchial needle aspiration and biopsies, all of which revealed acute inflammation on rapid onsite evaluation. After multiple biopsies, a white pearly object with a detached brown cover was revealed; the object was found to be an aspirated almond. The almond and its peel were retrieved. The patient acknowledged that he had frequently eaten almonds in the supine position while recovering from a previous injury. His symptoms completely resolved at 3-month follow up, and he has ceased smoking and no longer consumes food while supine.

Pulmonary Artery Pseudoaneurysm: A Rare Cause of Fatal Massive Hemoptysis.

Pulmonary artery pseudoaneurysm (PAPA), an uncommon complication of pyogenic bacterial and fungal infections and related septic emboli, is associated with high mortality. The pulmonary artery (PA) lacks an adventitial wall; therefore, repeated endovascular seeding of the PA with septic emboli creates saccular dilations that are more likely to rupture than systemic arterial aneurysms. The most common clinical presentation of PAPA is massive hemoptysis and resultant worsening hypoxemia. Computed tomography angiography is the preferred diagnostic modality for PAPA; typical imaging patterns include focal outpouchings of contrast adjacent to a branch of the PA following the same contrast density as the PA in all phases of the study. In mycotic PAPAs, multiple synchronous lesions are often seen in segmental and subsegmental PAs due to ongoing embolic phenomena. The recommended approach for a mycotic PAPA is prolonged antimicrobial therapy; for massive hemoptysis, endovascular treatment (e.g., coil embolization, stenting, or embolization of the feeding vessel) is preferred. PAPA resection and lobectomy are a last resort, generally reserved for patients with uncontrolled hemoptysis or pleural hemorrhage. We present a case of a 28-year-old woman with necrotizing pneumonia from intravenous drug use who ultimately died from massive hemoptysis and shock after a ruptured PAPA.

Angioinvasive Aspergillus-associated Stroke in an Immunocompetent Host Following Cardiac Surgery and ECMO.

INTRODUCTION: Invasive cerebral aspergillosis is an uncommon cause of stroke among immunocompetent patients and has not been reported in association with cardiac surgery or extracorporeal membrane oxygenation (ECMO). We report the case of an immunocompetent host who developed aspergillus-associated stroke following coronary artery bypass graft (CABG) and ECMO. CASE REPORT: A 59-year-old woman developed cardiogenic shock after 3-vessel-CABG requiring intra-aortic balloon pump placement and subsequent veno-arterial ECMO. Noncontrast computed tomography of the brain was suggestive of multiple bihemispheric ischemic infarcts. Postmortem pathologic analysis revealed aspergillus-associated inflammation of blood vessels and ischemic and petechial hemorrhagic strokes in the affected territories. DISCUSSION AND CONCLUSIONS: Ischemic infarcts in the setting of CABG or ECMO are often presumed to be thromboembolic from the heart or device, related to underlying hemodynamic instability, or due to a clinically apparent systemic infection such as endocarditis. This report suggests that invasive cerebral aspergillosis should be considered in seemingly immunocompetent patients following CABG or ECMO. The mechanism is unclear, but may be related to systemic inflammatory dysregulation resulting in increased susceptibility to uncommon pathogens.

Data from a pre-publication independent replication initiative examining ten moral judgement effects.

We present the data from a crowdsourced project seeking to replicate findings in independent laboratories before (rather than after) they are published. In this Pre-Publication Independent Replication (PPIR) initiative, 25 research groups attempted to replicate 10 moral judgment effects from a single laboratory's research pipeline of unpublished findings. The 10 effects were investigated using online/lab surveys containing psychological manipulations (vignettes) followed by questionnaires. Results revealed a mix of reliable, unreliable, and culturally moderated findings. Unlike any previous replication project, this dataset includes the data from not only the replications but also from the original studies, creating a unique corpus that researchers can use to better understand reproducibility and irreproducibility in science.