Influence of right ventricular structure and function on hospital outcomes in COVID-19 patients.

BACKGROUND: The impact of the right ventricular (RV) structure and function on the in-hospital outcomes in patients with COVID-19 infection has not been rigorously investigated. OBJECTIVES: The main aim of our study was to investigate in-hospital outcomes including mortality, ICU admission, mechanical ventilation, pressor support, associated with RV dilatation, and RV systolic dysfunction in COVID-19 patients without a history of pulmonary hypertension. METHODS: It was a single academic tertiary center, retrospective cohort study of 997 PCR-confirmed COVID-19 patients. One hundred ninty-four of those patients did not have a history of pulmonary hypertension and underwent transthoracic echocardiography at the request of the treating physicians for clinical indications. Clinical endpoints which included mortality, ICU admission, need for mechanical ventilation or pressor support were abstracted from the electronic charts. RESULTS: Patients' mean age was 68+/-16 years old and 42% of the study population were females. COPD was reported in 13% of the study population, whereas asthma was 10%, and CAD was 25%. The mean BMI was 29.8+/-9.5 kg/m2. Overall mortality was 27%, 46% in ICU patients, and 9% in the rest of the cohort. There were no significant differences in co-morbidities between expired patients and the survivors. A total of 19% of patients had evidence of RV dilatation and 17% manifested decreased RV systolic function. RV dilatation or decreased RV systolic function were noted in 24% of the total study population. RV dilatation was significantly more common in expired patients (15% vs 29%, p = 0.026) and was associated with increased mortality in patients treated in the ICU (HR 2.966, 95%CI 1.067-8.243, p = 0.037), who did not need require positive pressure ventilation, IV pressor support or acute hemodialysis. CONCLUSIONS: In hospitalized COVID-19 patients without a history of pulmonary hypertension, RV dilatation is associated with a 2-fold increase in inpatient mortality and a 3-fold increase in ICU mortality.

Clinical Outcomes of Early Versus Late Intubation in COVID-19 Patients.

Background The implications of intubation timing in COVID-19 patients remain highly debatable due to the scarcity of available evidence. Objectives Our study aims to assess the clinical characteristics and outcomes of COVID-19 patients undergoing early intubation compared to those undergoing late intubation. Methods This is a single-center retrospective study of adult COVID-19 patients admitted between March 1, 2020 and January 10, 2021. Early intubation was defined as intubation within 24 hours of a) hospital admission; b) respiratory status deterioration requiring FiO2 60% and higher; or c) moderate/severe acute respiratory distress syndrome (ARDS) diagnosis. Results Among the 128 COVID-19 patients included, 66.4% required early intubation, and 33.6% required late intubation. The 28-day all-cause mortality and other outcomes of mechanical ventilation duration, hospital and ICU length of stay were equal regardless of intubation timing. Clinical characteristics, inflammatory markers, COVID-19 therapies, PaO2/FiO2 ratio, and pH were comparable for both groups. Better lung compliance was observed during early intubation than late intubation based on plateau (mean 21.3 vs. 25.5 cmH2O; P < 0.01) and peak pressure (mean 24.1 vs. 27.4 cmH2O; P = 0.04). Conclusions In critically ill COVID-19 patients, the timing of intubation was not significantly associated with poor clinical outcomes in the setting of matching clinical characteristics. More research is needed to determine which subset of patients may benefit from intubation and the predictors for optimal intubation timing.

Incidental Discovery of Embryonal Rhabdomyosarcoma on CT Imaging.

Rhabdomyosarcoma is an uncommon soft tissue sarcoma that rarely presents in adults. Clinical presentation is dependent on site and size. We present the case of a woman who presented with acute-onset dyspnoea and whose pathology report confirmed embryonal rhabdomyosarcoma (ERMS) seen as an incidental finding on chest computed tomography. We also describe the clinical, laboratory and radiological work-up conducted to diagnose and manage ERMS in the critical care setting. LEARNING POINTS: Rhabdomyosarcoma is a rare malignancy with a poor prognosis in adults compared with children, especially if it presents in an unfavourable primary site and has an unfavourable histological diagnosis.Immunohistochemical diagnosis remains the gold standard for embryonal rhabdomyosarcoma diagnosis and differentiation from similar malignancies on initial imaging studies.Management of adult rhabdomyosarcoma is usually multimodal with surgical resection and a combination of chemo and radiotherapy.

Incidence, Risk Factors, and Outcomes of Rhabdomyolysis in Hospitalized Patients With COVID-19 Infection.

INTRODUCTION: There is a paucity of studies examining the prevalence and clinical characteristics of rhabdomyolysis in hospitalized patients with COVID-19 infection. The purpose of this study is to examine the incidence, clinical characteristics, and outcome of hospitalized patients with COVID-19 infection who develop rhabdomyolysis. METHODOLOGY: This is a single-center retrospective analysis of all hospitalized patients with COVID-19 admitted between March 8, 2020, and January 11, 2021. All patients with creatinine kinase (CK) levels available during the hospital admission were included. Rhabdomyolysis was defined as an elevation in CK level higher than five times the upper limit of normal (i.e., 1125 U/L). We compared clinical characteristics and outcomes of patients who developed rhabdomyolysis with patients who did not develop rhabdomyolysis. RESULTS: The incidence of rhabdomyolysis in hospitalized patients with COVID-19 infection was 9.2%. There was no significant difference noted in comorbidities and clinical characteristics between the two groups. Moreover, there was no significant difference noted in the presence of severe COVID-19 infection (72.7% vs 54.6%, p = 0.1), mortality (27.3% vs 23.9%, p = 0.72), acute kidney injury (59.1% vs 42.7%, p = 0.14), or need for intensive care unit (ICU) care (72.7% vs 51.4%, p = 0.051). However, a higher percentage of patients in the rhabdomyolysis group required physical rehabilitation after discharge (40.9% vs 19.3%, p = 0.02). CONCLUSION: The overall incidence of rhabdomyolysis in hospitalized patients with COVID-19 infection was high (9.2%). The presence of rhabdomyolysis was not associated with the increased severity of the disease. Patients with rhabdomyolysis more frequently required physical rehabilitation compared to those without rhabdomyolysis.

Pneumothorax in critically ill patients with COVID-19 infection: Incidence, clinical characteristics and outcomes in a case control multicenter study.

BACKGROUND: The clinical features and outcomes of mechanically ventilated patients with COVID-19 infection who develop a pneumothorax has not been rigorously described or compared to those who do not develop a pneumothorax. PURPOSE: To determine the incidence, clinical characteristics, and outcomes of critically ill patients with COVID-19 infection who developed pneumothorax. In addition, we compared the clinical characteristics and outcomes of mechanically ventilated patients who developed a pneumothorax with those who did not develop a pneumothorax. METHODS: This study was a multicenter retrospective analysis of all adult critically ill patients with COVID-19 infection who were admitted to intensive care units in 4 tertiary care centers in the United States. RESULTS: A total of 842 critically ill patients with COVID-19 infection were analyzed, out of which 594 (71%) were mechanically ventilated. The overall incidence of pneumothorax was 85/842 (10%), and 80/594 (13%) in those who were mechanically ventilated. As compared to mechanically ventilated patients in the non-pneumothorax group, mechanically ventilated patients in the pneumothorax group had worse respiratory parameters at the time of intubation (mean PaO2:FiO2 ratio 105 vs 150, P<0.001 and static respiratory system compliance: 30ml/cmH2O vs 39ml/cmH2O, P = 0.01) and significantly higher in-hospital mortality (63% vs 49%, P = 0.04). CONCLUSION: The overall incidence of pneumothorax in mechanically ventilated patients with COVID-19 infection was 13%. Mechanically ventilated patients with COVID-19 infection who developed pneumothorax had worse gas exchange and respiratory mechanics at the time of intubation and had a higher mortality compared to those who did not develop pneumothorax.

Hodgkin's Lymphoma Presenting as Multiple Cavitary Lung Lesions.

Hodgkin Lymphoma (HL) typically presents similarly to an infectious etiology, thus awareness of its atypical presentations is essential. We present a case of an adult woman who was found to have HL after presenting with a dry, non-productive cough and showing cavitary lesions on chest computed tomography (CT). We also describe the clinical, laboratory, and radiological workup done leading to the diagnosis and management of HL in a critical care setting. LEARNING POINTS: Cavitary lung lesions, particularly multiloculated, are often caused by mycobacterium tuberculosis (TB), aspergillosis, granulomatosis with polyangiitis, sarcoidosis, and rheumatic nodules.Pulmonary infiltration is a rare disorder of an extra-nodal site in Hodgkin's Lymphoma. The mediastinum and head and neck regions remain the most common sites affected by HL.Radiologically, primary pulmonary HL may mimic pneumonia, carcinoma making the diagnosis unclear.

Successful surgical retrieval of Celt ACD® vascular closure device embolised in the tibioperoneal trunk.

BACKGROUND: This report presents a case of surgical retrieval of a Celt ACD® vascular closure device (VCD) situated in the tibioperoneal trunk, following a failed attempt at deployment. Existing literature mostly recommends an endovascular approach when attempting to retrieve embolised VCDs. CASE PRESENTATION: A 55 year old male presented with right sudden right lower limb pain and numbness 1 week following a successful left retrograde superficial femoral artery (SFA) angioplasty. Computed tomography (CT) angiogram revealed that the Celt ACD® VCD had embolised in the right tibioperoneal trunk. An endovascular approach was initially attempted to retrieve the VCD; however, this was unsuccessful due to the small diameter of the target artery. Due to the failure of the endovascular approach, surgical exploration of the right tibioperoneal trunk was undertaken, which led to the successful retrieval of the embolised VCD. CONCLUSION: The case presented herein demonstrates the critical need for swift and decisive surgical exploration of patients with suspected embolisation of Celt ACD® devices in smaller distal arteries. Our experience has led to the recommendation that, due to the sharp edges of the Celt ACD® accompanied with the small diameter of the occluded vessels, surgical exposure and retrieval is the safest option if endovascular retrieval is unsuccessful.