Jejunal closed-loop obstruction without prior abdominal surgery during COVID-19 ICU admittance: A case report.

INTRODUCTION: and importance: Closed-loop obstruction is a specific case of small bowel obstruction in which two sites of the bowel obstruct at one adjacent location. This can result in strangulation with high mortality. This condition is most often observed after abdominal surgery. The exact underlying pathology in patients without prior abdominal surgery is still largely unclear, and only scarce literature on the role of COVID-19 or long-term prone position is available. CASE PRESENTATION: A 74-year-old male patient without prior abdominal surgery was presented to the emergency department with pulmonary and gastro-intestinal symptoms of COVID-19. The patient was known to have diverticulosis of colon and sigmoid. After a complicated ICU course, the patient developed a jejunal closed loop obstruction, and a diagnostic laparoscopy was performed. Fixation of the omentum to the retroperitoneum was released, without observation of further adhesions, bowel torsion or ischemic bowel. Further abdominal course was uncomplicated, however, unfortunately the patient died following pulmonary deterioration. CLINICAL DISCUSSION: The differential diagnosis of small bowel obstruction is extensive; however, adhesions are most often observed. In patients without prior surgery, also adhesions are observed, mainly caused by earlier infections. There might be a role for abdominal COVID-19 infection and prolonged prone position in the emergence of adhesions; however, literature is lacking. Alternatively, asymptomatic diverticulitis might have led to adhesion formation. CONCLUSION: Closed loop obstructions in patients without prior abdominal surgery are uncommon and post-infectious abdominal status might cause adhesions. It is unclear whether abdominal manifestations of COVID-19 and prolonged prone position can also cause adhesions and, thereby, small bowel obstructions.

Clinically relevant potential drug-drug interactions in intensive care patients: A large retrospective observational multicenter study.

PURPOSE: Potential drug-drug interactions (pDDIs) may harm patients admitted to the Intensive Care Unit (ICU). Due to the patient's critical condition and continuous monitoring on the ICU, not all pDDIs are clinically relevant. Clinical decision support systems (CDSSs) warning for irrelevant pDDIs could result in alert fatigue and overlooking important signals. Therefore, our aim was to describe the frequency of clinically relevant pDDIs (crpDDIs) to enable tailoring of CDSSs to the ICU setting. MATERIALS & METHODS: In this multicenter retrospective observational study, we used medication administration data to identify pDDIs in ICU admissions from 13 ICUs. Clinical relevance was based on a Delphi study in which intensivists and hospital pharmacists assessed the clinical relevance of pDDIs for the ICU setting. RESULTS: The mean number of pDDIs per 1000 medication administrations was 70.1, dropping to 31.0 when considering only crpDDIs. Of 103,871 ICU patients, 38% was exposed to a crpDDI. The most frequently occurring crpDDIs involve QT-prolonging agents, digoxin, or NSAIDs. CONCLUSIONS: Considering clinical relevance of pDDIs in the ICU setting is important, as only half of the detected pDDIs were crpDDIs. Therefore, tailoring CDSSs to the ICU may reduce alert fatigue and improve medication safety in ICU patients.

Calcium ionophore A23187 induces interleukin 2 reactivity in human T cells.

In the present study the activation of purified human T lymphocytes by the calcium ionophore A23187 was analysed in the light of current concepts of receptor-linked inositol lipid metabolism. It was found that A23187 was only slightly mitogenic, with a narrow optimum at 400-500 nM. The proliferation could be blocked by anti-Tac ascites at 10(-3) dilution, suggesting an interleukin 2 (IL-2)-dependent pathway of activation. However, an unexpectedly large proportion of A23187-stimulated cells expressed the IL-2 receptor. Reculturing the cells with exogenous IL-2 after removal of A23187 resulted in strongly enhanced proliferation. Phorbol myristic acetate (PMA) at non-mitogenic concentrations exerted an extremely strong synergistic effect on A23187-induced cell proliferation, which was, again, mediated via an IL-2-dependent pathway. Supernatants of A23187-stimulated T cells did not contain detectable amounts of IL-2. Combination of PMA and A23187 resulted in considerable IL-2 production. It is concluded that A23187 induces the expression of IL-2 receptors without concurrent stimulation of IL-2 production, thus allowing only low levels of proliferation. Addition of exogenous IL-2 or of PMA restores the imbalance between the occurrence of IL-2 and its receptor and results in high rates of proliferation.