Isolated Respiratory Failure as a Presentation for Early Perinuclear Antineutrophil Cytoplasmic Antibody-Associated Vasculitis.

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is an autoimmune inflammatory disease that usually affects the small-sized vasculature, most notably of the lungs and kidneys. One of the challenges of suspecting and diagnosing the condition lies in the insidious and unclear symptoms of presentation. In this case report, we discuss the case of a patient who initially presented with solely unclear pulmonary symptoms, without other organ system dysfunction.

Successful Utilization of Life-saving Extra-Corporeal CO2 Removal in Catastrophic Status Asthmaticus: A Case Report.

Acute asthma exacerbations can be severe and life-threatening. In some cases, standard interventions and management do not result in reversal of bronchoconstriction. It is crucial to detect patients with impending respiratory failure and escalate management to invasive mechanical ventilatory support and, in refractory cases, interventions like extracorporeal membrane oxygenation (ECMO). This technique is not frequently utilized but has proven to be effective in settings of resistant status asthmaticus. We describe a Case of respiratory distress secondary to asthma exacerbation, which rapidly devolved into status asthmaticus. It was resistant to all standard and off-label management modalities, which necessitated the use of veno-venous extracorporeal CO2 removal (VVECCO2R). ECMO was utilized in our case with great success. In this article, we aim to raise awareness of the importance of VVECCO2R in the treatment of refractory status asthmaticus and the difficulties that prevent widespread implementation of the technique across healthcare facilities.

Colonic Actinomycosis Presenting One Year After Partial Sigmoid Colectomy.

Actinomycetes are commensal inhabitants of the oral cavity and gastrointestinal tract that can acquire pathogenicity through invasion of injured mucosa. Appendix and ileocecal regions are the most common sites involved in abdominal actinomycosis. We report a case of unusual site actinomycosis, in the recto-sigmoid colon, presenting with abdominal pain and diarrhea after one year of partial sigmoid colectomy. A colonoscopy was done, which showed a 21 mm polypoid partially obstructing mass in the recto-sigmoid colon. Histopathology showed granulation tissue with severe acute inflammation, fibrinopurulent debris with areas of abscess, and branching filamentous organisms with sulfur granules consistent with actinomycosis. Abdominal actinomycosis can infect almost all organs within the abdominal cavity; however, it is more common around the ileocecal region.

Serratia marcescens Endocarditis.

Infective endocarditis (IE) secondary to Staphylococcus aureus and streptococcus species comprises the majority of cases in literature with Gram negative bacterial insults occurring infrequently. Serratia marcescens is a Gram negative bacillus which is classified as motile, non-lactose fermenting, and a facultative anerobe. The presumed risk factor for the development of S. marcescens IE is intravenous drug use (IVDU). We report two cases of IE causes by S. marcescens: first case describes IE of tricuspid and aortic valve requiring surgical intervention further complicated by epidural abscess. The second case was associated with renal and splenic infarct. These cases highlight the severity and complicated nature of S. marcescens IE. Given S. marcescens IE has been infrequently described in the literature, we believe that our cases are worth reporting to contribute to the present incidence and management of S. marcescens IE.

A rare report of Rothia dentocariosa endocarditis.

Rothia species are gram positive, round to rod-shaped bacteria that are normally oral and respiratory tract flora. They were first isolated in 1967 from dental caries. We present a 69-year-old male with no risk factors for aforementioned bacteria however was found to have thickened anterior leaflet of the mitral valve with a small isoechoic lesion consistent with vegetation on Transthoracic echocardiogram. Blood cultures grew pan sensitive Rothia dentocariosa. Patient was treated with long-term antibiotics. This case adds to the limited number of cases of Rothia dentocariosa Endocarditis.

An Atypical Presentation of Severe Dissecting Aortic Aneurysm: A Case Report and Literature Review.

A 55-year-old male patient with no past medical history presents to the ED to complain of exertional dyspnea and bilateral lower limb swelling. The patient was diagnosed with a severe dissecting aortic aneurysm on trans-thoracic echocardiography and later confirmed by a contrast CT aortogram. The patient was immediately started on anti-impulse therapy with labetalol infusion and underwent emergent aortic dissection repair. This case demonstrates an atypical presentation of a life-threatening condition that might have been missed on the initial assessment.

Methylenedioxymethamphetamine (MDMA)-Induced Hyponatremia: Case Report and Literature Review.

3,4-Methylenedioxymethamphetamine, MDMA, or "ecstasy", is a trending recreational drug used by the young crowd for obtaining "euphoria." Over the past few years, there have been multiple reports of teenagers committing suicide and suddenly dying post ingesting MDMA. Compared to other illicit drugs such as heroin, hash and cocaine, ecstasy is relatively new hence the popularity. There are multiple toxicities associated with MDMA, including but not limited to seizures, depression, liver failure, or thrombosis. However, in this report, we will focus on hyponatremia and one of the most feared complications of such electrolyte disturbance: seizures. The rapid reversal of the hyponatremia with hypertonic saline in such acute setting is key to reduce risk of cerebral swelling. We report a case of a young female with no past medical history who presented to emergency department post ecstasy use with tonic-clonic seizure and hyponatremia.

A Young COVID-19-Positive Male Patient Presented With Bilateral Pulmonary Emboli and Multiple Strokes.

COVID-19 has been repeatedly related to a variety of extra-pulmonary manifestations since its emergence. COVID-19-positive patients have been shown to develop neurological deficits, deep venous thrombosis, acute kidney injury, acute hepatic injury, and myocarditis, among other conditions. The mechanism of some of these injuries remains unclear, but one factor that has been revealed is hypercoagulability. A hypercoagulable state, whether secondary to dysfunctional coagulation cascades or microvascular angiopathy, has been reported in the literature in COVID-19 patients. We present a case of a patient diagnosed with COVID-19 presented with venous thromboembolism and then shortly developed innumerable strokes.

A Rare Case Report of Herbal Medication Induced Pancreatitis.

Acute pancreatitis is an acute inflammation of the pancreas that varies in clinical manifestation from mild to life-threatening that may require hospitalization. A 56-year-old male patient with a past medical history of diabetes mellitus and osteoarthritis developed acute pancreatitis likely secondary to the use of herbal medication intended for weight loss. Other causes of pancreatitis were excluded. This report describes a case of herbal medication-associated pancreatitis after the exclusion of other causes. The incidence of herbal medication-associated pancreatitis is indeterminate due to inadequate literature on similar cases. The aim of this review is to describe the effect of herbal-based medicines and their counteraction on developing acute pancreatitis.

Meta-analysis of Safety and Efficacy of Anticoagulation versus no Anticoagulation in Octogenarians and Nonagenarians with Atrial Fibrillation.

INTRODUCTION: The role of anticoagulation in octogenarians and nonagenarians with atrial fibrillation (AF) is controversial due to the lack of evidence from randomized controlled trials (RCTs), owing to the under representation of these patients in clinical trials. AIM: In the present meta-analysis we aim at comparing the clinical benefits and risk of anticoagulation (AC) with no AC in octogenarians and nonagenarians. METHODS: We systematically searched MEDLINE/PubMed, EMBASE/Ovid, and Web of Science databases from the inception to October, 2020. Studies were eligible for inclusion if they met the following criteria: studies comparing AC with no AC in patients aged 80 or more for AF and reported thromboembolic events (TE) and bleeding outcomes. We used Mantel-Haenszel method with a Paule-Mandel estimator of Tau2 with Hartung Knapp-Sidik-Jonkman adjustment to estimate risk ratio (RR) with a 95% confidence interval (CI). Outlier analysis was used to adjust for statistical heterogeneity. RESULTS: A total of 10 observation studies and 1 RCT were included in the final analysis. There was no difference in the risk of TE with AC in octogenarians and nonagenarians compared with no AC, before [RR: 0.87, 95% CI 0.62-1.23, I2: 71%, GRADE confidence "very low"] and after [RR: 0.83, 95% CI 0.66-1.04, I2: 55.5%] adjusting for statistical heterogeneity among studies. In the unadjusted analysis, no difference in the risk of bleeding events was observed between both groups [RR: 1.05, 95% CI 0.62-1.77, I2: 86%, GRADE confidence "very low"]. After adjusting for heterogeneity, AC was associated with an increased risk of bleeding compared with those not receiving AC [RR: 1.57, 95% CI 1.44-1.71, I2: 0%]. AC in octogenarians was not associated with a net clinical benefit compared with no AC. CONCLUSIONS: This meta-analysis did not demonstrate any difference in the risk TE in octogenarians and nonagenarians with AF on AC vs. no AC, in both the adjusted and unadjusted analyses. Also, the risk of bleeding events in the unadjusted analysis was similar between both groups. The adjusted analysis showed an increased risk of bleeding in the AC group compared with no AC group. More data is needed to establish safety and efficacy of AC in this vulnerable patient population. The results of this analysis should be interpreted with caution due to the observational nature of most studies included, and the only RCT reported lower rates of TE and similar risk of bleeding.

Unfortunate Outcomes in Patients With SARS-CoV-2 Superimposed on Pneumococcal Pneumonia.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease it causes, coronavirus disease 2019 (COVID-19), continue to have socioeconomic as well as health implications worldwide. The virus has already led to over 200,000 deaths in the United States alone. This is most likely secondary to quick respiratory deterioration seen in patients inflicted with the virus. In other words, the heightened inflammatory response leads to major organ system damage, which leads to rapid decompensation of the patient's clinical condition. Interestingly enough, some patients present with both the novel virus as well as a superimposed bacterial infection that further complicates the management of the disease. We present a case of a patient with a positive polymerase chain reaction (PCR) test for SARS-CoV-2 as well as a pneumococcal urine antigen; he was treated with both appropriate antibiotics as well as dexamethasone and remdesivir for pneumonia and novel virus, respectively. The patient's hypoxemia continued to worsen with appropriate means of oxygenation and eventually led to cardiac arrest.

Proposed Orbital Products for Positioning Using Mega-Constellation LEO Satellites.

With thousands of low Earth orbit (LEO) satellites to be launched in the near future, LEO mega-constellations are supposed to significantly change the positioning and navigation service for ground users. The goal of this contribution is to suggest and discuss the feasibility of possible procedures to generate the LEO orbital products at two accuracy levels to facilitate different positioning methods-i.e., Level A orbits with meter-level accuracy as LEO-specific broadcast ephemeris, and Level B orbits with an accuracy of centimeters as polynomial corrections based on Level A orbits. Real data of the LEO satellite GRACE FO-1 are used for analyzing the error budgets. For the Level A products, compared to the orbital user range errors (OUREs) of a few centimeters introduced by the ephemeris fitting, it was found that the orbital prediction errors play the dominant role in the total error budget-i.e., at around 0.1, 0.2 and 1 m for prediction intervals of 1, 2 and 6 h, respectively. For the Level B products, the predicted orbits within a short period of up to 60 s have an OURE of a few centimeters, while the polynomial fitting OUREs can be reduced by a few millimeters when increasing the polynomial degree from one to two.

A GPS Spoofing Generator Using an Open Sourced Vector Tracking-Based Receiver.

Spoofing can seriously threaten the use of the Global Positioning System (GPS) in critical applications such as positioning and navigation of autonomous vehicles. Research into spoofing generation will contribute to assessment of the threat of possible spoofing attacks and help in the development of anti-spoofing methods. However, the recent commercial off-the-shelf (COTS) spoofing generators are expensive and the technology implementation is complicated. To address the above problem and promote the GPS safety-critical applications, a spoofing generator using a vector tracking-based software-defined receiver is proposed in this contribution. The spoofing generator aims to modify the raw signals by cancelling the actual signal component and adding the spoofing signal component. The connections between the spreading code and carrier, and the states of the victim receiver are established through vector tracking. The actual signal can be predicted effectively, and the spoofing signal will be generated with the spoofing trajectory at the same time. The experimental test results show that the spoofing attack signal can effectively mislead the victim receiver to the designed trajectory. Neither the tracking channels nor the positioning observations have abnormal changes during this processing period. The recent anti-spoofing methods cannot detect this internal spoofing easily. The proposed spoofing generator can cover all open-sky satellites with a high quality of concealment. With the superiority of programmability and diversity, it is believed that the proposed method based on an open source software-defined receiver has a great value for anti-spoofing research of different GNSS signals.