Outcomes of Noninvasive Ventilation in Obese Patients With Acute Asthma Exacerbations.

BACKGROUND: The role of noninvasive positive pressure ventilation (NIPPV) in acute asthma exacerbation is controversial. However, the outcome of NIPPV in obese patients with asthma during such exacerbation has not been well studied despite well-established relationship between obesity and asthma. STUDY QUESTION: Does body mass index (BMI) play a role in the outcome of NIPPV during an acute exacerbation and does it predict of the success or failure of NIPPV? STUDY DESIGN: The study was a retrospective analysis by design. The purpose of the study was to assess factors predicting the success or failure of NIPPV. The entire cohort was divided into 2 groups: patients who failed NIPPV and patients who did not. Univariate and multivariate regression analysis was used to predict the variables. Stepwise selection method was used to select variables for final regression model. RESULTS: A total 96 patients were included in the study. Of those, 18 patients (18.9%) failed NIPPV and required endotracheal intubation (group 1). Rest (78.1%) did not fail NIPPV (group 2). Mean age of the study population was 48.8 years and 53% of patients were female. In the univariate analysis, the group that did not fail NIPPV (group 2) had significantly higher number of obese patients (47.9% versus 22.2%; P 0.013). Multivariate analysis showed significant association between BMI categories (BMI of 30 or more) and failure of NIPPV (odds ratio 0.26, 95% confidence interval, 0.08-0.85; P-value 0.017). Forced introduction of smoking status as a risk factor did not change the significance of association. CONCLUSION: Despite the limitations of the study design and the sample size, our analysis showed that patients with high BMI (obese) fared well with NIPPV during acute asthma exacerbation. Because there are controversies on use of NIPPV during asthma exacerbation, larger-scale prospective studies are needed to better understand the role of NIPPV in obese patients with asthma during acute exacerbation.

Profile of Acute Asthma Exacerbation in Drug Users.

The characteristics of patients who use heroin, cocaine, or both and present with acute asthma exacerbations have not been well studied. In this retrospective study, we aimed to study the demographic characteristics of this patient population, the characteristics of their asthma attack, and the risk factors for the need for invasive mechanical ventilation in this patient population. We reviewed the charts of patients discharged from an inner-city hospital with a diagnosis of acute asthma exacerbation. Individuals who used either heroin or cocaine or both within 24 hours of presenting to the emergency department were identified as a cohort of drug users. The rest were classified as non-drug users. Both groups were compared, and a univariate analysis was performed. To assess the predictive value of drug use for the need for intubation in the presence of confounding factors, logistic regression analysis was performed to identify whether using cocaine or heroin or both was an individual predictor for the need for invasive ventilation. Data from 218 patients were analyzed. Drug users (n = 85) were younger (mean age in years 43.9 vs. 50.5, P < 0.01), predominantly male (63.5% vs. 33.8%, P < 0.01), and more likely to be cigarette smokers (90.6% vs. 57.6%, P < 0.01). A medical history of intubation and admissions to the intensive care unit (ICU) was more common among drug users (56.5% vs. 29.3%, P < 0.01 and 54.1% vs. 38.3%, P < 0.03, respectively). Drug use was associated with increased need for invasive mechanical ventilation (35% vs. 23.3%, P = 0.05). Non-drug users were more likely to be using inhaled corticosteroids (48.9% vs. 32.9%, P = 0.03) and had longitudinal care established with a primary care provider (50.6% vs. 68.9%, P < 0.01). After adjusting for a history of mechanical ventilation, history of ICU admission, use of systemic corticosteroids, smoking, and acute physiological assessment and chronic health evaluation 2 score, drug use remained predictive for the need for mechanical ventilation (P = 0.026). Acute asthma exacerbations triggered by cocaine and heroin should be treated aggressively because they represent a cohort with poor follow-up and undertreated asthma as outpatients and are associated with increased need for invasive mechanical ventilation and ICU admission during acute exacerbation.

Cardiovascular Oncologic Emergencies.

Oncologic emergencies can present either as a progression of a known cancer or as the initial presentation of a previously undiagnosed cancer. In most of these situations, a very high degree of suspicion is required to allow prompt assessment, diagnosis, and treatment. In this article, we review the presentation and management of cardiovascular oncologic emergencies from primary and metastatic tumors of the heart and complications such as pericardial tamponade, superior vena cava syndrome, and hyperviscosity syndrome. We have included the cardiovascular complications from radiation therapy, chemotherapeutic agents, and biologic agents used in modern cancer treatment.

Sleep: important considerations for the prevention of cardiovascular disease.

PURPOSE OF REVIEW: Sleep plays many roles in maintenance of cardiovascular health. This review summarizes the literature across several areas of sleep and sleep disorders in relation to cardiometabolic disease risk factors. RECENT FINDINGS: Insufficient sleep duration is prevalent in the population and is associated with weight gain and obesity, inflammation, cardiovascular disease, diabetes, and mortality. Insomnia is also highly present and represents an important risk factor for cardiovascular disease, especially when accompanied by short sleep duration. Sleep apnea is a well-characterized risk factor for cardiometabolic disease and cardiovascular mortality. Other issues are relevant as well. For example, sleep disorders in pediatric populations may convey cardiovascular risks. Also, sleep may play an important role in cardiovascular health disparities. SUMMARY: Sleep and sleep disorders are implicated in cardiometabolic disease risk. This review addresses these and other issues, concluding with recommendations for research and clinical practice.

Sleep Duration and Diabetes Risk: Population Trends and Potential Mechanisms.

Sleep is important for regulating many physiologic functions that relate to metabolism. Because of this, there is substantial evidence to suggest that sleep habits and sleep disorders are related to diabetes risk. In specific, insufficient sleep duration and/or sleep restriction in the laboratory, poor sleep quality, and sleep disorders such as insomnia and sleep apnea have all been associated with diabetes risk. This research spans epidemiologic and laboratory studies. Both physiologic mechanisms such as insulin resistance, decreased leptin, and increased ghrelin and inflammation and behavioral mechanisms such as increased food intake, impaired decision-making, and increased likelihood of other behavioral risk factors such as smoking, sedentary behavior, and alcohol use predispose to both diabetes and obesity, which itself is an important diabetes risk factor. This review describes the evidence linking sleep and diabetes risk at the population and laboratory levels.

It Is Not Always the Pulmonary Embolism.

One of the leading reasons for emergency department visits happens to be chest pain and shortness of breath with estimated 6.3 million visits for chest pain and 3 million visits for shortness of breath. Over the years, there has been an upward trend in these demographics. The primary workup is usually toward cardio pulmonary causes. Paraesophageal hernia is a term to describe the herniation of gastroesophageal junction and the gastric fundus through the paraesophageal membrane. Paraesophageal hernias account for 5% of all the hiatal hernias, and patients are usually asymptomatic or have complaints of gastroesophageal reflux. However, on rare occasions, they are notorious to develop complications such as incarceration, gangrene, obstruction of intrathoracic stomach, collapse of the lung, and even death. We take this opportunity to present a 49-year-old man who presented with shortness of breath and chest pain. The initial workup revealed a pulmonary embolism on a computerized tomography scan. However, with better clinical judgment and more imaging, he was diagnosed with a paraesophageal hernia with gastric obstruction and early strangulation causing his symptoms.

Perioperative Management of Anticoagulation-Review of Latest Evidence.

Periprocedural anticoagulation bridging is recommended to reduce the risk of thromboembolic events in patients at a higher risk of developing thromboembolism during the perioperative period. The optimal periprocedural anticoagulation strategy has not been established. Unfractionated heparin and low molecular heparin are used in preventing thromboembolism in the special population. Novel oral anticoagulants that directly inhibit thrombin (dabigatran) or factor Xa (rivaroxaban, apixaban) are shown as effective anticoagulants in preventing thromboembolism (venous thromboembolism) in various medical conditions. They have the advantage of having a faster onset, shorter half-lives, easier monitoring, and predicable doses. But there are disadvantages to newer anticoagulants such as the unavailability of definitive reversal agents and lack of data in patients with renal insufficiency. We review the latest evidence on the effects of newer oral anticoagulants in preventing thromboembolism and its bleeding risks.

Near Fatal Asthma in an Inner City Population.

Near-fatal asthma (NFA) is highly prevalent in inner city population. Patients who present with NFA require timely intervention, which necessitates knowledge of appropriate associated risk factors. The purpose of the study was to look and identify the salient features of an asthma exacerbation that are more likely to be associated with NFA in inner city population. We conducted a retrospective analysis of patients who were discharged from the hospital with a diagnosis of acute asthma exacerbation. Two hundred eighteen patients were included in the study. Patients who required intubation during the course of their hospitalization were defined as NFA and the rest were defined as non-near-fatal asthma (NNFA). Multiple patient parameters were compared between the 2 groups; 60 patients met the definition of NFA. There was no difference between NFA and NNFA groups with respect to sex, race, and history of smoking and asthma treatment modalities before presentation. NFA was seen more commonly in heroin (40% vs. 25.9%; P < 0.05) and cocaine users (28.3% vs. 16.5%; P < 0.05). A history of exacerbation requiring intensive care unit (ICU) care was more common among the NFA patients (55% vs. 40.5%; P = 0.05). A history of intubation for an exacerbation was more commonly seen in patients presenting with NFA (51.7% vs. 35.4%; P < 0.05). The NNFA group was more likely to have a primary care physician and to be discharged home (65.6% vs. 51.7%, P < 0.05; and 71.7 vs. 79.1%, P < 0.05). In a multi-logistic regression model, including age, sex, race, heroin and cocaine use, history of intubation and ICU admission, medications, use of noninvasive ventilation, primary care physician, and pH <7.35, PCO2 >45 mm Hg, and FiO2 >40% on initial blood gas, NFA was predicted only by PaCO2 >45 [odds ratio (OR = 6.7; P < 0.001)] and FiO2 >40% (OR = 3.5; P = 0.002). Use of noninvasive ventilation was a negative predictor of NFA (OR = 0.2; P < 0.001). Asthmatic patients who carry a history of intubation with mechanical ventilation for an asthma exacerbation, admissions to the ICU, or those who indulge in recreational drugs like cocaine or heroin should be closely monitored for clinical deterioration.

Use of noninvasive ventilation in adult patients with acute asthma exacerbation.

Noninvasive ventilation (NIV) has been found to be beneficial for respiratory failure in many disease states; however, limited data are available supporting its use in acute asthma exacerbation. A retrospective chart analysis of adult patients admitted for acute asthma exacerbation and treated with NIV between January 2007 and December 2009 at a tertiary care community hospital was done. Ninety-eight patient encounters were identified. Mean age of the patients was 48.3 years, and 46% were male. Nineteen patients failed NIV and required invasive ventilation. There was no significant difference in the mean age, sex, race, and initial blood gas between patients with successful versus failed NIV. Usage of drugs, smoking, and history of past hospital or intensive care unit admission or intubation did not significantly influence the rate of failure of NIV. Patients who needed higher initial FiO2 were more likely to get intubated during their hospital stay (46.2 vs. 20.4%, P = 0.019). Patients who failed NIV were found to have longer duration of hospital stay (6.8 vs. 3.9 days, P= 0.016) and longer intensive care unit stay (4 vs. 0.9 days, P = 0.002). Use of inhalers and other medications was not found to significantly influence the rate of failure of NIV. NIV can be used initially in patients with acute asthma exacerbation, as it is associated with shorter duration of hospital stay and can prevent the morbidity of mechanical intubation. Patients with initial requirement of higher FiO2 were more likely to fail NIV and should be carefully monitored.

Heparin-Induced Thrombocytopenia and Cardiac Surgery.

Heparin-induced thrombocytopenia (HIT) is an immune-mediated condition characterized by thrombocytopenia with possible arterial and/or venous thrombosis. The overall incidence of HIT is low but ranges from 0.1% to 5%.1,2 The incidence can be as high as 3% in patients undergoing cardiac surgery. The use of unfractionated heparin (UFH) is ubiquitous in patients who undergo cardiac procedures and carries a 10-fold higher incidence of HIT over low molecular weight heparin. Patients undergoing cardiac surgery thus form a unique group that warrants specific attention to this clinicopathologic entity considering the relatively high incidence and associated morbidity and mortality with a delay in diagnosis. In this article, we will discuss 5 clinical aspects pertinent to the diagnosis and management of HIT in cardiac surgery patients and review the current literature.

Hemosuccus Pancreaticus.

Hemosuccus pancreaticus (HP) defined as bleeding into the pancreatic duct was first described in 1931 by Lower and Farell. HP also popularly known as wirsungorrhaghia and pseudohemobilia is a rare cause of gastrointestinal bleed. The unfamiliarity of this condition makes HP a diagnostic challenge. HP should be considered in patients with chronic pancreatitis presenting with acute gastrointestinal bleeding. The diagnosis is usually confirmed with a computerized tomography (CT) scan of the abdomen. A mesenteric angiogram with coil embolization can be performed to arrest the bleeding. The literature on this condition is restricted to case reports, case series and retrospective studies. We describe a case of HP in a patient with gastrointestinal bleeding and take this opportunity to review the literature outlining the diagnosis and management of HP.

Management of calcium channel blocker overdoses.

Calcium channel blockers (CCBs) are some of the most commonly used medications in clinical practice to treat hypertension, angina, cardiac arrhythmias, and some cases of heart failure. Recent data show that CCBs are the most common of the cardiovascular medications noted in intentional or unintentional overdoses.(1) Novel treatment approaches in the form of glucagon, high-dose insulin therapy, and intravenous lipid emulsion therapies have been tried and have been successful. However, the evidence for these are limited to case reports and case series. We take this opportunity to review the various treatment options in the management of CCB overdoses with a special focus on high-dose insulin therapy as the emerging choice for initial therapy in severe overdoses.