Nonresolving pneumonia in the setting of malignancy.

PURPOSE OF REVIEW: This article reviews recent literature and experience in the diagnosis of nonresolving and slowly resolving pneumonia as it pertains to malignancy. RECENT FINDINGS: Malignancy must be considered as an important cause of pneumonia that resolves slowly or has incomplete resolution. Airway obstruction is more common than malignant infiltration as a cause of pneumonia that does not resolve appropriately. Infection due to resistant or unusual organisms must also be considered in the differential diagnosis. SUMMARY: Nonresolving pneumonia remains an important clinical challenge. Bronchoscopic evaluation in conjunction with computed tomography and PET scanning is still the most important technique for diagnosis.

And yet, migration, population growth or mortality are not balanced among Cantabrian brown bear subpopulations. Reply to Blanco et al (2020).

In a recent paper, we presented new evidence and provided new insights on the status of Cantabrian brown bear subpopulations, relevant for this species conservation. Namely, we revealed the likely phylogeographic relation between eastern Cantabrian subpopulation and the historical Pyrenean population. We have also detected an asymmetric flow of alleles and individuals from the eastern to the western subpopulation, including seven first-generation male migrants. Based on our results and on those of previous studies, we called the attention to the fact that Eastern Cantabrian brown bears might be taking advantage of increased connectivity to avoid higher human pressure and direct persecution in the areas occupied by the eastern Cantabrian subpopulation. In reply, Blanco et al (2020) [11] have criticized our ecological interpretation of the data presented in our paper. Namely, Blanco and co-authors criticize: (1) the use of the exodus concept in the title and discussion of the paper; (2) the apparent contradiction with source-sink theory; (3) the apparent overlooking of historical demographic data on Cantabrian brown bear and the use of the expression of population decline when referring to eastern subpopulation. Rather than contradicting the long and growing body of knowledge on the two brown bear subpopulations, the results presented in our paper allow a new perspective on the causes of the distinct pace of population growth of the two brown bear subpopulations in the last decades. Here, we reply to the criticisms by: clarifying our ecological interpretation of the results; refocusing the discussion on how the new genetic data suggest that currently, the flow of individuals and alleles is stronger westward, and how it may be linked to direct persecution and killing of brown bears. We provide detailed data on brown bear mortality in the Cantabrian Mountains and show that neither migration, gene flow, population increase nor mortality are balanced among the two subpopulations.

Sepsis-induced cardiomyopathy is associated with higher mortality rates in patients with sepsis.

BACKGROUND: Patients with sepsis are at risk for developing sepsis-induced cardiomyopathy (SIC). Previous studies offer inconsistent results regarding the association of SIC and mortality. This study sought to assess whether SIC is linked to mortality in patients with sepsis and to evaluate predictors of the development of SIC. METHODS: In this retrospective study, patients admitted to the medical intensive care unit with a diagnosis of sepsis in the absence of acute coronary syndrome were included. SIC was identified using transthoracic echo and was defined by a new onset decline in left ventricular ejection fraction (LVEF) ≤50%, or ≥10% decline in LVEF compared to baseline in patients with a history of heart failure with reduced ejection fraction. Multivariable logistic regression analysis was performed using the R software program. RESULTS: Of the 359 patients in the final analysis, 19 (5.3%) had SIC. Eight (42.1%) of the 19 patients in the SIC group and 60 (17.6%) of the 340 patients in the non-SIC group died during hospitalization. SIC was associated with an increased risk for all-cause in-hospital mortality (odds ratio [OR], 4.46; 95% confidence interval [CI], 1.15-18.69; P=0.03). Independent predictors for the development of SIC were albumin level (OR, 0.47; 95% CI, 0.23-0.93; P=0.03) and culture positivity (OR, 8.47; 95% CI, 2.24-55.61; P=0.006). Concomitant right ventricular hypokinesis was noted in 13 (68.4%) of the 19 SIC patients. CONCLUSIONS: SIC was associated with an increased risk for all-cause in-hospital mortality. Low albumin level and culture positivity were independent predictors of SIC.

Oxygen Indications and Utilization in a Diverse, Urban Community Setting.

PURPOSE: Long-term oxygen therapy (LTOT) is widely used to treat chronic obstructive pulmonary disease (COPD) and other conditions with severe hypoxemia, imposing a large financial burden on the American health care system. METHODS: To better understand oxygen prescription and its use in a multiethnic community hospital, we completed a prospective, observational study with a survey design in our multicultural population to better recognize patient understanding of oxygen indications and utilization. RESULTS: The survey was conducted at three outpatient pulmonary clinics. Among the 94 respondents (42% men and 58% women; age 71.8 ± 13 yr), 64% were current or former smokers. Sixty-one percent had primary diagnoses other than COPD, most commonly interstitial lung disease and congestive heart failure. One-third used oxygen for <12 hr daily. Oxygen use was variable among those to whom it was prescribed. Thirty-two percent of patients described themselves as noncompliant with their prescribed therapy due to poor equipment ergonomics, burdensome machine weight, and negative self-image and social stigma when using oxygen. CONCLUSIONS: Chronic obstructive pulmonary disease represented <50% of LTOT patients who were surveyed. Our data suggest that more structured prescribing practices and patient education should be studied if compliance is to be increased.

Paths for colonization or exodus? New insights from the brown bear (Ursus arctos) population of the Cantabrian Mountains.

Over the centuries, the geographical distribution of brown bear (Ursus arctos) across the Iberian Peninsula has been decreasing, with the species currently confined to North Iberia. The Cantabrian brown bear population is one of the smallest in Europe and is structured into two subpopulations, positioned along an east-west axis. Given the current critically endangered status of this population, it is essential to have a clear picture of its within-population genetic patterns and processes. We use a set of three molecular markers (mitochondrial DNA, autosomal microsatellites and sex markers) to clarify the genetic origins and assess the migration patterns and gene flow of the Cantabrian brown bear population. Our results reveal the presence of two different mitochondrial (matrilineal) haplotypes in the Cantabrian population, both belonging to European brown bear clade 1a. The two haplotypes are geographically structured between Eastern (haplotype CanE) and Western Cantabrian (haplotype CanW) subpopulations, which is consistent with the genetic structure previously identified using nuclear markers. Additionally, we show that CanE is closer to the historical Pyrenean (Pyr) haplotype than to CanW. Despite strong structuring at the levels of mtDNA and nuclear loci, there is evidence of bidirectional gene flow and admixture among subpopulations. Gene flow is asymmetrical and significantly more intense from the Eastern to the Western Cantabrian subpopulation. In fact, we only detected first generation male migrants from the Eastern to the Western Cantabrian subpopulation. These results suggest more intense migration from the smaller and more vulnerable Eastern Cantabrian subpopulation towards the larger and more stable Western Cantabrian subpopulation. These new insights are relevant for assessments of on-going conservation measures, namely the role of dispersal corridors and enhanced connectivity. We discuss the importance of complementary conservation measures, such as human-wildlife conflict mitigation and habitat improvement, for the conservation of a viable Cantabrian brown bear population.

Characteristics and Outcomes of In-Hospital Cardiac Arrest Events During the COVID-19 Pandemic: A Single-Center Experience From a New York City Public Hospital.

BACKGROUND: Patients hospitalized for severe coronavirus disease 2019 (COVID-19) infection are at risk for in-hospital cardiac arrest (IHCA). It is unknown whether certain characteristics of cardiac arrest care and outcomes of IHCAs during the COVID-19 pandemic differed compared with a pre-COVID-19 period. METHODS: All patients who experienced an IHCA at our hospital from March 1, 2020 through May 15, 2020, during the peak of the COVID-19 pandemic, and those who had an IHCA from January 1, 2019 to December 31, 2019 were identified. All patient data were extracted from our hospital's Get With The Guidelines-Resuscitation registry, a prospective hospital-based archive of IHCA data. Baseline characteristics of patients, interventions, and overall outcomes of IHCAs during the COVID-19 pandemic were compared with IHCAs in 2019, before the COVID-19 pandemic. RESULTS: There were 125 IHCAs during a 2.5-month period at our hospital during the peak of the COVID-19 pandemic compared with 117 IHCAs in all of 2019. IHCAs during the COVID-19 pandemic occurred more often on general medicine wards than in intensive care units (46% versus 33%; 19% versus 60% in 2019; P<0.001), were overall shorter in duration (median time of 11 minutes [8.5-26.5] versus 15 minutes [7.0-20.0], P=0.001), led to fewer endotracheal intubations (52% versus 85%, P<0.001), and had overall worse survival rates (3% versus 13%; P=0.007) compared with IHCAs before the COVID-19 pandemic. CONCLUSIONS: Patients who experienced an IHCA during the COVID-19 pandemic had overall worse survival compared with those who had an IHCA before the COVID-19 pandemic. Our findings highlight important differences between these 2 time periods. Further study is needed on cardiac arrest care in patients with COVID-19.

Disseminated Cryptococcal Infection Resulting in Acute Respiratory Distress Syndrome (ARDS) as the Initial Clinical Presentation of AIDS.

Cryptococcosis is a cosmopolitan but rare opportunistic mycosis which is usually caused by Cryptococcus neoformans. Although the most common and worrisome disease manifestation is meningoencephalitis, pulmonary cryptococcosis has the potential to be lethal. The diagnosis of cryptococcal pneumonia is challenging, given its non-specific clinical and radiographic features. Respiratory failure leading to acute respiratory distress syndrome as a consequence of cryptococcal disease has been infrequently addressed in the literature. We herein present a case of disseminated cryptococcal infection leading to acute respiratory distress syndrome, refractory shock, and multiorgan dysfunction as the initial clinical manifestation in a patient who was newly diagnosed with acquired immunodeficiency syndrome.

Prolonged cardiac arrest complicating a massive ST-segment elevation myocardial infarction associated with marijuana consumption.

Recreational substance use and misuse constitute a major public health issue. The annual rate of recreational drug overdose-related deaths is increasing exponentially, making unintentional overdose as the leading cause of injury-related deaths in the United States. Marijuana is the most widely used recreational illicit drug, with approximately 200 million users worldwide. Although it is generally regarded as having low acute toxicity, heavy marijuana usage has been associated with life-threatening consequences. Marijuana is increasingly becoming legal in the United States for both medical and recreational use. Although the most commonly seen adverse effects resulting from its consumption are typically associated with neurobehavioral and gastrointestinal symptoms, cases of severe toxicity involving the cardiovascular system have been reported. In this report, the authors describe a case of cannabis-associated ST-segment elevation myocardial infarction leading to a prolonged cardiac arrest.

Effects of time and day of admission on the outcome of critically ill patients admitted to ICU.

BACKGROUND: Studies have shown that patients admitted to hospitals on weekends and after-hours experience worse outcome than those admitted on weekdays and daytime hours. Although admissions of patients to intensive care units (ICUs) occur 24 hours a day, not all critical care units maintain the same level of staffing during nighttime, weekends, and holidays. This raises concerns in view of evidence showing that the organizational structure of an ICU influences the outcome of critically ill patients. The objective of this study is to evaluate the effects of day and time of admission to ICU on patients' outcome. METHODS: A single-center, prospective, observational study was conducted among all consecutive admissions to ICU in a community teaching hospital during a 4-month period. RESULTS: A total of 282 patients were admitted during the study period. Their mean age was 59.5 years (median 59, range 17-96), and the majority were male (157, 55.7%). Mean Acute Physiology and Chronic Health Evaluation (APACHE)-II score was 18.9 (median 33, range 1-45), and mean ICU length of stay was 3.1 days (median 2, range 1-19). Of the patients, 104 patients (36.9%) were admitted during weekends and 178 (63.1%) during weekdays. A total of 122 patients (43.3%) were admitted after-hours, constituting 68.5% of all admissions during weekdays. Fifty-six patients (19.9%) were admitted during daytime hours, representing 31.5% of all weekday admissions. Forty-five patients (15.9%) died in ICU. Compared to patients admitted on weekends, those admitted on weekdays had increased ICU mortality (operating room (OR)=0.437; 95% confidence interval=0.2054-0.9196; p=0.0293). CONCLUSION: Admissions to ICU during weekends were not independently associated with increased mortality. A linear relationship between weekdays and after-hours admissions to ICU with mortality was observed at our institution.

The Wide and Unpredictable Scope of Synthetic Cannabinoids Toxicity.

Drug use and abuse continue to be a large public health concern worldwide. Over the past decade, novel or atypical drugs have emerged and become increasingly popular. In the recent past, compounds similar to tetrahydrocannabinoid (THC), the active ingredient of marijuana, have been synthetically produced and offered commercially as legal substances. Since the initial communications of their abuse in 2008, few case reports have been published illustrating the misuse of these substances with signs and symptoms of intoxication. Even though synthetic cannabinoids have been restricted, they are still readily available across USA and their use has been dramatically increasing, with a concomitant increment in reports to poison control centers and emergency department (ED) visits. We describe a case of acute hypoxemic/hypercapnic respiratory failure as a consequence of acute congestive heart failure (CHF) developed from myocardial stunning resulting from a non-ST-segment elevation myocardial infarction (MI) following the consumption of synthetic cannabinoids.

Triage of Patients Consulted for ICU Admission During Times of ICU-Bed Shortage.

BACKGROUND: The demand for specialized medical services such as critical care often exceeds availability, thus rationing of intensive care unit (ICU) beds commonly leads to difficult triage decisions. Many factors can play a role in the decision to admit a patient to the ICU, including severity of illness and the need for specific treatments limited to these units. Although triage decisions would be based solely on patient and institutional level factors, it is likely that intensivists make different decisions when there are fewer ICU beds available. The objective of this study is to evaluate the characteristics of patients referred for ICU admission during times of limited beds availability. METHODS: A single center, prospective, observational study was conducted among consecutive patients in whom an evaluation for ICU admission was requested during times of ICU overcrowding, which comprised the months of April and May 2014. RESULTS: A total of 95 patients were evaluated for possible ICU admission during the study period. Their mean APACHE-II score was 16.8 (median 16, range 3 - 36). Sixty-four patients (67.4%) were accepted to ICU, 18 patients (18.9%) were triaged to SDU, and 13 patients (13.7%) were admitted to hospital wards. ICU had no beds available 24 times (39.3%) during the study period, and in 39 opportunities (63.9%) only one bed was available. Twenty-four patients (25.3%) were evaluated when there were no available beds, and eight of those patients (33%) were admitted to ICU. A total of 17 patients (17.9%) died in the hospital, and 15 (23.4%) expired in ICU. CONCLUSION: ICU beds are a scarce resource for which demand periodically exceeds supply, raising concerns about mechanisms for resource allocation during times of limited beds availability. At our institution, triage decisions were not related to the number of available beds in ICU, age, or gender. A linear correlation was observed between severity of illness, expressed by APACHE-II scores, and the likelihood of being admitted to ICU. Alternative locations outside the ICU in which care for critically ill patients could be delivered should be considered during times of extreme ICU-bed shortage.