Effects of Etomidate on Postintubation Hypotension, Inflammatory Markers, and Mortality in Critically Ill Patients with COVID-19: An International, Multicenter, Retrospective Study.

OBJECTIVE: To evaluate the association of etomidate with postintubation hypotension, inflammation, and mortality in critically ill patients with COVID-19. DESIGN: International, multicenter, retrospective study. PARTICIPANTS: Critically ill patients hospitalized specifically for COVID-19 from three major academic institutions in the US and Europe. MAIN OUTCOME AND MEASURES: Patients were allocated into the etomidate (ET) group or another induction agent (OA) group. The primary outcome was postintubation hypotension. Secondary outcomes included postintubation inflammatory status, in-hospital mortality, and mortality at 30 days. RESULTS: 171 patients with a median age of 68 (IQR 58-73) years were included (ET, n = 98; OA, n = 73). Etomidate was associated with lower postintubation mean arterial pressure [74.33 (64-85) mm Hg versus 81.84 (69.75-94.25) mm Hg, p = 0.005] compared to other agents. No statistically significant differences were generally observed in inflammatory markers between the two groups at 7- and 14-days after admission to the intensive care unit. In-hospital mortality [77 (79%) versus 41 (56%), p = 0.003] and mortality at 30-days [78 (80%) versus 43 (59%), p = 0.006] were higher in the ET group. In multivariate logistic regression analysis, only etomidate (p = 0.009) and postintubation mean arterial pressure (p < 0.001) had a statistically significant effect on mortality, in contrast to stress-dose steroids (p = 0.301), after adjusting for creatinine (p = 0.695), blood urea nitrogen (p = 0.153), age (p = 0.055), oxygen saturation of hemoglobin (SpO2) (p = 0.941), and fraction of inspired oxygen (FiO2) (p = 0.712). CONCLUSIONS: Administration of a single-bolus dose of etomidate in critically ill patients with COVID-19 is associated with lower postintubation mean arterial pressure and higher in-hospital and 30-day mortality compared to other induction agents.

Pseudo-Ludwig's Angina: Spontaneous Sublingual Haematoma Elicited by Warfarin.

Spontaneous bleeding into the upper airways is a rare and potentially life-threatening complication of chronic anticoagulation. There are scarce cases in the literature demonstrating upper airway haematomas secondary to warfarin use, which is the predominant anticoagulant used by clinicians despite having a complex pharmacokinetic and pharmacodynamic profile. We report a compelling case featuring warfarin-induced sublingual haematoma, managed conservatively through the reversal of anticoagulation using fresh frozen plasma complemented by vigilant monitoring within the Intensive Care Unit (ICU). LEARNING POINTS: Sublingual haematomas, though uncommon, represent potentially serious complications arising from warfarin therapy.Distinguishing sublingual haematomas from infectious processes requires a high level of clinical suspicion and is crucial for prompt management.The preferred course of action involves reversing anticoagulation with a low threshold for implementing an artificial airway in cases of compromised airways.

The unpredictability of labile blood pressure: Afferent baroreflex failure in a critical patient with multiple thyroid surgeries and COVID-19 infection.

The carotid sinus-arterial baroreflex is essential in maintaining blood pressure (BP) regulation. Afferent baroreflex failure (ABF) can present with labile changes in BP within seconds and can be secondary to neck surgery or radiation. We present here the first case, to our knowledge, of ABF precipitated by thyroidectomy, in a patient with active COVID-19 pneumonia, causing difficult control of severely labile BP in a critical care unit. Contributing factors included her critical illness state with upregulation of IL-6 leading to pituitary-adrenal axis alteration, her thyroidectomy further exacerbating autonomic dysfunction, as well as downregulation of ACE2 via COVID-19 infection. Management was achieved with a combination of midodrine and clonidine catered to specific BP thresholds. Additional research with a multidisciplinary approach is warranted to fully optimize the treatment of ABF in patients with neck surgery and or inflammatory conditions such as COVID-19.

Pulmonary Sclerosing Pneumocytoma: An Essential Differential Diagnosis for a Lung Nodule.

Pulmonary sclerosing pneumocytoma, previously known as pulmonary sclerosing hemangioma, is a rare benign lung tumor with a low prevalence. We present this condition in a 26-year-old, young, non-smoking female with a slow-growing pulmonary nodule incidentally noted on imaging. Serial computed tomography(CT) scans revealed slow growth, and invasive testing was recommended. The patient underwent a left lateral thoracotomy and based on frozen section findings. A left lower lobectomy was performed. The final pathological diagnosis revealed sclerosing pneumocytoma. This is an atypical patient demographic considering the propensity of the disease for middle-aged Asian women. The case presentation and work-up highlight this critical differential diagnosis for incidental pulmonary nodules increasingly being noted due to widespread use of imaging for screening and routine care in the current medical climate. There are no specific imaging criteria to diagnose this condition. The final diagnosis is made only after surgical biopsy and histopathology. No additional treatment is needed following the diagnosis.

Use of Systemic Anticoagulation in COVID-19: Delving Beyond Theoretical Hypothesis.

Background Studies suggest that COVID-19 infection may induce increased hypercoagulability, leading to thrombotic complications. The high rates of thrombotic complications among patients receiving standard-dose deep venous thrombosis (DVT) prophylaxis have prompted some clinicians to support the empiric increase of anticoagulation (AC) doses used for prophylaxis in patients with COVID-19. At present, the optimal anticoagulant agents, dosages, and duration have not been designated. We conducted a retrospective study to assess for outcomes in patients who received treatment for COVID-19 based on various dosings of AC. Methods This was a single-institution, retrospective cross-sectional study including patients with a positive COVID-19 test who were admitted within the St. Joseph's Health Network from September to November of 2020. The inclusion criteria were men and women aged 18 years or older who had confirmed COVID-19 by polymerase chain reaction (PCR). Medical charts of patients who met the inclusion criteria were audited to obtain information. The patients were separated into three cohorts: those who received DVT prophylactic dose of AC, those who received an intermediate dose of AC, and those who received therapeutic AC. Results A total of 440 patients were included in the study, of whom 236 were Hispanic (50.3%), 131 were Caucasian (27.1%), 47 were African American (10.7%), and 26 were Asian (5.9%). The most common comorbidities were hypertension (273/440 [62.2%]), diabetes 189/440 [43.1%]), and coronary artery disease (60/440 [13.7%]). In the DVT prophylactic dose of AC cohort, there were 215 patients, and the average length of stay was 10.3 days. Eleven patients experienced bleeding events, five patients experienced thrombotic events, 16 patients required mechanical ventilation, and 20 patients died. In the intermediate dose of AC cohort, there were 63 patients, and the average length of stay was 10.3 days. Three patients experienced bleeding events, two patients experienced thrombotic events, seven patients required mechanical invasive ventilation, and 11 patients died. In the therapeutic dose of AC cohort, there were 162 patients, and the average length of stay was 14 days. In this cohort, 19 patients experienced bleeding events, 12 patients experienced thrombotic events, 26 patients required invasive mechanical ventilation, and 29 patients died. Patients who received intermediate dosing of AC also had the lowest risk of thrombotic events (0.05). Patients who received intermediate dosing of AC had the lowest rates of requiring both high-flow nasal cannula (p = 0.0001) and invasive mechanical ventilation (p = 0.031). Patients who received intermediate dosing of AC had a lower rate of bleeding compared to those who received the DVT prophylaxis dose and systemic AC dose (p = 0.037). The DVT prophylactic and intermediate dosing of AC groups had a shorter length of stay in comparison to the systemic AC group (p = 0.0002). Conclusion In comparison to the venous thromboembolism prophylaxis dose and systemic AC dose groups, intermediate dosing of AC had the lowest rates of hemorrhage, mortality, length of stay, and requirement of high-flow nasal cannula or mechanical invasive ventilation. In the systemic dose AC group, there were worse clinical outcomes in terms of length of stay, incidence of bleeding events, requirement of mechanical ventilator use, and rate of mortality.

Atypical Stroke-Like Presentation in a Critically-Ill Patient With Serratia marcescens Bullous Cellulitis.

Skin and soft-tissue infections are common in critically ill patients, especially with gram-positive bacteria such as Streptococcus or Staphylococcus species. However, it is imperative to consider gram-negative infections in atypical presentations of bullous cellulitis, where patients do not initially respond to common empiric therapy for skin infections. Serratia marcescens is a gram-negative organism that manifests in nosocomial settings due to its affinity for moisture-rich environments. This bacteria is often difficult to treat due to extensive antibiotic resistance, and thus treatment is generally catered towards culture sensitivity. Rarely, this bacteria is an infective agent of infective endocarditis. We present a case of a 44-year-old gentleman who presented with stroke-like symptoms and was found to have bullous cellulitis with deep wound cultures growing S. marcescens. This case report highlights an atypical, severe presentation, and aims to provide a literature review of this rare manifestation of S. marcescens in skin and soft-tissue infections. We intend to improve rapid diagnosis and proper treatment for future critically-ill patients with skin and soft-tissue infections.

A Case Report of Autoimmune Encephalitis: Could Post-COVID-19 Autoimmunity Become a Lethal Health Issue?

While it is primarily thought of as a respiratory illness, COVID-19 is now recognized as a multi-organ disease that can present with a wide range of clinical manifestations. Particularly in patients with severe respiratory illness, neurological manifestations ranging from headaches, and loss of smell to strokes have been associated with the virus. In the setting of resolving respiratory illness, it is important to consider autoimmune encephalitis (AE) in the instance of new-onset neurological manifestations. The typical patient presentation includes altered mental status, fever, seizures, and/or focal neurological deficits. These neurological manifestations make it crucial to consider either underlying COVID-19 infection or post COVID-19 autoimmunity so as not to delay the administration of the appropriate treatment. Herein, we present the case of an 88-year-old female with new-onset right leg weakness, and dysarthria, that progressively developed to altered mental status months after having respiratory symptoms of COVID-19. According to the criteria of AE diagnosis, the patient's clinical course and work-up findings proved the diagnosis.

A Rare Presentation of a Rare Case: Acute Respiratory Failure in Swyer-James-Macleod Syndrome.

Swyer-James-Macleod syndrome (SJMS) is a rare clinical entity acquired during childhood due to a respiratory infection leading to bronchiolitis obliterans. This inciting event is hypothesized to cause structural and functional changes of the developing alveoli, terminal bronchioles, and the corresponding pulmonary vasculature, resulting in emphysematous changes and a matched ventilation-perfusion defect. We present a 67-year-old male patient with hypercapnic respiratory failure requiring invasive mechanical ventilation, who had typical features of SJMS undiagnosed before this admission. He was extubated successfully, discharged home, and continues to be stable at a 90-day follow-up period. This marks one of the rare accounts where a patient with SJMS was given ventilatory support emergently, and one of the oldest patients reported. SJMS is under-reported due to its indolent clinical course and misdiagnosed as some other pulmonary abnormality. The clinical course progression and prognosis are unclear and variable in many affected patients due to this condition's rarity.

Remdesivir for the treatment of COVID 19: review of the pharmacological properties, safety and clinical effectiveness.

INTRODUCTION: Remdesivir is a nucleoside analog that inhibits viral RNA replication by blocking RNA-dependent RNA polymerase. First developed and tested during the Ebola epidemic, repurposed, and gained prominence during the Coronavirus disease 19 (COVID-19) pandemic. Based on data from three major trials, remdesivir became the first and only medication to obtain approval from the Food and Drug Administration (FDA) to treat patients hospitalized with COVID-19 disease. AREAS COVERED: The purpose of the article is to review available preclinical, clinical, and post-marketing data to assess the safety and efficacy of remdesivir in the treatment of COVID-19 patients. We performed a comprehensive literature review of articles published on remdesivir until January 2021. EXPERT OPINION: The substantial evidence of its effectiveness in a few trials together with the favorable safety profile makes remdesivir a primary therapeutic candidate for treatment in adult and pediatric patients who are hospitalized with COVID-19 and requiring oxygen supplementation. While remdesivir does not improve mortality, it has been shown to reduce the recovery time and increase the odds for clinical improvement, specifically in patients with early presentation and moderate COVID-19 disease. Remdesivir is well tolerated and has an acceptable safety profile in the pediatric and adult populations.

The importance in early identification of a herpetic endobronchial mass.

We present a case of a 78 year old female that required intubation for hypercapnic, hypoxic respiratory failure, found to have an obstructing mass in the right main stem bronchus positive for Herpes Simplex (HSV) I and II on biopsy and immunohistochemistry (IHC). Herpetic endobronchial masses are described rarely, and having them on the differential when investigating endobronchial masses can promote prompt treatment and decrease unnecessary investigations. Our goals in highlighting this report include incidence of HSV pneumonia [7], the need to include it as part of the differential diagnosis in working up endobronchial masses, especially in intubated patients, and the various modalities of treatment.

Emphysematous cholecystitis: A deadly disguise of a common culprit.

Emphysematous cholecystitis is a critical differential diagnosis for physicians to consider when evaluating patients with acute abdomen. Patients who are unable to undergo emergency surgery can benefit from percutaneous cholecystostomy.

Transection of lung as rare complication of pigtail catheter placement.

Pigtail catheters and chest tubes are commonly used for effective resolution of pneumothoraces and drainage of simple pleural effusions. Given their small calibers, better flexibility and more ease at the time of insertion, pigtail catheters are associated with lower risks of complications when compared to traditional chest tubes. Commonly reported complications of the pigtail catheters include the higher probability for clogging, kinking, and obstruction. Rare complications as air embolism, penetration of the heart and transection of the lungs are seldom reported in the literature. We present a case of an 81-year-old female presented with covid-19 pneumonia who developed bilateral spontaneous pneumothoraces requiring bilateral pigtail insertion. The patient developed worsening hypoxia and chest imaging revealed that the left pigtail was transected into the lung parenchyma. With this case report, we hope to bring to light a rare complication of pigtail placement.

Endovascular Embolization of Pulmonary Sequestration Presenting With Hemoptysis: A Promising Alternative to Surgery.

Pulmonary sequestration is abnormal lung parenchyma separated from the normal tracheobronchial system and supplied by an aberrant systemic artery. It is usually asymptomatic; however, it can present with hemoptysis and recurrent pulmonary infections. Although surgery is the classical treatment, arterial embolization is recently established as an alternative treatment to avoid surgical complications. We present a case of left lower lobe intralobar pulmonary sequestration presented with hemoptysis and was successfully treated with coil embolization.

Crazy vaping and crazy-paving, a case of E-Cigarette/Vaping-Associated Lung Injury (EVALI) with chest CT showing crazy-paving pattern.

E-cigarettes are devices that generate an aerosol by heating a fluid containing multiple chemicals, such as nicotine, additives, and flavorings. They were developed to aid in smoking cessation and were promoted as socially acceptable, healthier, cheaper than conventional cigarettes. Multiple lung disorders related to e-cigarette use are reported, and they range from mild cases of pneumonitis to life-threatening lung disorders that may require intubation and mechanical ventilation. Most of the complications are due to the generation of various unknown and potentially harmful chemicals within the aerosol generated in the e-cigarette. These disorders are known collectively as e-cigarette/Vaping-associated lung injury (EVALI). E-cigarettes are marketed as safer alternatives to traditional cigarettes, with the highest rates of use are noted in young smokers. Given the significant prevalence of e-cigarettes use and their pulmonary complications, EVALI should be considered a potential etiology in the broad differential diagnosis of patients with pulmonary disease and a history of vaping. Herein, we present a case of cryptogenic organizing pneumonia with a chest C.T. showing a crazy-paving pattern in a patient with a history of vaping.

Searching for the Culprit: When Diabetic Ketoacidosis Presents With Insulin Autoantibodies.

OBJECTIVE: The main objective was to describe and review a unique case that presented with diabetic ketoacidosis, positive insulin autoantibodies (IAAbs, which are found in Hirata disease and are usually present with hypoglycemia), and laboratory findings characteristic of type B insulin resistance syndrome (TBIRS) and systemic lupus erythematosus. Confirmation of TBIRS was obtained in Germany as immunoassay for insulin receptor antibodies (IRAbs) is not available in the United States. METHODS: A literature review on TBIRS and cases that present with IAAbs and IRAbs simultaneously was conducted. RESULTS: We found 6 cases presenting with hypoglycemia, both antibodies, and treatment attempts with various management approaches that were different from the proposed National Institutes of Health (NIH) protocol for TBIRS. Our case is distinct because of the demographic background, presentation with diabetic ketoacidosis, comparatively lower insulin requirement, and no significant hypoglycemic episodes in the third phase. CONCLUSION: We propose that access to IRAb immunoassays may be important for diagnosing milder cases of TBIRS, while IAAbs may provide prognostic and therapeutic insights. Despite completely different presentation from other TBIRS patients reviewed, we observed that the proposed NIH protocol consisting of dexamethasone, rituximab, and cyclophosphamide was successfully employed in our patient. Thus, we propose that our case and the findings regarding antibody testing and the NIH treatment regimen may assist clinicians with earlier recognition and effective management of milder cases of TBIRS.

A review of the characteristics and outcomes of 900 COVID-19 patients hospitalized at a Tertiary Care Medical Center in New Jersey, USA.

INTRODUCTION: There is a paucity of literature surrounding the in-hospital mortality and associated risk factors among coronavirus disease 2019 (COVID-19) affected patient populations in our geographical area, northern New Jersey. MATERIAL AND METHODS: A retrospective observational cohort study was performed in a tertiary care academic medical center with two locations in Paterson and Wayne serving Passaic County in northern New Jersey. The study included all 900 patients with a positive reverse transcriptase-polymerase chain reaction (RT-PCR) nasopharyngeal swab sample for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) viral test. We determined the in-hospital 75-day mortality of patients treated in the intensive care unit (ICU) compared to the medical-surgical floor unit. RESULTS: Overall in-hospital 75-day mortality was 40.7% (n = 367). The ICU group had a 77.1% (n = 237) mortality and the floor group a 21.9% (n = 130) mortality. The ICU group of patients had a higher incidence of cardiac injury, acute renal injury, liver failure, vasopressor use and the elevation of serum markers: ferritin, lactate dehydrogenase, interleukin 6 (IL-6), D-dimer, procalcitonin, and C-reactive protein compared to the floor group. Multiple logistic regression analyses revealed that age > 65 years, elevated IL6, acute renal injury, cardiac injury, and invasive mechanical ventilation were risk factors associated with mortality. CONCLUSIONS: Age > 65 years, elevated IL6, acute renal injury, cardiac injury, and invasive mechanical ventilation were risk factors associated with mortality in our COVID-19 patients.

Efficacy and adverse effects of drugs used to treat adult cystic fibrosis.

INTRODUCTION: Cystic fibrosis (CF) is an autosomal recessive disease and is the most commonly seen monogenetic disease in Caucasians. The disease has various manifestations resulting from the abnormal thick secretions, most common being chronic lung infection and airway obstruction. Many new promising drugs have appeared on the horizon over the years. This review here is an attempt to bring together the various treatments being used to prolong and enhance the quality of life of CF patients. AREAS COVERED: A literature review of published as well as ongoing clinical trials, meta-analysis and systematic reviews regarding the drugs used in CF management was carried out using PubMed and Ovid databases. EXPERT OPINION: New concepts have been formed and some positive results in this direction have already led to the approval of cystic fibrosis transmembrane conductance regulator potentiator drug. Gene therapy and stem cell therapy are under development. The current therapies such as dornase alfa and pancreatic enzymes targeting the symptoms continue to evolve as they play an important complementary role. Development of new simple and cost-effective markers, which help assess the efficacy and safety of these constantly emerging new drugs, is also being investigated.

Umeclidinium for treating COPD: an evaluation of pharmacologic properties, safety and clinical use.

INTRODUCTION: Umeclidinium (UMEC) is a long-acting inhaled antagonist of muscarinic cholinergic receptors. The FDA approved UMEC for maintenance treatment of chronic obstructive pulmonary disease (COPD) in 2013 and it became available for commercial use as a single agent in 2014. After tiotropium, this is the only other once daily LAMA available for COPD patients. AREAS COVERED: In this article, we have comprehensively reviewed the pharmacokinetic properties and analyzed the currently available randomized controlled trials on the efficacy and safety profile of UMEC. We have discussed the current clinical application of UMEC and its future implication. EXPERT OPINION: UMEC is the newer long-acting antimuscarinic agent (LAMA) that has demonstrated significant improvement in lung function and improved the quality of life in moderate-to-severe COPD patients. It is suitable for once daily dosing, has low anticholinergic side effects and is well tolerated. Overall, it is a safe, effective and convenient LAMA for maintenance therapy in COPD patients.

Pulmonary nodule: a comprehensive review and update.

The incidental detection of solitary pulmonary nodules and ground-glass nodules has increased substantially with the use of computed tomography as a diagnostic modality and is expected to rise exponentially as lung cancer screening guidelines are more widely implemented by primary care physicians. The lesions should then be classified as low, indeterminate, or high risk for malignancy, depending on the clinical and radiological characteristics. Once classified, these lesions should be evaluated and managed as per expert consensus-based recommendations for performing follow-up computed tomography scans and tissue sampling depending on the pretest probability. When weighing the risks and benefits of further investigations, patient preference and suitability for surgery should be taken into consideration as well.