ABSTRACT
Background: Acute respiratory distress syndrome (ARDS) is characterized by hypoxemia and non-hydrostatic pulmonary edema. While ARDS is associated with a high mortality rate, its conjunction with cardiogenic shock (CS) can lead to devastating outcomes. ARDS is managed via lung protective ventilation with low tidal volumes and positive end expiratory pressures. Prone positioning has emerged as a supplementary strategy with beneficial effects on gas exchange, respiratory mechanics, and hemodynamics. Our case underlines the feasibility of intra-aortic balloon pump counterpulsation (IABP) with concurrent prone positioning in a patient with ARDS and CS. Case: 71-year-old male with history of coronary artery disease, hypertension, hyperlipidemia, and chronic kidney disease, presented to the emergency department with new onset chest pain. EKG showed ST-segment elevations in leads V1-V2 consistent with acute anterior wall myocardial infarction. Patient underwent percutaneous coronary intervention to the left anterior descending artery.Due to worsening hemodynamics and CS, it was decided to place a left axillary IABP. Hospital course was further complicated by acute pulmonary edema and ARDS requiring emergent intubation and mechanical ventilation. Patient was also started on renal replacement therapy given progression of renal failure. Decision-making: Given the onset of ARDS, the patient was placed in prone position for 12-16 hours/day for 5 days. There was no special technique required during proning, other than additional staff to ensure IABP stability. Gradual improvement in hemodynamics was attained, including an increase in cardiac index from 2.1 to 3.4, and a decrease in pulmonary vascular congestion. Conclusion: With the emergence of COVID-19 pandemic, the incidence of ARDS has increased significantly, with simultaneous occurrence of CS in some of these patients. Prone positioning has become one of the main therapeutic modalities in the management of ARDS. Our case highlights the feasibility of axillary IABP while implementing prone positioning in patients with concomitant ARDS and CS.
ABSTRACT
Background and objectives: Spain is in a situation of indefinite lockdown due to the ongoing coronavirus disease 2019 (COVID-19) pandemic. One of the consequences of this lockdown is delays in medical and surgical procedures for common diseases. The aim of this study was to model the impact on survival of tumor growth caused by such delays in patients with squamous cell carcinoma (SCC) and melanoma. Material and methods: Multicenter, retrospective, observational cohort study. We constructed an exponential growth model for both SCC and melanoma to estimate tumor growth between patient-reported onset and surgical excision at different time points. Results: Data from 200 patients with SCC of the head and neck and 1000 patients with cutaneous melanoma were included. An exponential growth curve was calculated for each tumor type and we estimated tumor size after 1, 2, and 3 months of potential surgical delay. The proportion of patients with T3 SCC (diameter > 4cm or thickness > 6mm) increased from 41.5% (83 patients) in the initial study group to an estimated 58.5%, 70.5%, and 72% after 1, 2, and 3 months of delay. Disease-specific survival at 2, 5, and 10 years in patients whose surgery was delayed by 3 months decreased by 6.2%, 8.2%, and 5.2%, respectively. The proportion of patients with ultrathick melanoma (> 6mm) increased from 6.9% in the initial study group to 21.9%, 30.2%, and 30.2% at 1, 2, and 3 months. Five- and 10-year disease-specific survival both decreased by 14.4% in patients treated after a potential delay of 3 months. Conclusions: In the absence of adequate diagnosis and treatment of SCC and melanoma in the current lockdown situation in Spain, we can expect to see to a considerable increase in large and thick SCCs and melanomas. Efforts must be taken to encourage self-examination and facilitate access to dermatologists in order to prevent further delays.
ABSTRACT
BACKGROUND AND OBJECTIVES: Spain is in a situation of indefinite lockdown due to the ongoing coronavirus disease 2019 (COVID-19) pandemic. One of the consequences of this lockdown is delays in medical and surgical procedures for common diseases. The aim of this study was to model the impact on survival of tumor growth caused by such delays in patients with squamous cell carcinoma (SCC) and melanoma. MATERIAL AND METHODS: Multicenter, retrospective, observational cohort study. We constructed an exponential growth model for both SCC and melanoma to estimate tumor growth between patient-reported onset and surgical excision at different time points. RESULTS: Data from 200 patients with SCC of the head and neck and 1000 patients with cutaneous melanoma were included. An exponential growth curve was calculated for each tumor type and we estimated tumor size after 1, 2, and 3 months of potential surgical delay. The proportion of patients with T3 SCC (diameter >4cm or thickness >6 mm) increased from 41.5% (83 patients) in the initial study group to an estimated 58.5%, 70.5%, and 72% after 1, 2, and 3 months of delay. Disease-specific survival at 2, 5, and 10 years in patients whose surgery was delayed by 3 months decreased by 6.2%, 8.2%, and 5.2%, respectively. The proportion of patients with ultrathick melanoma (>6 mm) increased from 6.9% in the initial study group to 21.9%, 30.2%, and 30.2% at 1, 2, and 3 months. Five- and 10-year disease-specific survival both decreased by 14.4% in patients treated after a potential delay of 3 months. CONCLUSIONS: In the absence of adequate diagnosis and treatment of SCC and melanoma in the current lockdown situation in Spain, we can expect to see to a considerable increase in large and thick SCCs and melanomas. Efforts must be taken to encourage self-examination and facilitate access to dermatologists in order to prevent further delays.