Pulmonary and Critical Care Fellowship Program Directors' Perspective on the Virtual Interview Process.

Background: Since the start of the coronavirus disease (COVID-19) pandemic, the residency and fellowship recruitment process has changed significantly with the use of virtual interview (VI) platforms. Pulmonary and critical care medicine (PCCM) candidates reported in a survey that VIs hindered their ability to evaluate their fit within the program. However, the program directors' (PDs') opinion of this process remains unknown. Objective: We aim to provide insight into the PCCM fellowship PDs' perspective regarding the virtual recruitment process since the first class of fellows undergoing this process has now completed 1 year of training. Methods: An anonymous survey was sent to the PDs of PCCM programs participating in the National Resident Matching Program match process in 2020 and 2021. The survey consisted of five sections and 26 closed-ended questions and was distributed via email using the SurveyMonkey platform. The survey was conducted for a total of 6 weeks. A follow-up email to nonrespondents was sent every week. The collected responses were divided into two categories: favoring VIs versus not favoring VIs. A multivariable logistic regression analysis was performed to determine the factors associated with favoring VIs. Results: The survey was sent to 190 email accounts from the Fellowship and Residency Electronic Interactive Database Access System website. Over the course of 6 weeks, 64 respondents participated in the survey, with a response rate of 33.68%. Of 64 respondents, 56 (87.5%) fully completed the survey and 8 (12.5%) partially completed the survey. The final sample size was 59. Thirty-six (61.02%) of the PDs favored VIs for future recruitment, and 23 (38.98%) did not (P < 0.001). Ninety-seven percent of PDs who favored VIs versus 72.73% of those who did not perceived the current fellows to fit well in the program (P = 0.007). The multivariable logistic regression analysis showed a trend toward higher odds of favoring VIs if PDs believed they were able to represent the program well virtually (adjusted odds ratio, 6.99; 95% confidence interval, 0.79 - 61.58) and if they found that the current fellows fit the program well (adjusted odds ratio, 7.15; 95% confidence interval, 0.76-66.52); however, these results were not statistically significant. Conclusion: In this survey research, we found that the majority of the PCCM fellowship PDs favored a virtual process for future recruitment.

Prior Use of Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers and Clinical Outcomes of Sepsis and Septic Shock: A Systematic Review and Meta-analysis.

ABSTRACT: Sepsis and septic shock are life-threatening conditions that are associated with high mortality and considerable health care costs. The association between prior angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) use and outcomes after sepsis is elusive. The aim of this study was to evaluate the role of the prior use of ACEi or ARBs and outcomes after sepsis and septic shock. A relevant literature review was performed in 4 databases from inception until July 2022. Independent reviewers first screened the title, abstract, and full text, and then, data extraction and analysis were performed. One post hoc analysis of a trial and 6 retrospective cohort studies were included in this review. There were 22% lower odds of in-hospital/30-day mortality among patients who have used ACEi/ARBs in the past [23.83% vs. 37.20%; odds ratio (OR), 0.78, 95% confidence interval (CI), 0.64-0.96], and reduced 90-day mortality (OR, 0.80, 95% CI, 0.69-0.92). ACEi/ARBs users were found to have 31% lesser odds of developing acute kidney injury as compared with nonusers (OR, 0.69, 95% CI, 0.63-0.76). There was no significant difference in the length of hospital stay (MD 1.26, 95% CI, ‒7.89 to 10.42), need for renal replacement therapy (OR, 0.71, 95% CI, 0.13-3.92), mechanical ventilation (OR, 1.10, 95% CI, 0.88-1.37) or use of vasopressors (OR, 1.21, 95% CI, 0.91-1.61). Based on this analysis, prior use of ACEi/ARBs lowers the risk of mortality and adverse renal events in patients with sepsis and septic shock.

Correction: Low serum albumin and the risk of hospitalization in COVID-19 infection: A retrospective case-control study.

[This corrects the article DOI: 10.1371/journal.pone.0250906.].

Outcome of In-Hospital Cardiac Arrest among Patients with COVID-19: A Systematic Review and Meta-Analysis.

BACKGROUND: Outcomes following in-hospital cardiac arrest (IHCA) in patients with COVID-19 have been reported by several small single-institutional studies; however, there are no large studies contrasting COVID-19 IHCA with non-COVID-19 IHCA. The objective of this study was to compare the outcomes following IHCA between COVID-19 and non-COVID-19 patients. METHODS: We searched databases using predefined search terms and appropriate Boolean operators. All the relevant articles published till August 2022 were included in the analyses. The systematic review and meta-analysis were conducted as per Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. An odds ratio with a 95% confidence interval (CI) was used to measure effects. RESULTS: Among 855 studies screened, 6 studies with 27,453 IHCA patients (63.84% male) with COVID-19 and 20,766 (59.7% male) without COVID-19 were included in the analysis. IHCA among patients with COVID-19 has lower odds of achieving return of spontaneous circulation (ROSC) (OR: 0.66, 95% CI: 0.62-0.70). Similarly, patients with COVID-19 have higher odds of 30-day mortality following IHCA (OR: 2.26, 95% CI: 2.08-2.45) and have 45% lower odds of cardiac arrest because of a shockable rhythm (OR: 0.55, 95% CI: 0.50-0.60) (9.59% vs. 16.39%). COVID-19 patients less commonly underwent targeted temperature management (TTM) or coronary angiography; however, they were more commonly intubated and on vasopressor therapy as compared to patients who did not have a COVID-19 infection. CONCLUSIONS: This meta-analysis showed that IHCA with COVID-19 has a higher mortality and lower rates of ROSC compared with non-COVID-19 IHCA. COVID-19 is an independent risk factor for poor outcomes in IHCA patients.

Use of Computed Tomography of the Head in Patients With Acute Atraumatic Altered Mental Status: A Systematic Review and Meta-analysis.

Importance: The usefulness of computed tomography of the head (CTH) in patients with acute-onset atraumatic altered mental status (AMS) is poorly understood, but use in these patients remains high. Objective: To evaluate the use of CTH (event rate) in patients with AMS and the positive outcome event rate of the performed CTH studies. Data Sources: The PubMed/MEDLINE, PubMed Central, Embase, and CINAHL databases were searched using predefined Boolean parameters. All studies that met inclusion criteria until January 31, 2022, were included. Study Selection: Randomized clinical trials and observational, cohort, and case-control studies were included. Conference abstracts, reviews, letters, case reports, case series, systematic literature, and meta-analyses were excluded. Data Extraction and Synthesis: The systematic literature review was performed per Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data were independently extracted by 2 authors. Data were pooled using a random-effects method. Main Outcomes and Measures: Event rate of CTH use in patients with acute atraumatic AMS. The CTH event rates and positive CTH event rates were calculated with 95% CIs. Results: Of 9338 studies identified, 26 qualified for the systematic review and 25 for the meta-analysis. The 25 studies in the meta-analysis included a total of 79 201 patients. The CTH event rate was 94% (proportion, 0.94; 95% CI, 0.76-1.00), and the positive CTH event rate was 11% (proportion, 0.11; 95% CI, 0.07-0.15). There was significant heterogeneity among the studies included (I2 > 50%, P < .001), for which a random-effects model was used. There was significant publication bias, as evident by an asymmetric funnel plot. There was no fluctuation of the results during the sensitivity analysis, which reassured the reliability of the data. Conclusions and Relevance: In this meta-analysis, CTH use among patients with acute-onset atraumatic AMS was very high with a low yield. Large-scale studies are needed to guide clinical decision-making in such a situation.

Workplace violence against nurses: a narrative review.

Background and Aim: Any harmful act Physical, sexual, or psychological committed against the nurses in the workplace by a patient or visitor is called workplace violence (WPV) against nurses. WPV is directly related to decreasing job satisfaction, burnout, humiliation, guilt, emotional stress, intention to quit a job, and increased staff turnover. The purpose of this narrative review is to explore the concept of WPV, its prevalence, consequences, influence on nursing, and strategies developed to prevent such incidences. WPV is not acceptable and, regardless of the culprit's physical or psychological status, should be held responsible for such a heinous crime. WPV can have a vastly negative impact on nurses. Unfortunately, violence in the workplace has become so common that it is now considered an unpleasant part of the job and ignored instead of being reported. Nurses should be educated appropriately on hospital policies against WPV and be encouraged to report any incidence. Relevance for Patients: WPV is detrimental to nurse and patient's relationship which negatively affects patient care.

Midodrine in Liver Cirrhosis With Ascites: A Systematic Review and Meta-Analysis.

Ascites is the most common complication of liver cirrhosis. Midodrine is a vasoconstrictor that improves splanchnic and systemic hemodynamics, reduces ascites, and improves clinical outcomes. Here, we aimed to examine the role of midodrine in cirrhosis-related ascites. Scopus, Embase, PubMed, and PubMed Central databases were searched for relevant randomized controlled trials comparing midodrine with other interventions in patients with cirrhotic ascites on November 25, 2020, using appropriate keywords like "midodrine", "ascitic cirrhosis", "peritoneal paracentesis" and suitable Boolean operators. Odds ratio (OR) and mean difference (MD) were used to analyze pool data as appropriate with a 95% confident interval (CI). A total of 14 studies were included in our analysis including 1199 patients. The addition of midodrine resulted in statistically significant improvement in mean arterial pressure (MAP) (MD, 3.95 mmHg; 95% CI, 1.53-6.36) and MELD (Model for End-Stage Liver Disease) score (MD, -1.27; 95% CI, -2.49 to -0.04) compared to standard medical treatment (SMT). There was also a significant improvement in plasma renin activity and plasma aldosterone concentration. However, there was no significant improvement in mortality or serum creatinine compared to SMT. In addition, there was no statistically significant improvement in MAP, plasma renin activity, plasma aldosterone concentration, MELD score, overall mortality, and paracentesis-induced circulatory dysfunction comparing midodrine with albumin. Midodrine alone leads to significant improvement in various clinical parameters in patients with cirrhotic ascites compared to standard medical care. At the same time, it was found to be non-inferior to albumin. Therefore, further well-designed studies need to be carried out on midodrine in addition to albumin for optimal clinical benefits among patients with ascites due to cirrhosis.

Vasopressin versus norepinephrine as the first-line vasopressor in septic shock: A systematic review and meta-analysis.

Background and Aim: Norepinephrine is currently the first-line vasopressor for septic shock. We conducted this meta-analysis to examine the outcomes of adult patients with septic shock who received vasopressin instead of norepinephrine. Methods: We selected studies in adults with septic shock that compared the outcomes of patients treated with vasopressin versus norepinephrine. Cochrane ROB 2.0 and the Joanna Briggs Institute quality assessment tools were used to assess the risk of bias in RCTs and observational studies. Meta-analysis was conducted using RevMan 5.4. Results: Eight studies were included in this meta-analysis. There were no significant differences in 28-day mortality rates (OR, 1.07; CI, 0.80-1.44) and intensive care unit (ICU) mortality (OR, 0.74; CI, 0.21-2.67) between the two groups. Similarly, length of ICU stay, length of hospital stay, mean arterial pressure at 24 h, urine output at 24 h, and serious adverse events also did not differ significantly. However, the odds of renal replacement therapy (RRT) requirement in the vasopressin group were substantially lower than in the norepinephrine group (OR, 0.68; CI, 0.47-0.98). Conclusion: There were no differences in mortality, duration of hospitalization, and adverse effects in adults with septic shock across the two groups. However, the patients treated with vasopressin had lower chances of requiring RRT. Relevance for Patients: Vasopressin use as the first-line vasopressor in septic shock showed a significant reduction in RRT, though there were no significant differences in terms of mortality and other adverse events. Therefore, vasopressin can be considered as a first-line vasopressor in septic shock patients with other risk factors which may contribute to renal failure requiring RRT.

A Retrospective Cross-Sectional Study of Severe Breakthrough SARS-CoV-2 Infection in the General Population Requiring Hospitalization Within a Single Health System.

BACKGROUND: Despite coronavirus disease 2019 (COVID-19) vaccination efforts, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in vaccinated individuals ("breakthrough SARS-CoV-2 infections") have emerged. Our understanding of breakthrough SARS-CoV-2 infections continues to evolve, and there is a paucity of information describing severe breakthrough SARS-CoV-2 infections. We conducted this study with the aim of describing breakthrough SARS-CoV-2 infections requiring hospitalization and exploring factors associated with severe breakthrough infection. METHODS: The study included patients within our health network who received at least one dose of a messenger RNA (mRNA) COVID-19 vaccine and required hospitalization due to breakthrough SARS-CoV-2 infection from January 1 to August 15, 2021. We performed a descriptive analysis of vaccinated patients requiring hospitalization. Multivariable logistic regression (LR) analysis was performed to explore factors associated with severe breakthrough infection. RESULTS: Out of 67,223 vaccinated individuals, 78 (0.12%) patients were hospitalized with breakthrough SARS-CoV-2 infection, of which 25 individuals (0.04% of those vaccinated, and 32% of all hospitalized) developed severe infection. The mean age of those with breakthrough infection was 72 years, the majority were White (60%), and dyspnea was the most common reason for hospital admission (53%), with bimodal peaks of hospitalization in January-February (40%) and July-August (34%). In LR analysis, male patients had 4.03 times the odds of developing severe SARS-CoV-2 infection than female patients (adjusted odds ratio (aOR): 4.03, 95% confidence interval (CI): 1.21 - 13.40), and an immunocompromising condition had 6.32 times the odds of developing severe COVID-19 disease (aOR: 6.32, 95% CI: 1.48 - 26.18). CONCLUSIONS: The rate of severe breakthrough SARS-CoV-2 infection was very low, and male sex and immunocompromising conditions were associated with severe breakthrough infection. Clinicians and health systems should continue to campaign for COVID-19 vaccination aggressively.

Pulmonary barotrauma in COVID-19: A systematic review and meta-analysis.

BACKGROUND: An ever-increasing number of studies have reported an increased incidence of spontaneous pulmonary barotrauma such as pneumothorax, pneumomediastinum, and subcutaneous emphysema in patients with COVID-19. We conducted this systematic review and meta-analysis to assess the value and significance of the available data. METHODS: A thorough systematic search was conducted to identify studies of barotrauma in hospitalized patients with COVID-19. Data analysis of case reports was done using a statistical package for the social sciences (SPSS) version 22, and meta-analysis was performed using CMA-3. RESULTS: We identified a total of 4488 studies after thorough database searching.118 case reports and series, and 15 observational studies were included in the qualitative analysis. Fifteen studies were included in the quantitative analysis. The observational studies reported barotrauma in 4.2% (2.4-7.3%) among hospitalized patients; 15.6% (11-21.8%) among critically ill patients; and 18.4% (13-25.3%) in patients receiving invasive mechanical ventilation, showing a linear relationship of barotrauma with the severity of the disease. In addition, barotrauma was associated with a longer length of hospital stay, more extended ICU stay, and higher in-hospital mortality. Also, a slightly higher odds of barotrauma was seen in COVID-19 ARDS compared with non-COVID-19 ARDS. CONCLUSION: COVID-19 pneumonia is associated with a higher incidence of barotrauma. It presents unique challenges for invasive and non-invasive ventilation management. Further studies are required to unravel the underlying pathophysiology and develop safer management strategies.

Risk of post-intubation cardiac arrest with the use of high-dose rocuronium in COVID-19 patients with acute respiratory distress syndrome: A retrospective cohort study.

BACKGROUND: Post-intubation cardiac arrest (PICA) is an uncommon complication of intubation, but numbers have risen to over 1.5 times the usual number since the coronavirus disease 2019 (COVID-19) pandemic. Due to expert recommendations, high-dose rocuronium (HDR) has become a commonly used pre-intubation neuromuscular blocking agent. AIM: We conducted this retrospective case-control observational study with the hypothesis that high-dose rocuronium was not associated with higher incidence of PICA. METHODS: We included 93 patients who were intubated using the rapid sequence intubation (RSI) technique with rocuronium for acute respiratory distress syndrome (ARDS) due to confirmed COVID-19 pneumonia, admitted from March 2020 to February 2021 to a tertiary care hospital in North Carolina, USA. The patients were grouped based on high (1.5 mg/kg of ideal body weight and above) versus low (<1.5 mg/kg of ideal body weight) dose rocuronium used for RSI. The differences of the various outcomes between the groups were analyzed. RESULTS: The baseline demographics were similar in both groups except for higher body mass index in high-dose group 39 versus 32 (kg/m2), p = 0.009. There was a total of six PICA events (6.45%). The HDR group had 8.0% of PICA versus 4.7% in the low-dose group. In-hospital mortality was 60.0% in the HDR group versus 72.1% in the low-dose group. CONCLUSION: The incidence of PICA in COVID-19 patients with ARDS who were intubated using the RSI technique was higher than in the pre-COVID-19 era. RELEVANCE FOR PATIENTS: The use of high-dose paralytics during invasive ventilation with RSI and their consequences should be explored with the help of large-scale studies. The rate of PICA is still very low, and perhaps, the use of HDR is safe, as suggested by the expert panel.

Fluid resuscitation and outcomes in heart failure patients with severe sepsis or septic shock: A retrospective case-control study.

BACKGROUND: The use of ≥30 mL/Kg fluid bolus in congestive heart failure (CHF) patients presenting with severe sepsis or septic shock remained controversial due to the paucity of data. METHODS: The retrospective case-control study included 671 adult patients who presented to the emergency department of a tertiary care hospital from January 01, 2017 to December 31, 2019 with severe sepsis or septic shock. Patients were categorized into the CHF group and the non-CHF group. The primary outcome was to evaluate the compliance with ≥30 mL/Kg fluid bolus within 6 hours of presentation. The comparison of baseline characteristics and secondary outcomes were done between the groups who received ≥30 mL/Kg fluid bolus. For the subgroup analysis of the CHF group, it was divided based on if they received ≥30 mL/Kg fluid bolus or not, and comparison was done for baseline characteristics and secondary outcomes. Univariate and multivariable analyses were performed to explore the differences between the groups for in-hospital mortality and mechanical ventilation. RESULTS: The use of ≥30 mL/Kg fluid bolus was low in both the CHF and non-CHF groups [39% vs. 66% (p<0.05)]. Mortality was higher in the CHF group [33% vs 18% (p<0.05)]. Multivariable analysis revealed that the use of ≥30 mL/Kg fluid bolus decreased the chances of mortality by 12% [OR 0.88, 95% CI 0.82-0.95 (p<0.05)]. The use of ≥30 mL/Kg fluid bolus did not increase the odds of mechanical ventilation [OR 0.99, 95% CI 0.93-1.05 (p = 0.78)]. In subgroup analysis, the use of ≥30 mL/Kg fluid bolus decreased the chances of mortality by 5% [OR 0.95, 95% CI 0.90-0.99, (p<0.05)] and did not increase the odds of mechanical ventilation. The presence of the low ejection fraction did not influence the chance of getting fluid bolus. CONCLUSION: The use of ≥30 mL/Kg fluid bolus seems to confer protection against in-hospital mortality and is not associated with increased chances of mechanical ventilation in heart failure patients presenting with severe sepsis or septic shock.

Low Serum Albumin Predicts Severe Outcomes in COVID-19 Infection: A Single-Center Retrospective Case-Control Study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) can cause serious complications such as multiorgan failure and death which are difficult to predict. We conducted this retrospective case-control observational study with the hypothesis that low serum albumin at presentation can predict serious outcomes in COVID-19 infection. METHODS: We included severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase-polymerase chain reaction (RT-PCR) confirmed, hospitalized patients from March to July 2020 in a tertiary care hospital in the USA. Patients were followed for 21 days for the development of the primary endpoint defined as the composite outcome which included acute encephalopathy, acute kidney injury, the requirement of new renal replacement therapy, acute hypercoagulability, acute circulatory failure, new-onset heart failure, acute cardiac injury, acute arrhythmia, acute respiratory distress syndrome (ARDS), high flow oxygen support, intensive care unit (ICU) stay, mechanical ventilation or death; and the secondary endpoint of death only. Univariate and multivariate logistic regression analyses were performed to study the effect of albumin level and outcomes. RESULTS: The mean age was 56.76 years vs. 55.67 years (P = 0.68) in the normal albumin vs. the low albumin group. We noticed an inverse relationship between serum albumin at presentation and serious outcomes. The low albumin group had a higher composite outcome (93.88% vs. 6.12%, P < 0.05) and higher mortality (13.87% vs. 2.38%, P < 0.05) in comparison to the normal albumin group. The multivariate logistic regression analysis revealed higher odds of having composite outcomes with lower albumin group (odds ratio (OR) 10.88, 95% confidence interval (CI) 4.74 - 24.97, P < 0.05). In the subgroup analysis, the multivariate logistic regression analysis revealed higher odds of having composite outcomes with the very low albumin group (OR 7.94, 95% CI 1.70 - 37.14, P < 0.05). CONCLUSIONS: Low serum albumin on presentation in COVID-19 infection is associated with serious outcomes not limited to mortality. The therapeutic option of albumin infusion should be investigated.

Low serum albumin and the risk of hospitalization in COVID-19 infection: A retrospective case-control study.

BACKGROUND: The data on the COVID-19 patients who were discharged to self-quarantine is lacking. AIM: The aim of the study was to investigate the percentage of COVID-19 positive patients that were hospitalized within a three-week period after discharge from ED to self-quarantine. METHODS: The patients who had confirmed SARS-CoV-2 on RT-PCR of the nasopharyngeal swab and were discharged from ED of a tertiary care hospital in the USA to self-quarantine from March 01- July 31, 2020, were included. Patients were divided into two groups based on serum albumin levels and were followed up for three weeks to see if low level of albumin increased the risk of hospitalization. Univariate and multivariate logistic regression analyses were performed to study the effect of albumin level and outcomes. RESULTS: A total of 112 patients were included in the study out of which 65 had low serum albumin (<3.5 g/dL) and 47 had normal serum albumin (≥3.5 g/dL). More than 10% of patients discharged to self-quarantine needed hospitalization within three weeks. The Low albumin group had more co-morbidities at baseline. The low serum albumin group had 10 (15.38%) vs 2 (4.26%), p = 0.06 hospitalizations as compared to the normal serum albumin group. The multivariate logistic regression analysis did not reveal lower odds of hospitalization in the group with normal albumin, (OR 0.26, 95% CI 0.03-1.92, p = 0.19) after controlling for age, sex, and various co-morbidities. CONCLUSION: The low serum albumin was not associated with the risk of hospitalization in COVID-19 patients who were initially discharged to self-quarantine.

Delayed onset serotonin syndrome in the setting of polypharmacy.

Serotonin syndrome is a rare but well-known condition that can be life-threatening if not diagnosed early. Onset is usually within 4 to 13 h of starting the offending medication. We present a case of delayed onset of serotonin syndrome that presented after 48 h. Polypharmacy played a role in causing the onset of symptoms. Clinicians should keep a high index of suspicion for serotonin syndrome when dealing with elderly confused patients who take multiple medications even when the onset is delayed or atypical because the outcome can be disastrous.

An unusual case of severe hypercalcemia: as dehydrated as a bone.

Objective: Severe hypercalcemia is a medical emergency. Hyperparathyroidism, malignancy, vitamin D toxicity, infections such as tuberculosis, or systemic illness such as sarcoidosis are all possible etiologies. Among the less studied causes is dehydration. Our objective is to identify dehydration as an etiology of hypercalcemia. Methods: Extensive literature review did not recognize dehydration as an etiology of hypercalcemia. We present a case of dehydration leading to severe hypercalcemia in a 60-years-old female with a presentation of altered mental status and corrected calcium level of 19 mg/dL in the absence of parathyroid abnormality, vitamin D toxicity, systemic disease, or malignancy. Results: Dehydration caused hypercalcemia which led to a feed-forward mechanism and caused further worsening dehydration, worsening kidney function, and severe hypercalcemia. The patient responded very well to intravenous fluid and at the time of discharge had a serum calcium of 9.8 mg/dL with improved mental status back to the baseline. Conclusion: Our literature review demonstrated many causes of hypercalcemia, with dehydration being exceptionally rare. It is our hope that this case report may serve as evidence of one such instance, allowing providers to keep a working differential of dehydration in severely elevated calcium levels.

Diabetes mellitus as a risk factor for cryptococcal meningitis in immunocompetent.

Cryptococcal meningoencephalitis (CM) is one of the major causes of mortality and morbidity in immunocompromised patients estimating 650,000 deaths each year. Across the globe, CM has been occasionally seen in apparently immunocompetent patients who otherwise don't have established risk factors. The clinical presentation of CM in immunocompetent hosts is subtle and often results in complications including persistent neurological deficits and death. We present a case of Cryptococcal neoformans meningitis in a diabetic female with no other identified risk factors. Although her clinical presentation was atypical, her clinical course was uncomplicated. The pathophysiology in immunocompetent hosts appears somewhat different, so is the clinical presentation. Since there are no separate evidence-based treatment recommendations, it is challenging to treat this group of patients. There seems to be a need for further studies for management in CM for HIV negative, non-transplant immunocompetent patients.

Myxedema Coma: A Forgotten Medical Emergency With a Precipitous Onset.

Myxedema coma is a rare life-threatening disorder characterized by severe hypothyroidism leading to multiorgan failure and even death. This case also reminds clinicians that the misnomer "coma" is misleading, and the patient can present with less severe symptoms. We present a case of a 72-year-old female with a history of primary hypothyroidism who presented to the emergency department with progressively worsening confusion for three days. Laboratory results revealed thyroid-stimulating hormone (TSH) 402.0 µU/L and free thyroxine (T4) 0.22 ng/dL. The patient was compliant with the levothyroxine but she found to be malnourished on presentation. The patient was treated with intravenous levothyroxine and liothyronine. The patient's mental status improved to the baseline, and she was discharged to a skilled nursing facility. Myxedema coma is a rare but life-threatening disorder that providers should be familiar with, including management and treatment. To the best of our knowledge, this is the highest TSH level ever reported so far, and the first case of myxedema coma precipitated due to malnutrition.

Postpartum Transient Hypervagotonic Sinus Node Dysfunction Leading to Sinus Bradycardia: A Case Report.

Sinus bradycardia is common in children and adults, especially during sleep. The heart rate can drop below 30 beats per minute. Up to 35% of healthy individuals below 25 years of age, trained athletes, and those with a rare form of the familial syndrome with potassium/sodium hyperpolarization-activated cyclic nucleotide-gated channel 4 (HCN4) mutation may have asymptomatic sinus bradycardia without any heart diseases. The increased vagal tone has been associated with profound bradycardia in various pathophysiologic settings including pain. Herein, we report the first case of a young Caucasian female with transient symptomatic bradycardia due to postpartum hypervagotonic sinus node dysfunction (SND).

Obstructive Sleep Apnea: Risk Factor for Arrhythmias, Conduction Disorders, and Cardiac Arrest.

Background Obstructive sleep apnea (OSA) has been described as a risk factor for cardiac arrhythmias. Its association with atrial fibrillation has been established. However, relationships with other arrhythmias and conduction disorders have not been fully studied. Methods We used the National Inpatient Sample database from 2009 to 2011 to explore the relationship between OSA and arrhythmias and conduction disorders. The presence of diagnosis was determined based on the International Classification of Disease-9 (ICD-9) codes. Univariate and multivariate logistic regressions were used to establish mortality risks among all groups. Results Multivariate logistic regression showed increased mortality in patients with OSA in comparison to patients without OSA and patients across all categories of arrhythmias and conduction disorders. One significant finding was the increased association of cardiac arrest in patients with OSA versus patients without OSA (OR: 95.72; CI: 89.13-105.81, p < 0.001). Conclusions OSA is significantly associated with non-atrial fibrillation arrhythmias, conduction disorders, and sudden cardiac arrest. Awareness regarding this association is important for early screening for OSA in obese patients to prevent cardiovascular morbidity and mortality. The use of continuous positive airway pressure (CPAP) might be beneficial against all kinds of arrhythmias and sudden cardiac death.