Electrolyte disturbances in patients hospitalized for COVID-19 infection: An observational study.

There are multiple mechanisms by which The Coronavirus-19 (COVID-19) infection can cause electrolyte abnormalities, which may not be the case for bacterial causes of pneumonia. This study aimed to assess the differences in electrolyte levels between patients suffering from COVID-19 and bacterial pneumonia. This is an original, retrospective study. Two cohorts of hospitalized patients were included, 1 suffering from COVID-19 and the other from bacterial pneumonia. Their day 1 and day 3 levels of sodium, potassium, magnesium, and phosphorus, as well as their outcomes, were extracted from the charts. Statistical analysis was subsequently performed. Mean admission levels of sodium, potassium, phosphorus, and magnesium were 135.64 ±â€…6.13, 4.38 ±â€…0.69, 3.53 ±â€…0.69, and 2.03 ±â€…0.51, respectively. The mean day 3 levels of these electrolytes were 138.3 ±â€…5.06, 4.18 ±â€…0.59, 3.578 ±â€…0.59, and 2.11 ±â€…0.64, respectively. Patients suffering from bacterial pneumonia were significantly older (N = 219, mean = 64.88 ±â€…15.99) than patients with COVID-19 pneumonia (N = 240, mean = 57.63 ±â€…17.87). Bacterial pneumonia group had significantly higher serum potassium (N = 211, mean = 4.51 ±â€…0.76), and magnesium (N = 115, mean = 2.12 ±â€…0.60) levels compared to COVID-19 group (N = 227, mean = 4.254 ±â€…0.60 for potassium and N = 118, mean = 1.933 ±â€…0.38 for magnesium). Only magnesium was significantly higher among day 3 electrolytes in the bacterial pneumonia group. No significant association between electrolyte levels and outcomes was seen. We found that COVID-19 patients had lower potassium and magnesium levels on admission, possibly due to the effect of COVID-19 on the renin-angiotensin-aldosterone system as well as patient characteristics and management. We did not find enough evidence to recommend using electrolyte levels as a determinator of prognosis, but more research is needed.

Point-of-Care Ultrasound Unveils Life-Threatening Conditions: A Case Series Highlighting Its Vital Diagnostic Role.

Point-of-care ultrasound (POCUS) has emerged as a powerful diagnostic tool in healthcare, offering rapid and cost-effective evaluation of cardiovascular and respiratory conditions. This case series highlights the vital role of POCUS in diagnosing life-threatening conditions and emphasizes the need for adequate training in its use. The first case describes a patient with chest pain, where POCUS revealed findings suggestive of thoracic aortic dissection, leading to timely transfer and surgical repair. The second case involves a patient with altered mental status and hypoxia, where POCUS identified a right atrial thrombus leading to thrombectomy. The discussion explores the expanding applications of POCUS in various medical specialties, including critical care and trauma, and its potential to improve patient outcomes. While POCUS has shown great promise, it remains a user-dependent technology, necessitating comprehensive training and collaboration among healthcare professionals to ensure its effective and safe use.

Sinus of Valsalva Aneurysm: An Atypical Etiology of Recurrent Syncope.

The sinus of Valsalva presents the initial segment of the aorta from where the coronary vessels arise. Sinus of Valsalva aneurysms (SOVAs) present as progressive dilatation of the aortic sinus. SOVA arises both from the congenital and acquired weakness of the elastic lamina of the aortic media. Though most of the SOVAs are asymptomatic and diagnosed on screening for other pathologies, patients can present with symptoms of arrhythmia, aortic insufficiency, aorto-cardiac fistulas, and, in a few cases, with rupture. We describe a patient who presented with recurrent syncope and was found to have a 6 cm dilated SOVA with an ectatic ascending aorta. Further assessment revealed a left anterior fascicular block, aortic regurgitation, and mitral regurgitation. On further assessment, no other cause of syncope was found. There was no family history of aneurysm or sudden cardiac death. The patient was eventually discharged with outpatient follow-up with cardiothoracic surgery. In patients presenting with asymptomatic SOVA, a dilatation with a maximum diameter of 6.0 cm requires stringent monitoring and should be considered for surgery.

Candida lusitaniae, an Emerging Opportunistic Pathogen in Immunocompetent Populations: A Case Report.

Candida lusitaniae is an emerging opportunistic pathogen in immunocompromised hosts and hospitalized patients. However, the incidence is low in immunocompetent hosts. Because of their characteristic similarities, C. lusitaniae may be confused with other fungal species, such as Candida tropicalis, Candida parapsilosis, and even Saccharomyces cerevisiae. Recently reported cases of serious infections caused by C. lusitaniae have proven detrimental, and some cases reported amphotericin resistance. Here, we present a case report of empyema caused by C. lusitaniae in an immunocompetent patient who was admitted to the intensive care unit and intubated for acute hypoxic respiratory failure. This case demonstrates the importance of recognizing this organism and initiating early treatment for the prevention of fatal complications.

An Acute Large Pericardial Effusion in a Scleroderma Renal Crisis.

This case report describes a patient with systemic sclerosis (SSc) who presented with a large pericardial effusion and a scleroderma renal crisis (SRC). The patient's clinical presentation, diagnostic workup, and treatment plans are reviewed. The coexistence of these complications presents a challenging clinical scenario requiring an interdisciplinary approach. The management of pericardial effusion in SSc and SRC is discussed, emphasizing the need for early detection and prompt treatment. Further research is needed to better understand and manage these complex complications in SSc patients.

Heart Block and Sinus Pause Following Abdominal Surgery: A Case Requiring Temporary Pacemaker Insertion.

This case report presents the clinical course of a 70-year-old female with a history of hypertension who developed sinus pauses following abdominal surgery, ultimately requiring the placement of a pacemaker. The patient initially presented with altered mental status preceded by abdominal pain, which progressed to confusion and obtundation. Examination revealed signs of toxicity, tachycardia, tachypnea, and a distended abdomen with absent bowel sounds. A computed tomography (CT) scan of the abdomen indicated closed-loop small bowel obstruction with free air and ascites. The patient underwent exploratory laparotomy, revealing purulent fluid and a necrotic, perforated appendix, leading to appendectomy and peritoneal irrigation. Subsequent surgeries addressed the coagulative necrosis of the omentum and wound closure. During the recovery period, the patient exhibited bradycardia with sinus pauses, including episodes of complete heart block. Cardiology consultation attributed this to increased parasympathetic tone following surgery and recommended the placement of a temporary transvenous pacemaker. As the patient's condition improved, the sinus pacing function progressively returned, leading to the removal of the pacemaker. This case underscores the potential development of sinus pauses after abdominal surgery and highlights the importance of prompt recognition, appropriate management, and collaboration between surgical and cardiology teams to ensure patient recovery.

Cryotherapy for the Treatment of Tracheal Stenosis: A Systematic Review.

Tracheal stenosis (TS) is an iatrogenic sequela after intubation or tracheostomy that is increasing despite technological improvement and skilled respiratory care in the ICU. According to the studies, the rate of TS varies from 10 to 22%, but only 1-2% of these stenoses are severe and present with inspiratory dyspnea that does not respond to medical management. Bronchoscopy is considered the most appropriate diagnostic test, and laser surgery and tracheobronchial stenting are the most commonly performed procedures for tracheal stenosis. However, alternative treatment options, including cryotherapy for inoperable patients, have yet to be studied widely. As the number of patients requiring ICU admission with mechanical intubation is increasing, it is crucial to acknowledge this complication and consider alternative management options. Here we present a review of the use of cryotherapy for post-intubation tracheal stenosis.  Pubmed, Cochrane, and EMBASE databases were inquired for studies performed using the keywords 'airway stricture' OR 'airway obstruction' AND 'post-intubation' OR 'post-extubation' OR 'tracheostomy' AND 'cryotherapy'. After the primary and secondary screening, five studies were included in the analysis.  We included 67 patients were included in the analysis, with a mean age of 50.2 (range: 42-55) years. Tracheal stenosis and subglottic stricture were the most common sites of stenosis. Twenty-nine patients were treated with cryotherapy only, while the rest 38 patients had cryotherapy followed by balloon dilation. After the intervention, 48 patients experienced improvement, five experienced no change in the symptoms, 13 patients were asymptomatic before the treatment, and one died. No complication was reported in 65 patients, with only minor complications reported in rest.  Although, there is no clear treatment protocol for patients with inoperable tracheal stenosis. Our review demonstrates that cryotherapy for inoperable tracheal stenosis can be an acceptable alternative treatment with significant clinical improvement. Additionally, cryotherapy has fewer adverse effects compared to other treatment options.

Malignant Airway Obstruction and Endobronchial Stent Placement: A Systematic Review on the Efficacy and Safety.

The systematic review aims to evaluate the efficacy and safety of endobronchial stent placement for malignant airway obstruction.  A comprehensive search was conducted across multiple databases to identify relevant studies. Cohort studies, randomized controlled trials, and case-control studies examining the outcomes of endobronchial stent placement in patients with malignant airway obstruction were included. Data on pre-treatment evaluation, such as pulmonary function testing, dyspnea severity scoring systems, arterial blood gas parameters, imaging, and degree of obstruction, were also collected. Primary outcomes of interest included post-procedure stenosis, pulmonary function testing evaluation, blood gas parameters, and survival outcomes. Secondary outcomes encompassed improvements in clinical status, dyspnea grade, and procedure-related complications. A total of 27 studies met the inclusion criteria and were included in the systematic review. The included studies demonstrated promising outcomes of endobronchial stent placement in managing malignant airway obstruction. Post-procedure airway diameters, pulmonary function testing, and blood gas parameters improved significantly. Survival outcomes varied among studies. Furthermore, endobronchial stent placement was associated with improvements in clinical status and dyspnea grade. Procedure-related complications ranged from pain, hemoptysis and mucus plugging to stent obstruction, migration and pneumothorax.  This systematic review suggests that endobronchial stent placement is an effective and safe intervention for managing malignant airway obstruction. It offers significant improvements in post-procedure stenosis, pulmonary function testing, blood gas parameters, and clinical outcomes. However, further studies with larger sample sizes and standardized reporting are warranted to better evaluate the long-term efficacy and safety of endobronchial stent placement for malignant airway obstruction.

Leiomyosarcoma: Lung Metastasis.

Uterine leiomyosarcoma distant metastasis is common, and lung metastasis has been reported. However, unique cases have been identified either with late onset of metastatic disease or with large size of lung metastasis. A typical approach to avoid metastasis would be a hysterectomy. Nonetheless, metastatic recurrence is common. We encountered a case at our hospital with leiomyosarcoma metastatic to the lungs. Lung metastasis was noted to be 17 cm in diameter. This size has not yet been reported in the literature to the best of our knowledge.

Malignant Airway Obstruction and the Use of Nd:YAG Laser: A Systematic Review on Its Efficacy and Safety.

Endobronchial malignancies with significant airway obstruction can lead to multiple complications including pneumonia, and atelectasis over a period of time. Various intraluminal treatments have proven their value in palliative treatment for advanced malignancies. Nd:YAG (neodymium-doped yttrium aluminum garnet; Nd:Y3Al5O12) laser has established its role as a major palliative intervention due to its minimal side effects and improvement in quality of life by relieving local symptoms. The systematic review was conducted with the goal of elucidating the patient characteristics, pre-treatment parameters, clinical outcomes, and possible complications resulting from the use of the Nd:YAG laser. A thorough literature search for relevant studies was conducted on PubMed, Embase, and Cochrane Library from the inception of the idea to November 24, 2022. Our study included all original studies including retrospective studies and prospective trials, but excluded case reports, case series with less than 10 patients, and studies with incomplete or irrelevant data. A total of 11 studies were included in the analysis. The primary outcomes focused on the evaluation of pulmonary functional tests, postprocedural stenosis, blood gas parameters after the procedure, and survival outcomes. Improvement in clinical status, improvement in objective scale for dyspnea, and complications were the secondary outcomes. Our study shows that Nd:YAG laser treatment is an effective form of palliative treatment to provide subjective and objective improvement in patients with advanced and inoperable endobronchial malignancies. Due to the heterogeneous study populations in the studies reviewed and the presence of many limitations, more studies are still warranted to reach a definitive conclusion.

Phenobarbital and Alcohol Withdrawal Syndrome: A Systematic Review and Meta-Analysis.

Alcohol withdrawal syndrome (AWS) is a complication frequently encountered among patients who are chronic alcohol abusers. It is considered to have a significant impact on the United States healthcare system. It not only has a toll on the healthcare spending but also contributes to significant morbidity and mortality. Benzodiazepines are considered first line in the treatment of AWS. Since patients with alcohol use disorder have downregulated gamma aminobutyric acid (GABA) receptors, this often leads to benzodiazepine resistance. Phenobarbital is also used in the management of alcohol withdrawal syndrome. Here we present a systematic review and meta-analysis of the efficacy and safety of the drug. We conducted an electronic database search for relevant studies published between the inception of the project and November 20, 2022, in three databases, including Medline/PubMed, Embase, and Cochrane Library. Our study included all original studies with prime focus on the baseline characteristics of patients admitted to the intensive care unit (ICU) for alcohol withdrawal syndrome and management/monitoring protocol implemented for its treatment. The primary outcomes that were the focus of our study consisted of changes in the length of hospital stay, length of ICU stay, and changes in scoring systems (for alcohol withdrawal assessment and monitoring) following the implementation of phenobarbital. The secondary outcomes included complications such as intubation and mortality. Based on our analysis, the mean difference in hospital stay was statistically significant at -2.6 (95% CI, -4.48, -0.72, P=0.007) for phenobarbital compared to the benzodiazepine group. We were unable to comment on the heterogeneity in our meta-analysis due to the standard deviation not being reported in one study. There was no statistically significant difference regarding the length of stay in the intensive care unit compared to the control/comparative arm, with a mean difference of -1.17 (95% CI, -1.17, 0.09, P=0.07), with considerable heterogeneity (I2=77%, P=0.002). Our meta-analysis also investigated the risk of intubation between the phenobarbital and the control/comparative group. There was statistically significant difference in the incidence of intubation, relative risk (RR) 0.52 (95% CI, 0.25, 1.08, P=0.08), with considerable heterogeneity (I2=80%, P=0.0001). Our study concludes that phenobarbital is an effective tool in the management of AWS in an ICU setting. However, various studies have reported contradictory results, and vital information appears to be lacking. Moreover, there is a lack of uniformity in terms of phenobarbital dosing. Drug administration should be adapted according to the severity of the symptoms. Further studies need to be conducted discussing the safety profile and adverse effects of the drug when it comes to the management of alcohol withdrawal syndrome.

Gastrointestinal Stromal Tumor With a Rare Associated Meningioma: A Case Report.

Gastrointestinal stromal tumors (GISTs) tend to be associated with other tumors. In certain familial cancer syndromes, GIST has been associated with breast cancer or other endocrine tumors. Multiple endocrine neoplasia syndrome along with certain other genomic mutations such as succinate dehydrogenase complex mutations described GIST as one of the potential tumors of the syndrome. There has not yet been a definite association between GIST and meningioma. We present a case of a patient with a GIST who was later found to have a meningioma on incidental brain imaging. Despite being a benign tumor not requiring additional intervention, it is quite apparent that providers need to have a low threshold to scan for other tumors if suspicious symptoms arise.

Neuroendocrine Tumor Causing Carcinoid Syndrome in the Elderly.

Neuroendocrine tumors (NETs) causing carcinoid syndrome are very rare. Patients can have very general symptoms and tumors can be missed especially in the elderly where many symptoms may be attributed to the aging process. It is of the utmost importance to do a full workup on elderly patients even if the symptoms can be explained by aging alone.

Hypertension in the Setting of Hypertrophic Obstructive Cardiomyopathy and Cocaine Use.

Hypertrophic obstructive cardiomyopathy (HOCM) is most commonly an inherited genetic condition where hypertension can be challenging to treat as many antihypertensive medications cannot be used in this patient population. Any agent that decreases preload or afterload should be avoided in this condition, leaving beta-adrenergic receptor antagonists as the preferred agent of choice in these patients. However, a patient with HOCM and cocaine use can pose a significant challenge due to the risks associated with initiating beta-adrenergic receptor antagonists in cocaine users because of the unopposed alpha receptor effect of the treatment, which would in turn cause worsening hypertension. The fact that cocaine itself causes hypertension further complicates the issue. The only remaining class of medications that can be used are non-dihydropyridine calcium channel blockers, which may not be effective on their own against the vasoconstrictive properties of cocaine. Hence, it is paramount to educate all patients with HOCM to avoid cocaine use even more so than other patients.

A Case of Bronchopleural Fistula and Hydropneumothorax in a Patient With Necrotizing Pneumonia Complicated by Mycobacterium avium Complex.

A bronchopulmonary fistula is a pathological connection that develops between the bronchi and the pleural cavity as a result of etiologies including surgery, infection, blunt or penetrating trauma, radiation, chemotherapy, and chronic obstructive pulmonary disease sequela. Diagnosis and treatment are challenging for intensivists. We present a case report of bronchopulmonary fistula resulting in hydropneumothorax caused by necrotizing pneumonia and complicated by mycobacterium avium complex that resolved spontaneously. The aim of this case report is to discuss the presentation and treatment of bronchopleural fistulas.

Nephrotic Syndrome in Adult Patients With COVID-19 Infection or Post COVID-19 Vaccine: A Systematic Review.

Nephrotic syndrome is a condition characterized by damage to podocytes that results in significant proteinuria, edema, hyperlipidemia, and hypercoagulability. Infections and malignancies are frequently associated with nephrotic syndrome. The COVID-19 virus has been associated with several atypical presentations of upper respiratory infections and acute kidney injury. Considering that COVID-19 causes systemic inflammatory changes, it seems plausible that it may also lead to nephrotic syndrome. This study aimed to investigate if an association between COVID-19 and the different types of nephrotic syndromes exists. Data were extracted into a spreadsheet. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS, IBM Corp., Armonk, NY, USA). We performed a systematic search of PubMed/Medline and Embase databases using both medical subject headings (MeSH) and regular keywords associated with COVID-19 and nephrotic syndrome, including different types of nephrotic syndromes. The search was performed on 17th December 2021. We included case reports and case series about adult patients who developed findings suggestive of nephrotic syndrome shortly after infection or vaccination. We excluded cases involving children, pregnant women, articles written in languages other than English, and those that were not retrievable. The relevance and quality of identified articles were assessed. We included 32 articles in the study, primarily case reports and case series. In our study, COVID-19 and the COVID-19 vaccine have been associated with the development of nephrotic syndrome, primarily a collapsing form of focal segmental glomerulosclerosis, although other forms have been observed as well. There was little consistency in patient histories, clinical presentations, clinical courses, or treatment regimens, although it appeared that most cases eventually resolved. More cases need to be reported and analyzed before more definitive conclusions can be reached. In conclusion, nephrotic syndrome is a possible complication of both COVID-19 infection and the COVD-19 vaccine and should be considered in patients exhibiting sudden onset edemas or deterioration in kidney function. While the majority of cases respond to standard treatment, clearer guidelines will need to be developed once more data is available.

Mortality rate of COVID-19 infection in end stage kidney disease patients on maintenance hemodialysis: A systematic review and meta-analysis.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has been the most talked-about disease of the past few years. Patients with significant comorbidities have been at particular risk of adverse outcomes. This study looked at the outcomes and risk factors for adverse outcomes among patients on chronic hemodialysis for end-stage renal disease, a group of patients known to be particularly susceptible to infectious complications. AIM: To assess outcomes and risk factors for adverse outcomes of COVID-19 infection among patients on chronic hemodialysis. METHODS: We searched PubMed/MEDLINE, EMBASE, Reference Citation Analysis (https://www.referencecitationanalysis.com/) and Web of Science databases for relevant terms and imported the results into the Covidence platform. From there, studies were assessed in two stages for relevance and quality, and data from studies that satisfied all the requirements were extracted into a spreadsheet. The data was then analyzed descriptively and statistically. RESULTS: Of the 920 studies identified through the initial database search, only 17 were included in the final analysis. The studies included in the analysis were mostly carried out during the first wave. We found that COVID-19 incidence among patients on hemodialysis was significant, over 10% in some studies. Those who developed COVID-19 infection were most likely going to be hospitalized, and over 1 in 5 died from the infection. Intensive care unit admission rate was lower than the infection lethality rate. Biochemical abnormalities and dyspnea were generally reported to be associated with adverse outcomes. CONCLUSION: This systematic review confirms that patients on chronic hemodialysis are very high-risk individuals for COVID-19 infections, and a significant proportion was infected during the first wave. Their prognosis is overall much worse than in the general population, and every effort needs to be made to decrease their exposure.

A Case of Chronic Pulmonary Embolism Resulting in Pulmonary Hypertension and Decompensated Right Heart Failure.

Chronic thromboembolic pulmonary hypertension is a deadly condition that results from thrombus organization and formation of fibrous tissue in the large and/or middle-sized pulmonary artery; as a result, pulmonary vascular resistance increases resulting in pulmonary hypertension and right heart failure. Untreated chronic pulmonary embolism causes decompensated right heart failure. Early diagnosis and appropriate treatment are crucial for improving survival. Pulmonary endarterectomy (PEA) is the treatment of choice as it reduces pulmonary vascular resistance. For patients who are not a candidate for PEA, alternative treatment options improve quality of life.