Hemodynamic Effects of Ketamine Infusion in the Intensive Care Unit for Maintenance Sedation Compared With Propofol and Midazolam: A Retrospective Cohort Study.

Background: Sedation and analgesia in the intensive care unit (ICU) are major clinical challenges, and several continuous infusion medications have been used for these purposes. The use of these sedative medications has been associated with hemodynamic effects that complicate the patient's critical illness. Continuous ketamine infusion is an emerging sedative option that has been used more frequently in the ICU since 2017. The purpose of this study was to characterize the hemodynamic differences between 3 continuous sedative infusions: ketamine, propofol, and midazolam. Methods: For this single-center retrospective cohort study, we collected data for patients hospitalized between January 2015 and April 2020 at Saint Luke's Health System in Kansas City, Missouri. Adult patients in the ICU requiring a norepinephrine infusion and sedation were included. The change in norepinephrine requirement from baseline at 1 hour was the primary outcome. The change in vasopressor requirement at 3 and 30 hours after initiation of the infusion was also tabulated. Results: Sixty-eight critically ill patients with several types of shock requiring vasopressor support with norepinephrine were enrolled in our study. Patients who received ketamine had an increase in norepinephrine requirement compared to midazolam and propofol, although this difference was not statistically significant. Conclusion: In our study, continuous ketamine infusion did not reveal a statistically significant favorable hemodynamic effect compared with propofol and midazolam because of the small sample size. A trend toward an unfavorable hemodynamic effect is not expected, but large randomized trials are needed to further evaluate the hemodynamic effects of continuous ketamine infusion in the ICU.

Retracted: Allogeneic Natural Killer and Cytomegalovirus (CMV)-pp65 Pulsed Dendritic Cells Induced Complete Response Through 15 Months in a Patient with Recurrent Glioblastoma: A Case Study.

Retraction Notice: The manuscript contains inaccurate regulatory details about the treatment used in this case. Reference: Serhat Gumrukcu, Tung X. Nguyen, Rachel L. White, Gregory T. Howell, Phillip Musikanth. Allogeneic Natural Killer and Cytomegalovirus (CMV)-pp65 Pulsed Dendritic Cells Induced Complete Response Through 15 Months in a Patient with Recurrent Glioblastoma: A Case Study. Am J Case Rep. 2021; 22: e931030. DOI: 10.12659/AJCR.931030.

Allogeneic Natural Killer and Cytomegalovirus (CMV)-pp65 Pulsed Dendritic Cells Induced Complete Response Through 15 Months in a Patient with Recurrent Glioblastoma: A Case Study.

BACKGROUND Glioblastoma (GBM) is a highly aggressive brain tumor with poor survival outcomes. While conventional treatment strategies such as surgery, radiation, and chemotherapy can extend survival, the prognosis for GBM patients after 2 years remains low. One-year progression-free survival (PFS) and complete response (CR) with recurrent GBM is extremely low. Recent clinical trials using either engineered chimeric antigen receptor (CAR) T cells, autologous dendritic cell (DC) vaccination, or natural killer (NK) cells have shown promise for patients with GBM following initial diagnosis. Despite these significant immunotherapeutic advancements, new strategies need to be developed to address the poor survival outcomes for GBM. CASE REPORT A 36-year-old male patient with recurrent bilateral parietal GBM, following subtotal resection, was treated using an immunotherapeutic strategy combining lymphosuppressive conditioning with intravenous administration of highly purified allogeneic NK cells (mismatched for inhibitory killer Ig-like receptor [KIR]-human leukocyte antigen [HLA] ligand interactions), celecoxib, temozolomide (TMZ), tetanus-diphtheria vaccination, and multiple intradermal injections of human cytomegalovirus (CMV)-pp65 pulsed dendritic cells. This treatment did not exhibit any toxic effects and resulted in regression of intracranial residual disease on both hemispheres. Additionally, the clinical response was durable, persisting for more than 15 months after the first infusion of KIR-HLA-mismatched purified allogenic NK cells. CONCLUSIONS A patient with recurrent GBM achieved durable CR with a novel treatment strategy with allogeneic NK cells and DC pulsed with CMV-pp65 following subtotal surgical resection. If confirmed in additional patients, this combination approach could offer an effective therapeutic option for people with an otherwise dismal prognosis.

Evolution of Diagnostic and Treatment Patterns of Cardiac Sarcoidosis.

Cardiac sarcoidosis (CS) may impart substantial morbidity and mortality, and novel imaging modalities are now available to aid in early diagnosis of this clinically silent disease. A better understanding of the clinical experience with CS is important. Twenty-eight patients were diagnosed with the aid of multimodality imaging techniques and were treated by a multidisciplinary team. Demographics, symptomatology, imaging, and therapeutic interventions were compiled from our referral center. In patients with CS, nuclear and MR techniques were often the first studies performed. Echocardiographic findings differed widely. Immunosuppressive therapy and cardiac devices were frequently used. Importantly, isolated CS was not an infrequent finding.

Differences in Characteristics and Downstream Drug Use Among Opioid-Naïve and Prior Opioid Users with Low Back Pain.

BACKGROUND: Recent clinical practice guidelines have suggested conservative treatment approaches, including physical therapy, are indicated as first-line treatment for patients with low back pain (LBP); however, LBP continues to be managed with opioids, despite decreases in function, morbidity, and insignificant improvements in pain. OBJECTIVE: The primary purpose was to compare characteristics and downstream medication use between patients with LBP with prior opioid exposure vs. those who were opioid-naïve. The secondary purpose was to explore the role of prior opioid use by LBP disability. METHODS: Seven hundred and nine participants in a LBP self-management class were evaluated utilizing self-report data at baseline and longitudinal claims data from the Military Health System Data Repository. Participants were dichotomized into opioid-naïve and prior opioid use groups and then further divided into low and high disability groups based on Oswestry Disability Index (ODI) scores. Patient characteristics, comorbidities, and medication use were compared between groups. RESULTS: Prior opioid users had significantly higher baseline ODI and Fear Avoidance Beliefs Questionnaire physical activity subscale and work subscale scores as well as pre-index instances of mental health disorders, chronic pain, and insomnia than opioid-naïve individuals. Prior opioid users filled significantly more pain medication prescriptions in the year after the index date than did opioid-naïve individuals. Prior opioid users were significantly more likely to be taking opioids at 1 year after the index date, regardless of disability level. CONCLUSION: In patients presenting with LBP, prior opioid exposure appears to be related to increased analgesic use (opioid and non-opioid) and longitudinal analgesic utilization at 1 year after the index date.

Sulfhaemoglobinaemia caused by ferrous sulfate.

A 78-year-old man was referred from his primary care clinic to the emergency department due to bluish discolouration of his lips and decreased oxygen saturation on pulse oximetry. The patient was asymptomatic. Physical exam was normal except for lip cyanosis. A CT pulmonary angiogram was negative for pulmonary embolism. Arterial blood gas (ABG) analysis with co-oximetry showed low oxyhaemoglobin, normal partial pressure of oxygen and methaemoglobinaemia, but an unexplained 'gap' in total haemoglobin saturation. This gap was felt to be due to sulfhaemoglobinaemia. After a thorough review of his medications, ferrous sulfate was stopped which resulted in resolution in patient's cyanosis and normalisation of his ABG after 7 weeks.

Strongyloides hyperinfection syndrome and VRE pneumonia.

Immunocompromised patients have high risk of infections from bacteria, viruses, fungi and parasites. One of these infections is those caused by Strongyloides stercoralis Immunocompromised patients are at risk of hyperinfection syndrome which is characterised with more systemic manifestation and a higher risk of morbidity and mortality. This can be complicated by coinfection with enteric organisms, specifically Gram-negative. Enterococci are Gram-positive cocci which are inhabitants of the human gastrointestinal tract. Even though enterococci can cause serious infections in multiple sites, they are a rare cause of pneumonia. We present a case of disseminated strongyloides with vancomycin-resistant enterococcus causing pneumonia. The patient had a complicated course with respiratory failure and septic shock. He died eventually due to his severe infections. After a literature review, we could not find a similar case of coinfection of disseminated strongyloides with vancomycin-resistant enterococcus pneumonia in immune-compromised patients.

Intensive care units with low versus high volume of myocardial infarction: clinical outcomes, resource utilization, and quality metrics.

BACKGROUND: The volume-outcome relationship associated with intensive care unit (ICU) experience with managing acute myocardial infarction (AMI) remains inadequately understood. METHODS AND RESULTS: Within a multicenter clinical ICU database, we identified patients with a primary ICU admission diagnosis of AMI between 2008 and 2010 to evaluate whether annual AMI volume of an individual ICU is associated with mortality, length-of-stay, or quality indicators. Patients were categorized into those treated in ICUs with low-annual-AMI volume (≤50th percentile, <2 AMI patients/month, n=569 patients) versus high-annual-AMI volume (≥90th percentile, ≥8 AMI patients/month, n=17 553 patients). Poisson regression and generalized estimating equation with negative binomial regression were used to calculate the relative risk (95% CI) for mortality and length-of-stay, respectively, associated with admission to a low-AMI-volume ICU. When compared with high-AMI-volume, patients admitted to low-AMI-volume ICUs had substantially more medical comorbidities, higher in-hospital mortality (11% versus 4%, P<0.001), longer hospitalizations (6.9±7.0 versus 5.0±5.0 days, P<0.001), and fewer evidence-based therapies for AMI (reperfusion therapy, antiplatelets, ß-blockers, and statins). However, after adjustment for baseline patient characteristics, low-AMI-volume ICU was no longer an independent predictor of in-hospital mortality (relative risk 1.17 [0.87 to 1.56]) or hospital length-of-stay (relative risk 1.01 [0.94 to 1.08]). Similar findings were noted in secondary analyses of ICU mortality and ICU length-of-stay. CONCLUSIONS: Admission to an ICU with lower annual AMI volume is associated with higher in-hospital mortality, longer hospitalization, and lower use of evidence-based therapies for AMI. However, the relationship between low-AMI-volume and outcomes is no longer present after accounting for the higher-risk medical comorbidities and clinical characteristics of patients admitted to these ICUs.

Management of hemorrhage with the target-specific oral anticoagulants.

The target-specific oral anticoagulants have recently been introduced as alternatives to warfarin for both prophylactic and therapeutic indications. Although their efficacy and side-effect profiles have been favorable, there is significant concern about management of hemorrhage with these agents as there is no direct reversal agent available. It is important for clinicians to be aware of these agents and the issues that surround them. Most of the management of hemorrhage is based on expert opinion and case reviews. Given the potentially catastrophic consequences of acute hemorrhage while patients are on anticoagulation, specific treatments are needed. Some methods that have been described include activated charcoal, hemodialysis, prohemostatic agents, and transfusions. Target-specific therapies have been shown to be effective in early studies in animal models; however, the effects in humans are still under investigation. More investigation is needed on the management of bleeding complications from target-specific oral anticoagulants.

Spontaneous middle-lobe torsion.

Middle-lobe torsion is a well documented but rare entity that typically occurs following surgery, characteristically after right-upper lobectomy. It has also been described in the setting of pleural effusion, trauma, and neoplasm. We present a case of spontaneous middle-lobe torsion, occurring in the absence of the above risk factors, with emphasis on radiographic and CT findings.

Nonadherence to medical therapy in asthma: risk factors, barriers, and strategies for improving.

Asthma is a very prevalent disease in the United States, and the incidence is rising for a variety of reasons. Although progress has been made on several therapeutic fronts, adherence to asthma therapy, particularly controller medications, remains poor. This review of data from the past five years will focus on factors associated with nonadherence, barriers to adherence, factors associated with adherence, and finally strategies for improving. Communication between the health care provider and patient is paramount in improving adherence to medical therapy for asthma and thereby improving control of the disease.

Diagnosis of acute pulmonary embolism.

Acute pulmonary embolism (PE) is a common, serious and potentially fatal event. Due to the serious nature of this ailment and since therapy is usually with long-term anticoagulation, it is important for the clinician to be able to diagnose or exclude acute PE. Several diagnostic options are available to the clinician, and below is a review of the more common modalities.