Prehospital Extended FAST Exams Improve Clinical Decision Making by Helicopter EMS Crews: A Retrospective Case Series.

Point of Care Ultrasound (POCUS) has seen increasing use in the prehospital environment over the last decade, primarily with the extended focused assessment with sonography in trauma (eFAST) exam. Previous studies have shown prehospital eFAST exams are feasible in the helicopter transport environment but have yet to demonstrate effects on clinical care. This retrospective case series identified 655 patients with blunt thoraco-abdominal trauma or concern for pneumothorax due to penetrating injury transported by a single helicopter EMS (HEMS) program over a two-year period after introducing POCUS. Of those patients, 258 received prehospital ultrasound which was reported to change clinical care in seven cases (2.7%, 95%-CI [1.1-5.5]). This was primarily through preventing unnecessary needle thoracostomy and initiating blood transfusion for treatment of hemorrhagic shock in cases where the degree of shock was unclear due to inconsistent vital signs. This study highlights the improvements in clinical care that may result from the introduction of eFAST exams in the prehospital environment.

Mechanically ventilated COVID-19 patients admitted to the intensive care unit in the United States with or without respiratory failure secondary to COVID-19 pneumonia: a retrospective comparison of characteristics and outcomes.

BACKGROUND: There is increasing heterogeneity in the clinical phenotype of patients admitted to the intensive care unit (ICU) with coronavirus disease 2019 (COVID-19,) and reasons for mechanical ventilation are not limited to COVID pneumonia. We aimed to compare the characteristics and outcomes of intubated patients admitted to the ICU with the primary diagnosis of acute hypoxemic respiratory failure (AHRF) from COVID-19 pneumonia to those patients admitted for an alternative diagnosis. METHODS: Retrospective cohort study of adults with confirmed SARS-CoV-2 infection admitted to nine ICUs between March 18, 2020, and April 30, 2021, at an urban university institution. We compared characteristics between the two groups using appropriate statistics. We performed logistic regression to identify risk factors for death in the mechanically ventilated COVID-19 population. RESULTS: After exclusions, the final sample consisted of 319 patients with respiratory failure secondary to COVID pneumonia and 150 patients intubated for alternative diagnoses. The former group had higher ICU and hospital mortality rates (57.7% vs. 36.7%, P<0.001 and 58.9% vs. 39.3%, P<0.001, respectively). Patients with AHRF secondary to COVID-19 pneumonia also had longer ICU and hospital lengths-of-stay (12 vs. 6 days, P<0.001 and 20 vs. 13.5 days, P=0.001). After risk-adjustment, these patients had 2.25 times higher odds of death (95% confidence interval, 1.42-3.56; P=0.001). CONCLUSIONS: Mechanically ventilated COVID-19 patients admitted to the ICU with COVID-19-associated respiratory failure are at higher risk of hospital death and have worse ICU utilization outcomes than those whose reason for admission is unrelated to COVID pneumonia.

Malignant Pleural Effusions-A Review of Current Guidelines and Practices.

Malignant pleural effusion (MPE) occurs in 15% of all cancer patients and usually portends poor prognosis while also serving to limit the patient's quality of life. Palliation of symptoms has been the goal for the management of these effusions while keeping the patient's hospital stay to a minimum. Traditionally, this has been achieved by chest tube drainage followed by the instillation of sclerosing agents, such as talc, in the pleural space. A recent increase in evidence for the effectiveness and convenience of indwelling pleural catheters has changed the management of MPE, which is reflected in the guidelines released by the American Thoracic Society as well their European Counterpart (ERS/BTS). In this article, we aim to review the current management practices and guidelines for MPE.

The Use of High-Flow Nasal Oxygen in the ICU as a First-Line Therapy for Acute Hypoxemic Respiratory Failure Secondary to Coronavirus Disease 2019.

OBJECTIVES: Limited evidence is available regarding the role of high-flow nasal oxygen in the management of acute hypoxemic respiratory failure secondary to coronavirus disease 2019. Our objective was to characterize outcomes associated with high-flow nasal oxygen use in critically ill adult patients with coronavirus disease 2019-associated acute hypoxemic respiratory failure. DESIGN: Observational cohort study between March 18, 2020, and June 3, 2020. SETTING: Nine ICUs at three university-affiliated hospitals in Philadelphia, PA. PATIENTS: Adult ICU patients with confirmed coronavirus disease 2019 infection admitted with acute hypoxemic respiratory failure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 266 coronavirus disease 2019 ICU admissions during the study period, 124 (46.6%) received some form of noninvasive respiratory support. After exclusions, we analyzed 83 patients who were treated with high-flow nasal oxygen as a first-line therapy at or near the time of ICU admission. Patients were predominantly male (63.9%). The most common comorbidity was hypertension (60.2%). Progression to invasive mechanical ventilation was common, occurring in 58 patients (69.9%). Of these, 30 (51.7%) were intubated on the same day as ICU admission. As of June 30, 2020, hospital mortality rate was 32.9% and the median hospital length of stay was 15 days. Among survivors, the most frequent discharge disposition was home (51.0%). In comparing patients who received high-flow nasal oxygen alone (n = 54) with those who received high-flow nasal oxygen in conjunction with noninvasive positive-pressure ventilation via face mask (n = 29), there were no differences in the rates of endotracheal intubation or other clinical and utilization outcomes. CONCLUSIONS: We observed an overall high usage of high-flow nasal oxygen in our cohort of critically ill patients with acute hypoxemic respiratory failure secondary to coronavirus disease 2019. Rates of endotracheal intubation and mortality in this cohort were on par with and certainly not higher than other published series. These findings should prompt further considerations regarding the use of high-flow nasal oxygen in the management algorithm for coronavirus disease 2019-associated acute hypoxemic respiratory failure.

Bordetella bronchiseptica pneumonia: beware of the dog!

We report the case of a 35-year-old quadriplegic male with confirmed Bordetella bronchiseptica pneumonia, manifesting with acute hypoxic respiratory failure on a background of chronic hypercarbia requiring mechanical ventilation in intensive care.B. bronchiseptica are known to colonise the upper respiratory tracts of many mammals but are very rarely responsible for acute respiratory tract infections in humans.A review of the literature suggests preponderance for immunocompromised or immunoincompetent patients who have experienced environmental exposure to colonised animals. The disease pattern of B. bronchiseptica infection is non-uniform and while it is rarely described as a commensal or colonising organism, very few case reports describe severe respiratory infections.

Nematic molecular core flexibility and chiral induction.

Electroclinic measurements, in which an applied electric field E induces a rotation Δθ ([proportional]E) of the liquid crystal director about the electric field axis in a chiral environment, were performed on several configurationally achiral liquid crystals in the presence of an imposed helical director profile. This imposed twist establishes a chiral symmetry environment for the liquid crystal. It was observed that a conformationally racemic mesogen possessing a flexible phenyl benzoate core exhibits a measurable electroclinic response in the nematic phase. On the other hand, when the phenyl benzoate mesogen is mixed with a mesogen containing a rigid, conformationally achiral core (fluorenone), or with a racemic dopant with an axially chiral core that mimics a mesogen having rigid right- and left-handed conformations (2,2'-spirobiindan-1,1'-dione), the magnitudes of the electroclinic responses were found to decrease sharply, apparently going to zero when extrapolated to the pure 2,2'-spirobiindan-1,1'-dione or fluorenone limit. (Note that neither of these additives possesses a nematic phase.). The results suggest that the flexibility of the core and its ability to deracemize conformationally in order to compensate the elastic energy cost of the imposed twist is the primary mechanism behind the observed electroclinic response.

Pulmonary sporotrichosis: case series and systematic analysis of literature on clinico-radiological patterns and management outcomes.

Pulmonary infections by Sporothrix spp. manifest radiologically as cavitary or non-cavitary disease depending on whether the infection is primary pulmonary or multifocal sporotrichosis. Despite current guidelines, the optimal management for pulmonary sporotrichosis remains unclear. In order to clarify this, we present two cases of pulmonary sporotrichosis, as well as the results of a comprehensive literature review of treatment outcomes based on clinico-radiological presentation patterns of the disease. A literature search of all case reports in English language over the last 50 years (1960-2010) was conducted. Data on patient characteristics, risk factors, clinico-radiological patterns, treatment modalities and outcomes were collected and analyzed. A total of 86 cases were identified, i.e., 64 (74.4%) primary pulmonary and 22 (25.6%) multifocal sporotrichosis. Radiologically, primary pulmonary disease was commonly characterized by cavity formation which was lacking in multifocal infections (P = 0.0001). Immunosuppressant use was more common in multifocal sporotrichosis (P = 0.0001), while hemoptysis was more common in primary pulmonary form (P = 0.01). No other differences in patient characteristics or risk factors were noted. Extra-pulmonary multifocal sporotrichosis most commonly involved skin (81.8%) and joints (45.4%). For patients with cavitary primary pulmonary sporotrichosis, outcomes from medical therapy alone were inferior to surgical intervention (P = 0.02). However, for both primary pulmonary and multifocal sporotrichosis with non-cavitary disease, medical therapy alone provided good outcomes. Only 12 (16.7%) cases were treated with itraconazole. Treatment of pulmonary sporotrichosis should be guided by the clinico-radiological patterns of presentation. Medical therapy alone is likely sufficient for non-cavitary disease while early surgery should be considered for cavitary primary pulmonary sporotrichosis. The experience in treating cavitary disease with itraconazole alone is limited and further data are required.

Improving bedside to departure care in air transport of ST segment elevation myocardial infarction patients: a 2-year retrospective study of performance.

INTRODUCTION: Rapid treatment after the initial diagnosis of an ST segment elevation myocardial infarction (STEMI) is critical to ensure positive outcomes. The objective of the study was to evaluate time-sensitive indicators adversely affecting performance during helicopter transport of STEMI patients from remote areas to a percutaenous coronary intervention (PCI) facility. A particular focus was to examine confounding factors that affected the time from arrival at bedside/event to the time of departure to a PCI facility. METHODS: A 24-month retrospective chart audit of STEMI cases was undertaken. Data from initial liftoff to return of the patient from a referring facility were tracked for time-sequencing and patterns of events that lead to delayed transport. The standard deviation was used to assess abnormal variances. RESULTS: No deaths were recorded from any of the 32 cases identified for inclusion in the study, and survival analysis was unobtainable. There was a significant correlation (r = 0.613, P = .0001) between time spent on the ground stabilizing the patient and total mission time. The need for the transport team to initiate vasopressor therapy was the most cited reason for delay in liftoff to the receiving facility. CONCLUSION: Time from arrival at remote bedside and subsequent transfer to a PCI facility had the most variability. Enhancing communication times between referring agency and air medical personnel and stabilizing the patient before transport may be the most significant components in reducing transfer times and ensuring optimal outcomes.

The long posterior sacroiliac ligament: a histological study of morphological relations in the posterior sacroiliac region.

OBJECTIVES: To investigate the morphology of the long posterior sacroiliac ligament (LPSL) and its potential relationship to adjacent structures in the posterior sacroiliac region, and to consider any possible functional anatomical implications that may arise. METHODS: Four large cadaveric tissue blocks of the posterior sacroiliac region were utilised in this qualitative histological study. The blocks underwent demineralisation in ethyl-diamine-tetra-acetic acid (EDTA). The end-point was determined radiographically. The demineralised tissue blocks were subsequently processed and a base sledge microtome used to section the blocks. Sequential sections were stained with Harris haematoxylin and alcoholic eosin (H&E) and mounted on glass slides prior to viewing under a light microscope. RESULTS: The LPSL was observed to have proximal and distal regions of osseous attachment. Between these regions of attachment the middle LPSL was observed as a confluence of three layers: the erectores spinae aponeurosis, the 'deep fascial layer' and the gluteal aponeurosis. Deep to the 'deep fascial layer' a layer of adipose and loose connective tissue was observed. Lateral branches of the dorsal sacral rami were identified within this layer. CONCLUSIONS: The middle long posterior ligament appears to provide a pathway for the lateral branches of the dorsal sacral rami between the posterior sacral region and the gluteal region. This histological study provides a morphological basis for the proposal that putative sacroiliac joint pain may be due to an entrapment neuropathy of the lateral branches of the dorsal sacral rami at the long posterior sacroiliac ligament.