Infliximab-Induced Non-specific Interstitial Pneumonitis in a Patient With Ulcerative Colitis (UC).

Infliximab belongs to the family of tumor necrosis factor (TNF) alpha inhibitors and since its development, it has revolutionized treatment for both rheumatological diseases and inflammatory bowel disease (IBD). In IBD specifically, it has shown to result in symptomatic, endoscopic, and histological remission which is why it is one of the most widely used treatments for moderate to severe IBD. While common side effects include infections due to immunosuppression, cytopenias and hepatotoxicity, interstitial lung disease (ILD) has been infrequently reported to result from inflixiamb use. We present the case of a patient with ulcerative colitis (UC) who achieved remission with infliximab, however, after about two years of infusions, developed evidence of non-specific interstitial pneumonitis (NSIP). Extensive work up was done to rule out infections, mixed connective tissue disorders, and hypersensitivity pneumonitis. Although lung biopsy remains the gold standard for diagnosing NSIP; clinical, laboratory, and radiographic findings were sufficient in establishing this diagnosis. Initiation of empiric high dose steroids, and cessation of infliximab infusions showed improvement in respiratory status and resolution of lung findings. This case highlights the importance of recognizing adverse effects of infliximab on the pulmonary status of an IBD patient given that infliximab mediated ILD does not adhere to a specific timeline. Considering that respiratory function may be compromised post any number of infusions, it is imperative to acknowledge patients' respiratory complaints and initiate prompt investigation and evaluation for this rare complication.

Incidence of Secondary Bacterial Infections Following Utilization of Tocilizumab for the Treatment of COVID-19 - A Matched Retrospective Cohort Study.

INTRODUCTION: Immunosuppressive agents are theorized to target the cytokine storm syndrome in COVID-19. However, the downstream effects regarding susceptibilities to secondary infection risk remains unknown. This study seeks to determine risk differences for secondary infections among COVID-19 patients who did and did not receive tocilizumab. METHODS: We conducted a matched retrospective cohort study from two large, acute care hospitals in Western Connecticut from March 1, to May 31, 2020. We collected variables using manual medical record abstraction. The primary exposure variable was any dose of tocilizumab. The primary outcome was any healthcare-associated bacterial or fungal infection as defined by the National Healthcare Safety Network. We performed a Kaplan-Meier analysis to assess the crude difference in cumulative probability of healthcare-associated infection (HAI) across exposure groups. We also performed a multivariable Cox regression analysis to determine the hazard ratio for HAI by exposure group while controlling for potential confounders. RESULTS: The Kaplan-Meier analysis demonstrated no difference in the cumulative probability of HAI across groups. The adjusted hazard of HAI for patients given tocilizumab was 0.85 times that of patients not given tocilizumab (95% confidence interval = 0.29, 2.52, P = 0.780) after controlling for relevant confounders. CONCLUSIONS: Tocilizumab did not increase the incidence of secondary infection among COVID-19 patients. Larger, randomized trials should evaluate infection as a secondary outcome to validate this finding.

Medication Use Among Patients With COVID-19 in a Large, National Dataset: Cerner Real-World Data™.

PURPOSE: The outbreak of coronavirus disease 2019 (COVID-19) required clinicians to use knowledge of therapeutic mechanisms of established drugs to piece together treatment regimens. The purpose of this study is to examine the trends in medication use among patients with COVID-19 across the United States using a national dataset. METHODS: We conducted a cross-sectional study of the COVID-19 cohort in the Cerner Real-World Data warehouse, which includes deidentified patient information for encounters associated with COVID-19 from December 1, 2019, through June 30, 2020. The primary variables of interest were medications given to patients during their inpatient COVID-19 treatment. We also identified demographic characteristics, calculated the proportion of patients with each medication, and stratified data by demographic variables. FINDINGS: Our sample included 51,169 inpatients from every region of the United States. Males and females were equally represented, and most patients were white and non-Hispanic. The largest proportion of patients were older than 45 years. Corticosteroids were used the most among all patients (56.5%), followed by hydroxychloroquine (17.4%), tocilizumab (3.1%), and lopinavir/ritonavir (1.1%). We found substantial variation in medication use by region, race, ethnicity, sex, age, and insurance status. IMPLICATIONS: Variations in medication use are likely attributable to multiple factors, including the timing of the pandemic by region in the United States and processes by which medications are introduced and disseminated. This study is the first of its kind to assess trends in medication use in a national dataset and is the first large, descriptive study of pharmacotherapy in hospitalized patients with COVID-19. It provides an important glimpse into prescribing patterns during a pandemic.

Continuous Intravenous Flumazenil Infusion Used in Iatrogenic Chlordiazepoxide Overdose in the Setting of Alcoholic Withdrawal Syndrome Management.

Chlordiazepoxide is a benzodiazepine that is widely used in the treatment of alcohol withdrawal syndrome (AWS). Flumazenil is a competitive antagonist at the benzodiazepine receptor site and is the drug of choice for the treatment of benzodiazepine overdose. Reversal of benzodiazepine overdose is usually achieved by the use of a flumazenil bolus; however, the continuous infusion has been used when concomitant medical conditions may lead to delayed metabolism of the benzodiazepine involved. We present a patient with AWS, with inadvertent chlordiazepoxide overdose treated effectively with a prolonged flumazenil infusion.

Patient experiences during awake mechanical ventilation.

BACKGROUND: Sedation practices in an ICU have shifted significantly in the past 20 years toward the use of minimizing sedation in mechanically ventilated patients. While minimizing sedation is clearly in the best interest of patients, data are lacking about how this approach affects patients' experiences. METHODS: We interviewed mechanically ventilated patients receiving minimal sedation, over a 6-month period in an ICU, in order to explore their emotional, comfort, and communication experiences. Their responses were compared with the responses of their available family members regarding their attitudes and perceptions of the patients' experiences. RESULTS: Seventy-five percent of the patients agreed or strongly agreed that they experienced pain, and 50% agreed or strongly agreed that they were comfortable. Half of the patients agreed or strongly agreed that they preferred to be kept awake. Five patients (31%) indicated that they were frustrated while 17 relatives (89%) agreed or strongly agreed that the patients were frustrated. When controlling for age and gender of respondents, family members perceived higher levels of patient pain (least square [LS] mean [95% CI]: 4.2 [3.7, 4.7] vs. 3.1 [2.5, 3.8]; p=0.022), frustration (LS mean [95% CI]: 4.2 [3.7, 4.6] vs. 3.2 [2.6, 3.9]; p=0.031), and adequate communication with nurses and doctors (LS mean [95% CI]: 3.9 [3.5, 4.4] vs. 3.1 [2.4, 3.7]; p=0.046) than the patients themselves. CONCLUSION: Patients tolerated minimal sedation without significant frustration while mechanically ventilated despite experiencing discomfort. Patient and family member perceptions of the patient experience may differ, especially in regards to pain and frustration. The use of a communication tool can facilitate understanding of patient experiences and preferences.