Pulmonary Rehabilitation for Post-COVID-19.

PURPOSE: Patients with COVID-19 often report persistent respiratory symptoms. Limited data exist on how to mitigate long-term sequelae of exercise intolerance and dyspnea. We aimed to study the role of pulmonary rehabilitation (PR) in patients with post-COVID-19. METHODS: This was an observational study. Consecutive patients with post-COVID-19, admitted to three separate outpatient PR programs, were enrolled. The program consisted of 8-12 wk of PR sessions (3 times/wk). Data were gathered at the initial visit and discharge. The primary outcome was the change in the 6-min walk test (6MWT) distance. Secondary outcomes included the Shortness of Breath Questionnaire (SOBQ), modified Borg dyspnea scale, Patient Health Questionnaire-9 (PHQ-9), and Lung Information Needs Questionnaire (LINQ). RESULTS: A total of 56 patients completed the PR program (age 62.8 ± 14.7 yr, 57% were men). At baseline, the mean 6MWT was 313.3 ± 193.8 m. On average, the 6MWT improved by 84.3 m after PR ( P < .0001). Apart from the modified Borg dyspnea scale, there was improvement across secondary outcomes: SOBQ (-16.9 points), PHQ-9 (-2.6 points), and LINQ (-4.2 points); all P < .05. CONCLUSION: Pulmonary rehabilitation showed a promising positive effect on patients with with post-COVID-19. It improved exercise capacity, perception of dyspnea, depressive symptoms, and patient knowledge needed to manage their lung disease. Pulmonary rehabilitation should be considered for post-COVID-19 patients.

Identifying at risk populations amongst breast cancer survivors and their common symptoms and concerns.

PURPOSE: The survival rate amongst breast cancer survivors (BCS) have been increasing, with a 5-year survival rate of almost 90%. These women face many quality of life (QOL) issues either due to either cancer itself or the complex treatment regimen. Our retrospective analysis aims to identify at risk populations among the BCS and their most common concerns. METHODS: This is a single-institution, retrospective, descriptive analysis of patients who were seen at our Breast Cancer Survivorship Program from October 2016 to May 2021. Patients completed a comprehensive survey which assessed self-reported symptoms, their concerns and degree of worry and recovery to baseline. The descriptive analysis on the patient characteristics included age, cancer stage and treatment type. The bivariate analysis included the relationship between the patient characteristics and their outcomes. Analysis of group differences was completed with Chi-square test. When the expected frequencies were five or less, Fisher exact test was used. Logistic regression models were developed to identify significant predictors for outcomes. RESULTS: 902 patients (age 26-94; median 64) were evaluated. Majority of women had stage 1 breast cancer. The most common self-reported concerns affecting the patients were fatigue (34%), insomnia (33%), hot flashes (26%), night sweats (23%), pain (22%), trouble concentrating (19%), and neuropathy (21%). Though 13% of BCS felt isolated at least 50% of their time, the majority of patients (91%) reported having a positive outlook and felt that they have a sense of purpose (89%). Younger patients were more likely to worry about their cancer more than 50% of the time (p < 0.0001). Patients that were less likely to return back to at least 50% of their pre-treatment baseline were younger (age ≤ 45) (p = 0.0280), had higher stage breast cancer (Stage 2-4) (p = 0.0061), and had chemotherapy either alone or as part of their multi-modality treatment (p < 0.0001). CONCLUSION: According to our study, younger patients, those with higher stage breast cancer and survivors who had chemotherapy may experience significant QOL issues. Fortunately, majority of BCS report a positive and optimistic outlook post treatment. Identifying common concerns after treatments and vulnerable populations are especially important to deliver quality care and to optimize interventions. IMPLICATIONS FOR CANCER SURVIVORS: Our study identified the most common self-reported concerns affecting BCS. In addition, our results suggest that younger patients, patients with higher stage breast cancer and survivors who had chemotherapy were more likely to have QOL issues. Despite this, our study showed, the majority of BCS reported positive outlooks and emotions.

Effect of Electronic Cigarettes on the Gastrointestinal System.

INTRODUCTION: In the United States, the use of electronic cigarettes (EC) has seen an exponential rise with 12.6% of adults using an EC at least once in their lifetime, with use differing by age, sex, and race. The level of nicotine exposure of EC is highly variable with its liquids containing 14.8-87.2 mg/ml of nicotine. Its use has been documented to be associated with adverse effects on the respiratory, nervous, cardiovascular, and gastrointestinal (GI) systems. Common adverse effects on the GI system include xerostomia, oral mucositis, tongue discoloration, gingivitis, gum bleeding, nausea, vomiting, gastric burning, and altered bowel habits. METHODS: A retrospective review of the National Health and Nutrition Examination Survey (NHANES) data from 2015-16 was conducted. Data regarding the use of EC and a history of vomiting and diarrhea over a period of 30 days was analyzed using SAS 9.4 (2013; SAS Institute Inc., Cary, North Carolin, United States). Additionally, data regarding age, gender, and income were also analyzed. A p-value of <0.05 was considered statistically significant. Continuous variables were analyzed using the two-sample t-test, and categorical variables were analyzed using the Chi-Square test. RESULTS: A total of 944 participants were included in the study. Of these, 261 participants (males 62.84%) used EC at least one day and 683 participants (males 54.76%) never used EC, during the preceding 30 days. Amongst EC users (n=261), 10.73% had a stomach or intestinal illness manifesting as vomiting or diarrhea that started during those 30 days compared to 8.64% who never used EC during the same period (n=683). However, the results did not reach statistical significance (p = 0.3208) Conclusion: Conflicting views exist regarding the effects of EC on the GI tract. Our study demonstrated an association between EC consumption and vomiting and diarrhea. The study results are to be viewed by taking into consideration the limitations of a smaller sample, shorter duration, comorbidities, and undefined nicotine content in the EC. Although recent studies have shown no effect of EC on the oral or gut microbiota, our study findings could be attributed to EC-induced alteration of motility or irritation of the GI tract. However, further studies are required to establish a causal relationship and enunciate the mechanism by which EC components affect the GI tract. Careful consideration and diligence about the health effects of ECs are required before it is assumed to be safe as a cigarette substitute or as a means of smoking cessation.

Perioperative Multimodal Anesthetic Care Incorporating Transversus Abdominis Plane Block Is Associated With Reduced Narcotic Use in Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgery performed in North America. As our knowledge of the importance in limiting narcotic use in postoperative patients increases, we sought to evaluate the effect of transversus abdominis plane (TAP) blocks on inpatient narcotic use in patients undergoing LSG. METHODS: A retrospective review of LSG performed at a single institution by 3 bariatric surgeons was performed. All cases over a 15-month period were included, and anesthesia records were reviewed to stratify patients that received a TAP block and those that did not. Demographic, as well as surgical, outcomes were collected for all patients. Narcotic utilization, as reported in morphine equivalents (ME), was evaluated between the 2 groups. RESULTS: 384 LSG patients were identified, of which 37 (9.6%) received a TAP block. There was no statistically significant difference in postoperative morbidity, length of stay, or readmission between groups. Median narcotic utilization in hospital days 1 and 2 in patients with TAP blocks was 49 ME (Interquartile Range (IQR) 14.5-84.5) to 82.5 ME (IQR 57.4-106) in the no-TAP group (P < .001). After controlling for multiple demographic- and patient-related cofactors, multiple linear regression analysis demonstrated TAP block patients utilized 22.48 ME less than the no-TAP group (P < .001) in the first 2 days of their hospitalization. DISCUSSION: Patients that received a TAP block as a part of their perioperative anesthetic care utilized less in-hospital narcotics than those patients that did not receive a TAP block. TAP blocks should be considered as part of a multimodal pain control strategy for patients undergoing LSG.

COVID-19 pericarditis mimicking an acute myocardial infarction: a case report and review of literature.

The novel coronavirus disease (Covid-19) continues to spread all over the world with acute respiratory distress syndrome and multiorgan failure being a significant cause of morbidity and mortality. The involvement of the cardiovascular system is associated with increased mortality and there have been various manifestations reported in the literature. We present a case of a patient requiring intensive care unit (ICU) admission for acute respiratory distress syndrome from Covid-19 who developed ST elevations in inferior leads in electrocardiogram (ECG) and elevated troponins. The changes resolved in serial ECG accompanied by normalization of blood troponin levels. His subsequent echocardiogram did not reveal any abnormalities in wall motion or heart function leading to a diagnosis of focal pericarditis mimicking an acute myocardial infarction. We also present a review of literature on various cardiac manifestations reported so far in cases of Covid-19.

Effect of BioZorb® surgical marker placement on post-operative radiation boost target volume.

OBJECTIVE: BioZorb® is a tumor bed marker placed during partial mastectomy for targeted post-operative radiation. This study was designed to evaluate BioZorb® effect on radiation boost clinical target volume (CTV), planning target volume (PTV), median dose to ipsilateral lung (Gy), and heart irradiation in left-sided cancers. METHODS: Data was collected via a retrospective cohort study with two study arms: BioZorb® intra-operative placement versus no BioZorb® placement. Patients were stratified by BMI, age, tumor laterality and volume, and cancer stage. Mean, standard deviation, median, range of cubic centimeters of clinical and planning target volume, cardiac dose in left-sided cancers, ipsilateral lung dose, and volume of ipsilateral lung receiving 20 Gy were reported. RESULTS: Of 143 patients, median CTV (cm3) was 8.7 and 14.2 (P = 0.0048), median PTV (cm3) was 53.2 and 79.6 (P = 0.0010), median ipsilateral lung Gy was 7.53 and 6.74 (P = 0.0099) and volume (cc) of ipsilateral radiation lung at 20 Gy was 13.4 and 12 (P = 0.008), and median heart Gy in left-sided cancers was 2.01 and 2.21 (P = 0.9952) in BioZorb® and non-BioZorb® arms, respectively. Patients with BMIs of 25-30 had CTV medians of 7.8 and 11.1 in BioZorb® and non-BioZorb® arms, respectively (P = 0.0293). CONCLUSION: The BioZorb® arm showed statistically significant reductions in CTV and PTV but not ipsilateral lung or heart irradiation.

Effects of Long-Term Combination LT4 and LT3 Therapy for Improving Hypothyroidism and Overall Quality of Life.

OBJECTIVES: Hypothyroidism results in decreased mood and neurocognition, weight gain, fatigue, and many other undesirable symptoms. The American Association of Clinical Endocrinologists, the American Thyroid Association (ATA), and The Endocrine Society recommend levothyroxine (LT4) monotherapy as the treatment for hypothyroidism; however, after years of monotherapy, some patients continue to experience impaired quality of life. Combination LT4 and synthetic liothyronine (LT3) therapy or the use of desiccated thyroid extract (DTE), has not been suggested for this indication based on short-duration studies with no significant benefits. Our first observational study examined the role of combination therapy for 6 years in improving quality of life in a subset of a hypothyroid population without adverse effects and cardiac mortality. METHODS: An observational retrospective study examining patients prescribed thyroid replacements with serum triiodothyronine (FT3), LT4 with LT3 (synthetic therapy) or DTE (natural therapy), compared with LT4 alone in the United States from 2010 to 2016. Thyroid-stimulating hormone (TSH), serum thyroxine (FT4), and FT3 levels were documented for each patient in addition to any admissions of myxedema coma, thyrotoxicosis, or cardiovascular complications, such as arrhythmias, atrial fibrillation, and mortality. At the conclusion of the study, a cross-sectional interview assessed quality of life for each combination therapy through the Medical Outcomes Study Short Form-20 questionnaire. RESULTS: Compared with patients taking only LT4, 89.47% using synthetic therapy had therapeutic TSH (P < 0.05). Similarly, 96.49% using natural therapy had therapeutic TSH (P < 0.05). Less than 5% of patients had supratherapeutic FT3. None of the patients who had abnormally low TSH or elevated FT3 or FT4 levels had hospitalizations for arrhythmias or thyrotoxicosis. On the Medical Outcomes Study Short Form-20 questionnaire, >92% answered feeling "excellent, very good, or good" when questioned about their health while undergoing thyroid replacement compared with levothyroxine alone. CONCLUSIONS: This is the only retrospective study reported to use long-term (mean 27 months) thyroid replacements with combination therapy and to compare between the two forms of therapy: synthetic and natural. For patients undergoing either therapy, we did not identify additional risks of atrial fibrillation, cardiovascular disease, or mortality in patients of all ages with hypothyroidism.

Differences in nicotine dependence, smoke exposure and consumer characteristics between smokers of machine-injected roll-your-own cigarettes and factory-made cigarettes.

BACKGROUND: Consumption of machine-injected roll-your-own (RYO) filtered cigarettes made from pipe tobacco increased almost 7-fold from 2008 to 2011 in the United States. METHODS: We used data from the Pennsylvania Adult Smoking Study to compare the differences in sociodemographic, smoking topography, nicotine dependence, and cotinine levels between 280 smokers using factory made (FM) cigarettes and 68 smokers using RYO cigarettes. RESULTS: RYO smokers were older (41 vs. 37, P = 0.053), had significantly lower levels of income (P < 0.001) and education (P = 0.007), and were less likely to be fully employed (P = 0.009). RYO smokers consumed more cigarettes per day [CPD] (21 vs. 15, P < 0.001), and had a higher mean score on the Fagerström Test for Cigarette/Nicotine Dependence (5.2 vs. 4.1, P < 0.001). The main reasons for choosing RYO cigarettes were the lower cost (68%) and believed they are less harmful (12%). The average cost per pack of FM cigarettes was $5.74 vs. $1.13 for RYO. In multiple regression analyses, RYO smokers had significantly lower cotinine levels across all levels of CPD. Among smokers of king-size cigarettes, mean interpuff interval (P < 0.05) and total smoke duration (P < 0.01) per cigarette was significantly greater in RYO smokers. In laboratory measurements, RYO cigarettes contained more tobacco by weight than FM cigarettes, but weight varied by both tobacco and cigarette tube brands. CONCLUSIONS: Machine-injected RYO cigarettes made from pipe tobacco are cheaper than FM cigarettes but may have higher abuse liability. Smokers who might otherwise reduce their cigarette consumption or quit altogether may continue to smoke RYO cigarettes due to their affordability.

Prevalence and risk factors of heart failure in the USA: NHANES 2013 - 2014 epidemiological follow-up study.

Background: Heart Failure (HF) is a progressive epidemic associated with considerable morbidity and mortality. Self-reported data from the National Health and Nutrition Examination Survey (NHANES) provides a unique representation of individuals suffering from HF. The purpose of this study is to analyze updated NHANES 2013-2014 data to identify any changes in the prevalence and current risk factors of HF, especially given the novel lifestyles and increased medical awareness of current generations. Methods: NHANES uses a multistage probability sampling design under the Centers for Disease Control and Prevention (CDC). The Student's t-test and Chi-square test/ Fisher's exact test was used for analysis of variables. A multiple logistic regression model was used to identify statistically significant risk factors for HF. Analyses were performed with the use of SAS software, version 9.4. Results: Based on our analysis, the primary risk factor was coronary artery disease followed by hypertension, diabetes mellitus, age ≥ 65 years, and obesity. Conclusion: The findings revealed that despite improved population awareness and advancements in diagnostics and therapeutics, the same risk factors continue to persist. This provided an insight into the path towards which our resources need to be directed, so as to effectively tackle the aforementioned risk factors.

The Untapped Potential of Tunneled Pleural Catheters.

BACKGROUND: Tunneled pleural catheters (TPCs) are routinely used for outpatient drainage of malignant pleural effusions, although use in recurrent pleural effusions resulting from nonmalignant conditions requires further evaluation. We hypothesized that TPCs could decrease inpatient admission rates for exacerbations of nonmalignant pleural effusions. METHODS: A retrospective chart review was done of patients with TPCs inserted for recurrent nonmalignant pleural effusions. Patients were set up with home care nursing support and catheter draining two to three times per week and were then followed on an outpatient basis until spontaneous pleurodesis and catheter removal. Data collection included demographics, comorbidities, and hospital admission rates relative to TPC placement as well as removal. RESULTS: Thirty-seven patients with recurrent, nonmalignant pleural effusions were enrolled (17 female and 20 male patients). Patients had comorbid conditions including hypertension (86%), chronic kidney disease (59%), congestive heart failure (67%), liver disease (11%), and malnutrition (22%), and most patients (89%) had multiples of these conditions. Total admissions for pleural effusion exacerbations decreased from 59 to 15 in the 1 year before and after TPC placement and from 42 to 6 in the respective 3-month periods (p < 0.0001). Six of the 37 patients still had TPCs in place; for the remaining 31 patients, admissions decreased from 60 to 9 in the 1-year periods before and after TPC removal and from 33 to 2 in the respective 3-month periods (p < 0.0001); no patients required subsequent pleural interventions. CONCLUSIONS: The study results support TPC placement in recurrent nonmalignant pleural effusions refractory to medical management as an effective and plausible management option.

Decreased mortality with tight glycemic control in critically ill patients: a retrospective analysis in a large community hospital system.

OBJECTIVE: To measure the efficacy and possible adverse consequences of tight blood glucose (BG) control when compared to relaxed control. METHODS: A retrospective, observational study was conducted at a community-based teaching hospital system among adult, nonmaternity hospitalized patients admitted to the intensive care unit (ICU). Tight glycemic control of BG was compared with less strict BG control, and the following outcome measurements were compared: BG, average length of stay (ALOS), severe hypoglycemia, and mortality. RESULTS: Between 2008 and 2012, 18,919 patients were admitted to the ICU. The mortality rate was significantly lower (P = .0001) in patients with an average BG between 80 and 110 mg/dL (8%) and 111 and 140 mg/dL (9.4%) than in patients with average BG between 141 and 180 mg/dL (12.9%). Using tight glycemic control (80 to 110 mg/dL), the ALOS in the ICU decreased from 4 to 2.9 days (P<.0001) among all patients, and from 4.2 to 2.1 days (P<.0001) among patients who had undergone coronary artery bypass graft. Comparatively, the ALOS for the hospital decreased from 9.4 to 8 days. The incidence of severe hypoglycemia (BG <40 mg/dL) was higher (P = .01) in the tight BG control group (4.78%) compared with the relaxed control group (3.5%). This rate was lower than in previously published studies that analyzed the use of tight control. CONCLUSION: Tight glycemic control using protocolbased insulin administration resulted in a decrease in mortality and ALOS among all patients in the ICU. The incidence of severe hypoglycemic episodes was slightly higher in the tightly controlled group but remained lower than in previously published studies.

Safety and efficacy of flumazenil for reversal of iatrogenic benzodiazepine-associated delirium toxicity during treatment of alcohol withdrawal, a retrospective review at one center.

Both alcohol withdrawal syndrome (AWS) and benzodiazepines can cause delirium. Benzodiazepine-associated delirium can complicate AWS and prolong hospitalization. Benzodiazepine delirium can be diagnosed with flumazenil, a GABA-A receptor antagonist. By reversing the effects of benzodiazepines, flumazenil is theorized to exacerbate symptoms of AWS and precludes its use. For patients being treated for alcohol withdrawal, flumazenil can diagnose and treat benzodiazepine delirium without precipitating serious or life-threatening adverse events. Hospital admission records were retrospectively reviewed for patients with the diagnosis of AWS who received both benzodiazepines and flumazenil from December 2006 to June 2012 at a university-affiliated inpatient toxicology center. The day of last alcohol consumption was estimated from available blood alcohol content or subjective history. Corresponding benzodiazepine, flumazenil, and adjunctive sedative pharmacy records were reviewed, as were demographic, clinical course, and outcome data. Eighty-five patients were identified (average age 50.3 years). Alcohol concentrations were detectable for 42 patients with average 261 mg/dL (10-530 mg/dL). Eighty patients were treated with adjunctive agents for alcohol withdrawal including antipsychotics (n = 57), opioids (n = 27), clonidine (n = 35), and phenobarbital (n = 23). Average time of flumazenil administration was 4.7 days (1-11 days) after abstinence, and average dose was 0.5 mg (0.2-1 mg). At the time of flumazenil administration, delirium was described as hypoactive (n = 21), hyperactive (n = 15), mixed (n = 41), or not specified (n = 8). Response was not documented in 11 cases. Sixty-two (72.9 %) patients had significant objective improvement after receiving flumazenil. Fifty-six patients required more than one dose (average 5.6 doses). There were no major adverse events and minor adverse effects included transiently increased anxiety in two patients: 1 patient who received 0.5 mg on abstinence day 2 and another patient who received 0.2 mg flumazenil on abstinence day 11. This is the largest series diagnosing benzodiazepine delirium after AWS in patients receiving flumazenil. During the treatment of AWS, if delirium is present on day 5, a test dose of flumazenil may be considered to establish benzodiazepine delirium. With the limited data set often accompanying patients with AWS, flumazenil diagnosed benzodiazepine delirium during the treatment of AWS and improved impairments in cognition and behavior without serious or life-threatening adverse events in our patients.