Silent hypoxia: A harbinger of clinical deterioration in patients with COVID-19.

Patients infected with the SARS-CoV-2 virus can present with a wide variety of symptoms including being entirely asymptomatic. Despite having no or minimal symptoms, some patients may have markedly reduced pulse oximetry readings. This has been referred to as "silent" or "apathetic" hypoxia (Ottestad et al., 2020 [1]). We present a case of a 72-year-old male with COVID-19 syndrome who presented to the emergency department with minimal symptoms but low peripheral oxygen saturation readings. The patient deteriorated over the following days and eventually died as a result of overwhelming multi-organ system failure. This case highlights the utility of peripheral oxygen measurements in the evaluation of patients with SARS-CoV-2 infection. Self-monitoring of pulse oximetry by patients discharged from the emergency department is a potential way to identify patients needing to return for further evaluation.

Aquapheresis (AQ) in Tandem with Extracorporeal Membrane Oxygenation (ECMO) in Pediatric Patients.

Children with cardiopulmonary failure requiring extracorporeal membrane oxygenation (ECMO) are at risk for fluid overload (FO) despite the normal estimated glomerular filtration rate (eGFR). It has been shown that survival in the intensive care unit (ICU) is inversely proportional to FO. Therefore, fluid removal, or prevention of FO, in these critical cases has the potential to improve survival. Aquapheresis (AQ), a procedure used for fluid removal, with success in patients with heart failure has also been used in children with acute oliguric kidney injury (AKI), to prevent and treat FO. The purpose of this article was to describe the use of Aquadex FlexFlow® for AQ in pediatric patients on ECMO, as a means to provide a simplified and safe form of fluid removal with minimal impact on ECMO therapy. The principal variables collected include patients' demographics, urine output, serum creatinine, withdrawal and infusion pressures, ultrafiltration (UF) rates, and ECMO flow ranges, along with length of stay in pediatric ICU and survival. Patient survival was 100% with preserved eGFR. The ECMO flows were not affected by AQ. Urine output decreased somewhat during therapy, with little AQ machine pressure variations. Range of UF tolerated without hemodynamic abnormalities was 1.24-6.2 mL/kg/h, allowing the patients to maintain their pre-AQ body weight, while receiving intravenous (IV) nutrition and medications. This article describes the use of AQ in tandem with ECMO in a user-friendly and safe way to provide UF in children requiring cardiopulmonary support, with minimal flow and hemodynamic disturbance.

Pancrelipase-Induced Hypersensitivity Reaction: Case Report and Review of Literature.

INTRODUCTION: Drug-induced exanthems are commonly associated with NSAIDs, antibiotics, and anti-epileptics. Pancrelipase is frequently used for conditions resulting in pancreatic exocrine insufficiency. Published case reports of pancrelipase hypersensitivity focus on the respiratory manifestations. CASE REPORT: Here we report a case of skin hypersensitivity resulting from pancrelipase use. To further assess this association, we used a Naranjo nomogram, which determines the likelihood that an adverse drug reaction is the result of the drug itself. Our patient had a score of seven, suggesting our patient had a probably adverse drug reaction. DISCUSSION: As pancrelipase is a commonly prescribed drug, clinicians should be aware of the potential hypersensitivity skin reactions associated with pancrelipase.

Extracellular vesicle-mediated phenotype switching in malignant and non-malignant colon cells.

BACKGROUND: Extracellular vesicles (EVs) are secreted from many cells, carrying cargoes including proteins and nucleic acids. Research has shown that EVs play a role in a variety of biological processes including immunity, bone formation and recently they have been implicated in promotion of a metastatic phenotype. METHODS: EVs were isolated from HCT116 colon cancer cells, 1459 non-malignant colon fibroblast cells, and tumor and normal colon tissue from a patient sample. Co-cultures were performed with 1459 cells and malignant vesicles, as well as HCT116 cells and non-malignant vesicles. Malignant phenotype was measured using soft agar colony formation assay. Co-cultures were also analyzed for protein levels using mass spectrometry. The importance of 14-3-3 zeta/delta in transfer of malignant phenotype was explored using siRNA. Additionally, luciferase reporter assay was used to measure the transcriptional activity of NF-κB. RESULTS: This study demonstrates the ability of EVs derived from malignant colon cancer cell line and malignant patient tissue to induce the malignant phenotype in non-malignant colon cells. Similarly, EVs derived from non-malignant colon cell lines and normal patient tissue reversed the malignant phenotype of HCT116 cells. Cells expressing an EV-induced malignant phenotype showed increased transcriptional activity of NF-κB which was inhibited by the NF--κB inhibitor, BAY117082. We also demonstrate that knock down of 14-3-3 zeta/delta reduced anchorage-independent growth of HCT116 cells and 1459 cells co-cultured with HCT derived EVs. CONCLUSIONS: Evidence of EV-mediated induction of malignant phenotype, and reversal of malignant phenotype, provides rational basis for further study of the role of EVs in tumorigenesis. Identification of 14-3-3 zeta/delta as up-regulated in malignancy suggests its potential as a putative drug target for the treatment of colorectal cancer.

Excited Delirium Syndrome (ExDS): defining based on a review of the literature.

BACKGROUND: Patients present to police, Emergency Medical Services, and the emergency department with aggressive behavior, altered sensorium, and a host of other signs that may include hyperthermia, "superhuman" strength, diaphoresis, and lack of willingness to yield to overwhelming force. A certain percentage of these individuals will go on to expire from a sudden cardiac arrest and death, despite optimal therapy. Traditionally, the forensic community would often classify these as "Excited Delirium" deaths. OBJECTIVES: This article will review selected examples of the literature on this topic to determine if it is definable as a discrete medical entity, has a recognizable history, epidemiology, clinical presentation, pathophysiology, and treatment recommendations. DISCUSSION: Excited delirium syndrome is characterized by delirium, agitation, acidosis, and hyperadrenergic autonomic dysfunction, typically in the setting of acute-on-chronic drug abuse or serious mental illness or a combination of both. CONCLUSIONS: Based upon available evidence, it is the consensus of an American College of Emergency Physicians Task Force that Excited Delirium Syndrome is a real syndrome with uncertain, likely multiple, etiologies.

Diffuse retinal injury from a non-penetrating TASER dart.

To describe a non-penetrating TASER gun injury resulting in a small exudative retinal detachment but significant visual acuity and retinal function loss as demonstrated by electroretinography (ERG). A 39-year-old man presented to the emergency department with a TASER barb embedded in his right lower lid. A complete clinical ophthalmologic examination and surgical extrication were performed, as well as radiologic imaging and Ganzfeld electroretinography. No scleral penetration was observed on surgical exploration. Retinal examination showed a peripheral exudative detachment. Subsequent follow-up revealed progressive resolution of the detachment and improvement in visual acuity. The ERG showed a 63-70% decrease in rod a- and b-waves, while isolated cone responses were reduced by only 10%, with a minimal increase in implicit time. This case shows that periocular TASER injuries, even if apparently superficial, may result in significant ocular damage. ERG may be useful in the diagnosis of visual loss attributed to disturbance in photoreceptor function, in the absence of anatomically evident damage.

Hypertensive emergency associated with thoracoabdominal aneurysm: case report and review.

OBJECTIVE: To provide a description and thorough discussion of the diagnostic considerations for a rare case of malignant hypertension and aortic aneurysm in a pediatric patient. DESIGN: Case report. SETTING: A university pediatric intensive care unit. SUBJECT: A young child with a hypertensive crisis and a thoracoabdominal false aortic aneurysm. INTERVENTIONS: The child required urgent surgical intervention to resect the aneurysm and aggressive medical therapy in the pediatric intensive care unit to treat the underlying hypertension. CONCLUSIONS: Hypertensive emergencies and aortic aneurysms are unusual but potentially lethal entities in pediatric patients, requiring a high index of suspicion, prompt initiation of medical therapy, and urgent surgical consultation.