Biologics in Asthma: Emerging Biologics.

Advances in our understanding of asthma pathophysiology have led to the advent of multiple targeted asthma therapies such as biologics. However, partial response to biologics occurs, indicating residual disease activity in some patients. Hence, there exists a need for new therapies that focus on novel pathways, alongside perhaps evaluation of combination biologic therapies and modulators of downstream cytokine activation. Therefore, although our current focus is on biologics; it is critical to take a more holistic approach including consideration for nonbiologic therapies that have the potential to significantly advance asthma care.

Traumatic brain injury and variants of shock index.

Traumatic Brain Injury is a major cause of death and long-term disability. The early identification of patients at high risk of mortality is important for both management and prognosis. Although many modified scoring systems have been developed for improving the prediction accuracy in patients with trauma, few studies have focused on prediction accuracy and application in patients with traumatic brain injury. The shock index (SI) which was first introduced in the 1960s has shown to strongly correlate degree of circulatory shock with increasing SI. In this editorial we comment on a publication by Carteri et al wherein they perform a retrospective analysis studying the predictive potential of SI and its variants in populations with severe traumatic brain injury.

Reimagining critical care: Trends and shifts in 21st century medicine.

Critical care medicine has undergone significant evaluation in the 21st century, primarily driven by advancements in technology, changes in healthcare delivery, and a deeper understanding of disease processes. Advancements in technology have revolutionized patient monitoring, diagnosis, and treatment in the critical care setting. From minimally invasive procedures to advances imaging techniques, clinicians now have access to a wide array of tools to assess and manage critically ill patients more effectively. In this editorial we comment on the review article published by Padte S et al wherein they concisely describe the latest developments in critical care medicine.

Inhalational Drug Devices: Revisiting the Linchpin of Asthma Management.

Asthma remains a prevalent condition among all age groups globally. First-line treatment requires the delivery of medications into the distal respiratory tract via inhalers. Using appropriate inhaler techniques is a significant challenge in achieving disease control. A variety of inhalers are available for treating asthma, and selecting the appropriate inhaler type for any given patient is crucial to achieving and maintaining symptomatic control. This review will discuss the anatomy and physiology behind drug delivery via inhalers, the types of inhalers currently available for use, nebulizers, and future directions in the delivery of inhaled medications for asthma.

Driving pressure decoded: Precision strategies in adult respiratory distress syndrome management.

Mechanical ventilation (MV) is an important strategy for improving the survival of patients with respiratory failure. However, MV is associated with aggravation of lung injury, with ventilator-induced lung injury (VILI) becoming a major concern. Thus, ventilation protection strategies have been developed to minimize complications from MV, with the goal of relieving excessive breathing workload, improving gas exchange, and minimizing VILI. By opting for lower tidal volumes, clinicians seek to strike a balance between providing adequate ventilation to support gas exchange and preventing overdistension of the alveoli, which can contribute to lung injury. Additionally, other factors play a role in optimizing lung protection during MV, including adequate positive end-expiratory pressure levels, to maintain alveolar recruitment and prevent atelectasis as well as careful consideration of plateau pressures to avoid excessive stress on the lung parenchyma.

Community-acquired pneumonia: The importance of the early detection of drug-resistant organisms.

Pneumonia is a disease associated with significant healthcare burden with over 1.5 million hospitalizations annually and is the eighth leading cause of death in the United States. While community-acquired pneumonia (CAP) is generally considered an acute time-limited illness, it is associated with high long-term mortality, with nearly one-third of patients requiring hospitalization dying within one year. An increasing trend of detecting multidrug-resistant (MDR) organisms causing CAP has been observed, especially in the Western world. In this editorial, we discuss about a publication by Jatteppanavar et al which reported that a case of a MDR organism was the culprit in developing pneumonia, bacteremia, and infective endocarditis that led to the patient's death. The early detection of these resistant organisms helps improve patient outcomes. Significant advances have been made in the biotechnological and research space, but preventive measures, diagnostic techniques, and treatment strategies need to be developed.

Revisiting Asthma Obstructive Sleep Apnea Overlap: Current Knowledge and Future Needs.

Asthma and obstructive sleep apnea are highly prevalent conditions with a high cost burden. In addition to shared risk factors, existing data suggest a bidirectional relationship between asthma and OSA, where each condition can impact the other. Patients with asthma often complain of sleep fragmentation, nocturnal asthma symptoms, daytime sleepiness, and snoring. The prevalence of OSA increases with asthma severity, as evidenced by multiple large studies. Asthma may lower the threshold for arousal in OSA, resulting in the hypopnea with arousal phenotype. Epidemiologic studies in adults have shown that OSA is associated with worse asthma severity, increased frequency of exacerbation, and poor quality of life. The current literature assessing the relationship among OSA, asthma, and CPAP therapy is heavily dependent on observational studies. There is a need for randomized controlled trials to minimize the interference of confounding shared risk factors.

Update on the Role of FeNO in Asthma Management.

Asthma is a heterogenous disorder characterized by presence of different phenotypes and endotypes. Up to 10% of the individuals suffer from severe asthma and are at increased risk of morbidity and mortality. Fractional exhaled nitric oxide (FeNO) is a cost-effective, point of care biomarker that is used to detect type 2 airway inflammation. Guidelines have proposed to measure FeNO as an adjunct to diagnostic evaluation in individuals with suspected asthma and to monitor airway inflammation. FeNO has lower sensitivity, suggesting that it may not be a good biomarker to rule out asthma. FeNO may also be used to predict response to inhaled corticosteroids, predict adherence and deciding on biologic therapy. Higher levels of FeNO have been associated with lower lung function and increased risk for future asthma exacerbations and its predictive value increases when combined with other standard measurements of asthma assessment.

A rare case of isolated thoracic AL-amyloidoma causing complete atelectasis of the right lung.

Tumoral amyloidosis, or amyloidoma, is a benign, but rare form of amyloidosis that has been reported with a favorable prognosis following surgical resection in some case reports. We present a case of acute on chronic respiratory failure secondary to extensive growth of a thoracic amyloidoma causing atelectasis of the right lung. Our case patient had greater morbidity due to late presentation and extensive disease at diagnosis, precluding any surgical intervention. Radiation therapy and medical management were unsuccessful in reducing disease burden. Early diagnosis and detection are pivotal to improving survival in patients with isolated thoracic amyloidoma.

Phenotypes of Asthma-Chronic Obstructive Pulmonary Disease Overlap.

Asthma and chronic obstructive pulmonary disease are considered unique diseases with distinct characteristics. Asthma-chronic obstructive pulmonary disease overlap is a disorder in which the clinical characteristics of asthma and chronic obstructive pulmonary disease coexist. Asthma-chronic obstructive pulmonary disease overlap is a heterogenous condition; patients can have varied clinical presentations. There are significant gender variations among different phenotypes overlap. Age of symptom onset is another important consideration. Severity of symptoms, spirometry findings, smoking history, and type of airway inflammation varies between the different phenotypes. Understanding disease pathophysiology and establishing phenotypic models will improve a precision approach.

May-Thurner Syndrome: A Rare Case of Unilateral Deep Vein Thrombosis in an Elderly Woman.

BACKGROUND Deep vein thrombosis (DVT) is a critical disorder with a high incidence and a high disease burden. Multiple acquired and genetic factors leading to hypercoagulation, venous injury, and venous stasis account for its basic pathophysiology. One of the rarely considered underlying etiologies of DVT is May-Thurner Syndrome (MTS), also known as iliac vein compression syndrome. MTS is an anatomical variant in which the left common iliac vein is extrinsically compressed by the right common iliac artery against the lumbar spine, leading to the development of iliofemoral DVT. CASE REPORT We present the case of a 78-year-old woman who presented with chronic unilateral lower-extremity swelling and pain. Ultrasound was consistent with extensive DVT extending from the left common femoral vein to left popliteal vein. Further workup revealed left common iliac venous outflow obstruction due to the extrinsic compression by the overlying atherosclerotic calcified right common iliac artery crossing against the lumbosacral region. CONCLUSIONS MTS usually presents in the second to fourth decades of life, making it challenging to consider it as a differential diagnosis in older patients. The conventional treatment of DVT with anticoagulation alone is insufficient to address thrombotic MTS and can lead to recurrent DVT, post-thrombotic syndrome, and life-threatening complications. Our patient presented in the seventh decade of life, warranting a high index of clinical suspicion of MTS in patients presenting with unilateral leg DVT, regardless of patient age, for timely diagnosis and appropriate therapeutic management.

Potential predictors of outcomes among hospitalized COVID-19 patients treated with convalescent plasma: a single-center study.

Background: The coronavirus disease 2019 pandemic is a major international public health crisis, which has led to over 3 million deaths as of April 2021. Several therapeutics have been tried for this deadly illness including antivirals, immunosuppressive agents and convalescent plasma (CP). In this study, we present our inner-city safety net hospital experience with CP therapy. Methods: This was a retrospective chart review of hospitalized patients with confirmed COVID-19 who were treated with CP. Results: A total of 60 patients received CP during the study period. The mean age for patients in this study was 58.95 years. The most common presenting symptoms were shortness of breath (85%) and cough (73%). Hypertension (65%) and diabetes mellitus (55%) were the most common comorbidities in our patients. In our multivariate regression analysis, male sex, nausea and loss of appetite at presentation were associated with improvement in oxygenation after CP. Total survival time, history of obstructive airway disease, home use of angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers were associated with decreased survival, whereas Hispanic ethnicity showed a trend towards lower survival after CP therapy. Conclusions: Our study highlights several important characteristics of inner-city safety net hospital patient population who might benefit from CP therapy.

A Rare Case of Mycobacterium Monacense Osteomyelitis: A Case Report.

Mycobacterium monacense (M. monacense) is a yellow-pigmented, rapidly growing non-tuberculous mycobacterium (RGM). It is a rare pathogen in humans, and only a very few cases of skin and lung infection related to it have been reported. In this report, we present the case of a 70-year-old Hispanic male who was brought to the hospital with back pain for 11 months. His physical exam on admission showed point tenderness in the lumbar and thoracic spine. MRI demonstrated severe spinal stenosis, discitis, and adjacent osteomyelitis at the T11-T12 vertebral bodies. Mycobacterium culture with fluorochrome smear from thoracic spine T12 tissue revealed mycobacterium species, but not Mycobacterium tuberculosis (M. tuberculosis). The final culture report led to the identification of M. monacense, which was confirmed by DNA sequencing. This case illustrates the rare manifestations of M. monacense and highlights the use of molecular biologic techniques to reach a definitive diagnosis in suspected cases. Infections caused by M. monacense are rarely reported in humans. Even though a few cases have reported M. monacense isolated from human samples, the clinical importance of it is not fully understood. A drug susceptibility test for antibiotic therapy is essential for this patient population. The interpretation of these cultures often generates unclear results. However, the aggravation of the disease on imaging and isolation of M. monacense alone from the cultured specimens obtained suggested that this pathogen may have caused the infection presented in this case.

Ramucirumab-Induced Hepatocellular Carcinoma Rupture and Gastrointestinal Perforation.

BACKGROUND Hepatocellular carcinoma (HCC) is a primary liver malignant tumor that typically but not always develops in the setting of chronic liver disease, particularly in patients with cirrhosis or chronic hepatitis B virus infection. Advanced HCC portends a poor prognosis; however, recent advances in first-line and second-line treatment options yield significant survival improvements. Ruptured HCC is an uncommon presentation that occurs in approximately 3-26% of patients. CASE REPORT We present a case of a patient with HCC who was undergoing treatment with the antiangiogenic monoclonal antibody ramucirumab. Subsequently, he presented with signs and symptoms of acute abdomen. The abdominal imaging revealed pneumoperitoneum with multiple abdominal and pelvic collections. The patient underwent exploratory laparotomy and was found to have necrotic liver parenchyma, which appeared to be perforated. Also, a microperforation was noted in the proximal duodenum. The pathology report from liver specimens showed fragments of hepatocellular cancer with extensive necrosis. CONCLUSIONS The mechanism of tumor rupture in HCC is poorly understood. The so-called vascular injury hypothesis states that collagen expansion and elastin proliferation in the arterial wall supplying the tumor could be the leading cause of HCC rupture. We believe that the process mentioned above was accelerated in our patient using the antiangiogenic factor ramucirumab. A similar antiangiogenic mechanism is also implicated in gastrointestinal hemorrhage and perforation related to this drug.