Sedation Usage in COVID-19 Acute Respiratory Distress Syndrome: A Multicenter Study.

BACKGROUND: Patients with COVID-19 acute respiratory distress syndrome (ARDS) have been shown to have high sedation requirements. OBJECTIVE: The purpose of this study was to compare sedative use between patients with COVID-19 ARDS and non-COVID-19 ARDS. METHODS: This was a retrospective study of patients with COVID-19 ARDS compared with historical controls of non-COVID-19 ARDS who were admitted to 2 hospitals from March 1, 2020, to April 30, 2020, and April 1, 2018, to December 31, 2019, respectively. The primary outcome was median cumulative dose of propofol (µg/kg) at 24 hours after intubation. RESULTS: There were 92 patients with COVID-19 ARDS and 37 patients with non-COVID-19 ARDS included. Within the first 24 hours of intubation, patients with COVID-19 ARDS required higher total median doses of propofol: 51 045 µg/kg (interquartile range, 26 150-62 365 µg/kg) versus 33 350 µg/kg (9632-51 455 µg/kg; P = 0.004). COVID-19 patients were more likely receive intravenous lorazepam (37% vs 14%; P = 0.02) and higher cumulative median doses of midazolam by days 5 (14 vs 4 mg; P = 0.04) and 7 of intubation (89 vs 4 mg; P = 0.03) to achieve the same median Richmond Analgesia-Sedation Scale scores. COVID-19 ARDS patients required more ventilator days (10 vs 6 days; P = 0.02). There was no difference in 30-day mortality. CONCLUSION AND RELEVANCE: Patients with COVID-19 ARDS required higher doses of propofol and benzodiazepines than patients with non-COVID-19 ARDS to achieve the same median levels of sedation.

Nonalcoholic Fatty Liver Disease after Liver Transplant.

Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease in the world. The rising prevalence of nonalcoholic steatohepatitis (NASH) has led to a 170% increase in NASH cirrhosis as the listing indication for liver transplantation from 2004 to 2013. As of 2018, NASH has overtaken hepatitis C as an indication for liver transplantation in the USA. After liver transplantation, the allograft often develops recurrent NAFLD among patients with known NASH cirrhosis. In addition to recurrent disease, de novo NAFLD has been reported in patients with other indications for liver transplantation. In this review, we will discuss the risk factors associated with recurrent and de novo NAFLD, natural course of the disease, and management strategies after liver transplantation.

A multicomponent oxygen delivery strategy for COVID-19 patients in a step-down intensive care unit: A case series.

Coronavirus disease 2019 (COVID-19) is the cause of the pandemic that has affected millions of people worldwide with pulmonary manifestations ranging from mild pneumonia to ARDS and characterized by hypoxia. This has led to questions regarding the most efficacious and least harmful oxygen delivery strategies that minimize exposure to health care workers. In this case series, we present the hospital course of 4 patients that were managed with a multi-component oxygen delivery method in a COVID-19 step down unit.

A Rare Case of a Large, Deceitfully Quiet Brainstem Arteriovenous Malformation Presenting Only as Dizziness.

Dizziness is one of the most frequent complaints encountered in the medical practice affecting 15%-20% of adults yearly, and can be challenging to assess. Most patients use dizziness as a non-specific term, and thus suffer prejudice from the physicians' end and can be disregarded frequently. Dizziness can be a symptom of various diseases, some with sinister pathologies. We present a case of garden-variety vertigo that unfurled to be not-so-simple, emphasizing the importance of a thorough history and physical examination again even in the era of technology. A 32-year-old male patient with no past medical history presented with dizziness, later clarified as gradually progressive vertigo for two years, with unstable gait, dysarthria, and occasional diplopia. Physical examination found sustained nystagmus that changed direction with horizontal gaze, vertical nystagmus with upward gaze, dysarthria, and a wide-based ataxic gait. CT head without contrast revealed indeterminate hypodense areas in the left midbrain, pons, and cerebellar hemisphere. MRI brain identified a 2.8 x 3.4 x 4.2 cm Spetzler-Martin grade IV brainstem arteriovenous malformation (AVM) involving the left midbrain, pons, and cerebellum. Feeders were mostly from the posterior circulation, with three intranidal aneurysms, all draining into the deep venous system. The AVM was deemed inoperable, and the patient was treated with onyx embolization for two/three feeding vessel aneurysms. After treatment, the symptoms persisted, and the patient was diagnosed with major depressive disorder (MDD) six months after diagnosis, and was admitted a year later with suicidal ideation and substance use disorder. Brain AVMs are rare clinical entities that present in 0.1% of the population, mostly presenting as intracranial bleeds. When they do rarely present with isolated focal neurologic deficits, it has been attributed to a vascular steal phenomenon, hemorrhage, or a mass effect. The isolated findings of vertigo and dysarthria are highly non-specific; with such presentation, clinicians should consider etiologies under the realm of vertigo of central origin. An untreatable AVM reduces patients' quality of life and has been linked to depression and anxiety, and thus patients may benefit from psychosocial therapy. Although preventing intracranial hemorrhage (ICH) is the primary concern with brain AVMs, the rest of the patient's profile should not be forgotten.

Not Your Typical Mucocele: A Case Report of a Benign Sigmoidal Diverticular Mucocele.

In recent literature, mucoceles have been discovered to be in the appendix vermiformis or in the nasal sinuses. Although rare, colonic mucoceles, as well as rectal mucoceles, have also been encountered. Furthermore, colonic mucoceles arising from a diverticulum is an even more unusual occurrence, and to date, there has been only one reported case. We present a 48-year-old male with a past medical history of multiple episodes of diverticulitis who presented to the emergency department complaining of bilateral lower quadrant abdominal pain for three days. Upon arrival to the emergency department, the patient had a CT scan of the abdomen and pelvis, which showed an annular constricting 65 mm mass in the proximal sigmoid causing large bowel obstruction. The patient underwent unsuccessful endoscopies and inevitably underwent a hand-assisted laparoscopic sigmoid resection. The following days, the biopsy returned and resulted to be a mucocele arising from a sigmoid diverticulum. We encountered the very first benign colonic mucocele arising from a sigmoid diverticulum.

Looks can be Deceiving: A Case Report on the Clinical Value of CA 19-9 in Obstructive Jaundice.

Carbohydrate antigen CA19-9 is a marker that has been used for the diagnosis of pancreatic and biliary malignancies, but it can also be present in benign conditions. Herein, we present the case of an 82-year-old female admitted for sepsis secondary to cholangitis, with a CA19-9 level of 12,838.3 U/mL. Initial imaging suggested a potential cholangiocarcinoma, but after multiple studies and biopsies, she was found to have a benign biliary stricture which triggered the cholangitis, explaining the increased CA19-9 levels. Clinicians should keep an open mind when assessing significantly elevated CA19-9 levels.

Nanotechnology in the Treatment of Inflammatory Bowel Disease.

Due to the lack of cure for inflammatory bowel disease (IBD) and failure of current medical therapies in many patients with IBD, a need exists in finding novel ways to treat inflammation with a high benefit and the lowest risk possible. With current medical therapies, adverse events or risks of cancer/lymphoma and infections prevent patients-and sometimes providers-in using effective therapies for treatment. Some patients develop systemic side effects that preclude them from continuing a therapy that may have been efficacious, or in other cases, current medical therapies are not adequate to control disease. Nanotechnology is an emerging field where particles, in the size of nanometers, can be used to deliver medications directly to the area of inflammation thus avoiding drug-associated systemic side effects. When using nanoparticles (NPs), only a small amount of the drug is needed, and it can be delivered directly to the inflamed site without exposure to the rest of the body. Here we review conventional and unconventional therapies applied in the treatment of IBD underlying how the introduction of NPs has improved their safety and efficacy.

A Case of Immune Checkpoint Inhibitor Refractory Colitis Treated with Mycophenolate and High-dose Steroids.

Immune checkpoint inhibitors (ICPI) are a class of chemotherapy agents that have emerged as a front-line treatment option for multiple cancers. Nivolumab is an ICPI agent commonly used to treat metastatic melanoma. Although promising, the adverse reaction of this class is broad and per reports, the incidence of colitis is <6%. We present the case of a 71-year-old male with a history of metastatic melanoma who was being treated with nivolumab. The patient was two weeks into his treatment regimen when he began complaining of multiple loose, bloody stools. Because of these symptoms, his nivolumab was discontinued. However, despite discontinuation, his symptoms persisted and the patient underwent a colonoscopy. He was found to have diffuse inflammation of the colon and was diagnosed with nivolumab-induced colitis. Subsequently, the patient underwent multiple treatments, including high-dose steroids, infliximab, and vedolizumab (Entyvio), with no resolution of symptoms. After several months of failed treatment, the patient was readmitted to the hospital for refractory colitis. He was started on high-dose steroids and underwent a repeat colonoscopy, which again showed diffuse colitis. Because of the previously failed treatment options, mycophenolate, an immunosuppressant, was initiated in combination with his steroids. After three days of high-dose steroids and mycophenolate, the patient's symptoms resolved, with no subsequent apparent symptoms of colitis. We present a case of nivolumab-induced colitis, refractory to multiple immunosuppressive medications, which was successfully treated with mycophenolate and high-dose steroids.

Pharmabiotic Manipulation of the Microbiota in Gastrointestinal Disorders: A Clinical Perspective.

The advent and widespread availability of high-throughput technology has revolutionized the assessment of the communities of microorganisms that inhabit the gastrointestinal tract-the gut microbiota. As our understanding of the role of the microbiota in health and human disease increases, so also do efforts to prevent and treat disease through the modulation of the microbiota. Several strategies are available to us and range from time honored approaches, such as antibiotics and probiotics, to changes in diet, the administration of prebiotics as food supplements, and fecal microbiota transplantation. Of these, diet is perhaps the most pervasive but often ignored modulator of the microbiota, and a failure to recognize its impact complicates the interpretation of many microbiota studies. The impacts of antibiotics on the microbiota are more complex than originally thought and, though antibiotics can be life-saving, their effects on commensal bacterial populations can be clinically significant. Though there have been many studies of, and even more claims made for, probiotics, the majority of available studies suffer from significant deficits in study design and execution and many claims remain to be substantiated. Though holding much promise, the study of prebiotics in human disease is still in its infancy. Possibilities other than the administration of live organisms have been identified through efforts to mine the microbiota for novel therapeutics and include: dead organisms, bacterial components, small molecules elaborated by bacteria, and even bacterial DNA. Accordingly, the term pharmabiotic has been introduced to encompass the full range of therapeutic possibilities that the microbiota offers.