Clot-in-transit: A ticking time bomb in the heart with serious consequences.

Clot-in-transit is associated with severe pulmonary embolism and higher mortality than acute pulmonary embolism without clot-in-transit. The optimal treatment of clot-in-transit is not established. Multiple treatment options have been described, including anticoagulation alone, systemic thrombolysis, surgical embolectomy and endovascular catheter-based therapies. Clot-in-transit can embolize to the pulmonary circulation in a matter of seconds and be immediately fatal. We describe two cases of clot-in-transit which embolized quickly upon Intensivist's evaluation and were associated with serious consequences. Management decisions for clot-in-transit should be emergent and based on multidisciplinary discussion of the pulmonary embolism response team.

A Case Report of Listeria Meningitis with Severe Rhabdomyolysis and Normal Renal Function.

BACKGROUND Listeria monocytogenes is known to cause meningitis, bacteremia, and rhabdomyolysis, typically associated with acute kidney injury. We present the case of a young woman who developed severe rhabdomyolysis without kidney failure in the setting of listeriosis. CASE REPORT A 22-year-old woman with a past medical history of type 1 diabetes mellitus presented with fever, headache, and vomiting. Initial blood work revealed a white blood cell count of 22 K/µL, creatine phosphokinase (CPK) level of 275 U/L, blood urea nitrogen of 9 mg/dL, and creatinine of 0.89 mg/dL. A lumbar puncture (LP) was performed and was positive for Listeria monocytogenes. Her initial point-of-care ultrasound demonstrated hyperdynamic left ventricular (LV) function. Although she was immediately started on empiric coverage for bacterial and viral meningitis with intravenous vancomycin, ceftriaxone, and acyclovir, the antimicrobial regimen was changed to ampicillin and gentamicin after the LP results were obtained. On the second hospital day, a repeat echocardiogram demonstrated a dilated LV with severely reduced function with an ejection fraction (EF) of 30%. Her CPK increased and peaked at 299 637 U/L by day 6. Despite the low EF and elevated CPK, her kidney function remained at baseline at all times. Her EF improved to 60% by hospital day 20. She received large volumes of intravenous fluids, completed a 3-week course of ampicillin, continued to improve, and was discharged to a rehabilitation facility with no deficits. CONCLUSIONS Listeria infection can be associated with severe rhabdomyolysis, which is usually associated with kidney dysfunction. Administration of large volumes of intravenous fluids may decrease this likelihood.

Stress cardiomyopathy in critical care: A case series of 109 patients.

BACKGROUND: Critically ill patients are at risk of developing stress cardiomyopathy (SC) but can be under-recognized. AIM: To describe a case series of patients with SC admitted to critical care units. METHODS: We conducted a retrospective observational study at a tertiary care teaching hospital. All adult (≥ 18 years old) patients admitted to the critical care units with stress cardiomyopathy over 5 years were included. RESULTS: Of 24279 admissions to the critical care units [19139 to medical-surgical intensive care units (MSICUs) and 5140 in coronary care units (CCUs)], 109 patients with SC were identified. Sixty (55%) were admitted to the coronary care units (CCUs) and forty-nine (45%) to the medical-surgical units (MSICUs). The overall incidence of SC was 0.44%, incidence in CCU and MSICU was 1.16% and 0.25% respectively. Sixty-two (57%) had confirmed SC and underwent cardiac catheterization whereas 47 (43%) had clinical SC, and did not undergo cardiac catheterization. Forty-three (72%) patients in the CCUs were diagnosed with primary SC, whereas all (100%) patients in MSICUs developed secondary SC. Acute respiratory failure that required invasive mechanical ventilation and shock developed in twenty-nine (59%) MSICU patients. There were no statistically significant differences in intensive care unit (ICU) mortality, in-hospital mortality, use of inotropic or mechanical circulatory support based on type of unit or anatomical variant. CONCLUSION: Stress cardiomyopathy can be under-recognized in the critical care setting. Intensivists should have a high index of suspicion for SC in patients who develop sudden or worsening unexplained hemodynamic instability, arrhythmias or respiratory failure in ICU.

Learn to Live Again.

The COVID-19 pandemic has claimed more than 4.5 million lives so far throughout the world. These sudden, unnatural, and unexpected deaths have led to complicated grief reactions as families did not get time to prepare for death. I describe the experience of my family in India during the disastrous second wave of the pandemic. The experience of many such families of COVID-19 casualties is like a horror story that will continue to scare them each day of their life. These families have already suffered a serious and long-lasting harm and are at greater risk of suffering from prolonged grief disorder, post-traumatic stress disorder, depression, emotional distress, adult separation disorder, and generalized anxiety disorder for a long period of time. Creating support groups, empowering primary-care physicians to help and counsel their patients, providing them access to cognitive behavioral therapy, help with opening up and venting out some of their feelings, and training to develop resilience are some of the measures to help our grieving patients.

Long-Term Follow up of Renal and Other Acute Organ Failure in Survivors of Critical Illness Due to Covid-19.

BACKGROUND: Little is known about the long-term health sequelae and outcomes of various organ failures in ICU survivors of Covid-19. The aim of our research was to study the characteristics of 120-day ICU survivors of the initial pandemic surge and report their long term (>6 months) outcomes. METHODS: We conducted a telephone questionnaire-based follow up study of 120- day survivors of Covid-19 admitted to ICUs at Montefiore Medical Center, Bronx, NY from 3/10/2020 to 4/11/2020. The study period was 2 months (11/1/2020-12/31/2020). RESULTS: 126 out of 300 (42%) survived to 120-days post-hospital discharge. The median age of survivors was 54 (47-61) years. Seventy-eight (62%) patients developed acute kidney injury (AKI); thirty-five (44.9%) of them required renal replacement therapy (RRT). One hundred-five (83.3%) required invasive mechanical ventilation; ten of them required tracheotomy. 103 (81.7%) completed the telephone questionnaire-based study, at a median (IQR) of 216.5 (200-234.5) days after hospital discharge. 29 (28.2%) patients reported persistent shortness of breath, 24, (23.3%) complained of persistent cough, and persistent anosmia in 9 (8.8%). AKI resolved completely in 58 (74.4%) patients. Of 35 AKI patients who required initiation of RRT during hospitalization, 27 (77%) were liberated from RRT and 20 (57%) had resolution of AKI. Of 20 patients without AKI resolution, 12 developed chronic kidney disease, whereas 8 still require RRT. Thirty-three (32.4%) patients developed post-traumatic stress disorder (PTSD) and 10 (11.8%) reported major depression. Many of the patients (68%) regained baseline functional status. Readmissions occurred in 22.3% patients within first 6 months after discharge. CONCLUSION: Persistent symptoms of long Covid have been reported in ICU survivors of Covid-19 for extended durations. Outcomes of Covid-19 associated acute kidney injury are excellent. There is a high incidence of PTSD and depression in COVID-19 ICU survivors. Functional outcomes are good, but these patients remain at increased risk of hospital readmission.

Legionella Pneumonia in the ICU: A Tertiary Care Center Experience Over 10 Years.

Few studies have reported the complications and outcomes of patients with Legionella pneumonia requiring ICU admission. The objective of our study is to report the clinical course, complications, and 30-day mortality of patients with Legionella pneumonia admitted to the critical care units at our medical center over a 10-year period. DESIGN: Retrospective observational study. SETTING: Tertiary care teaching hospital. PATIENTS: All adult (≥ 18 yr old) patients with Legionella pneumonia admitted to the ICUs from January 1, 2010, to December 31, 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 88 patients with Legionella pneumonia were admitted to ICUs over the 10-year period. The majority of infections (n = 80; 90.9%) were community acquired. The median (interquartile range) age of patients was 60 years (51.5-71.0 yr); 58 (66%) were male, and 41 (46.6%) identified their race as Black. The median (interquartile range) Sequential Organ Failure Assessment score at ICU admission was 6 (3-9). The distribution of infections showed seasonal dominance with most cases (86%) occurring in the summer to early fall (May to October). Invasive mechanical ventilation was required in 62 patients (70.5%), septic shock developed in 57 patients (64.8%), and acute respiratory distress syndrome developed in 42 patients (47.7%). A majority of patients developed acute kidney injury (n = 69; 78.4%), with 15 (21.7%) receiving only intermittent hemodialysis and 15 (21.7%) requiring continuous renal replacement therapy. Ten patients required venovenous extracorporeal membrane oxygenation support; eight (80%) survived and were successfully decannulated. Overall 30-day mortality was 26.1% (n = 23). Advanced age, higher Sequential Organ Failure Assessment score at admission, and not receiving Legionella-specific antimicrobial therapy within 24 hours of hospital admission were predictors of 30-day mortality. CONCLUSIONS: Patients with Legionella pneumonia may require ICU admission and major organ support. Legionella-targeted antibiotics should be included in the empiric regimen for any patient with severe pneumonia. Outcomes of extracorporeal membrane oxygenation therapy in this population are encouraging.

Outcomes of severe Legionella pneumonia requiring extracorporeal membrane oxygenation (ECMO).

BACKGROUND: Legionella pneumonia with acute respiratory failure may necessitate extracorporeal membrane oxygenation (ECMO). The medical literature in this area is comprised primarily of case reports and small case series. Our goal was to summarize published data and contribute our institutional experience regarding survival in severe Legionella pneumonia requiring ECMO. METHODS: A National Library of Medicine (PubMed) search was conducted, identifying reports of ECMO therapy in patients with severe Legionella pneumonia. Electronic health records of Montefiore Medical Center (Bronx, NY) captured all such patients treated at our institution during the 10-year period 2010-2019. RESULTS: 23 articles reported 73 patients. Survival to hospital discharge was 78.1%. In an attempt to avoid publication bias, we culled from the search four series (53 patients), reporting surviving and non-surviving patients. Survival in this group was 71.7%. Our institutional experience included 10 patients with survival rate 80%. CONCLUSIONS: Review of clinical experience with ECMO for severe Legionella pneumonia yields a survival rate of over 70%. The similarity in survival rates among all published cases (78.1%), case series reporting surviving and non-surviving patients (71.7%), our institutional experience (80%), and recently reported Extracorporeal Life Support Organization (ELSO) registry data (71%) supports the veracity of this encouraging survival rate.

Thromboembolic Events and Role of Point of Care Ultrasound in Hospitalized Covid-19 Patients Needing Intensive Care Unit Admission.

BACKGROUND: Covid-19 associated coagulopathy (CAC) is associated with prothrombotic state and thromboembolism. However, true incidence of thromboembolic events is difficult to determine in the ICU setting. The aim of our study was to investigate the cumulative incidence of thromboembolic events in Covid-19 patients needing intensive care unit (ICU) admission and assessing the utility of point of care ultrasound (POCUS) to screen for and diagnose lower extremity deep venous thrombosis (DVT). METHODS: We conducted a prospective observational study between April 22nd and May 26th, 2020 where all adult patients with the diagnosis of Covid-19 pneumonia admitted to 8 ICUs of Montefiore Medical Center were included. POCUS exam was performed on all patients at day 1 of ICU admission and at day 7 and 14 after the first exam. RESULTS: The primary outcome was to study the cumulative incidence of thromboembolic events in Covid-19 patients needing ICU admission. A total of 107 patients were included. All patients got POCUS exam on day 1 in the ICU, 62% got day 7 and 41% got day 14 exam. POCUS diagnosed 17 lower extremity DVTs on day 1, 3 new on day 7 and 1 new on day 14. Forty patients developed 52 thromboembolic events, with the rate of 37.3%. We found a high 45-day cumulative incidence of thromboembolic events of 37% and a high 45-day cumulative incidence of lower and upper extremity DVT of 21% and 10% respectively. Twelve (30%) patients had failure of therapeutic anticoagulation. Occurrence of a thromboembolic event was not associated with a higher risk of mortality (HR 1.08, p value = .81). CONCLUSIONS: Covid-19 patients in ICU have a high cumulative incidence of thromboembolic events, but not associated with higher mortality. POCUS is an excellent tool to help screen and diagnose DVT during a pandemic.

COVID-19-Associated Critical Illness-Report of the First 300 Patients Admitted to Intensive Care Units at a New York City Medical Center.

BACKGROUND: The first confirmed case of novel coronavirus (2019-nCoV) infection in the United States was reported from the state of Washington in January, 2020. By March, 2020, New York City had become the epicenter of the outbreak in the United States. METHODS: We tracked all patients with confirmed coronavirus-19 (COVID-19) infection admitted to intensive care units (ICU) at Montefiore Medical Center (Bronx, NY). Data were obtained through manual review of electronic medical records. Patients had at least 30 days of follow-up. RESULTS: Our first 300 ICU patients were admitted March 10 through April 11, 2020. The majority (60.7%) of patients were men. Acute respiratory distress syndrome (ARDS) was documented in 91.7% of patients; 91.3% required mechanical ventilation. Prone positioning was employed in 58% of patients and neuromuscular blockade in 47.8% of mechanically-ventilated patients. Neither intervention was associated with decreased mortality. Vasopressors were required in 77.7% of patients. Acute kidney injury (AKI) was present on admission in 40.7% of patients, and developed subsequently in 36.0%; 50.9% of patients with AKI received renal replacement therapy (RRT). Overall 30-day mortality rate was 52.3%, and 55.8% among patients receiving mechanical ventilation. In univariate analysis, higher mortality rate was associated with increasing age, male sex, hypertension, obesity, smoking, number of comorbidities, AKI on presentation, and need for vasopressor support. A representative multivariable model for 30-day mortality is also presented, containing patient age, gender, body mass index, and AKI at admission. As of May 11, 2020, 2 patients (0.7%) remained hospitalized. CONCLUSIONS: Mortality in critical illness associated with COVID-19 is high. The majority of patients develop ARDS requiring mechanical ventilation, vasopressor-dependent shock, and AKI. The variation in mortality rates reported to date likely reflects differences in the severity of illness of the evaluated populations.

Characteristics, Outcomes and 60-Day Hospital Mortality of ICU Patients with COVID-19 and Acute Kidney Injury.

Background: AKI has been reported in patients with COVID-19 pneumonia and it is associated with higher mortality. The aim of our study is to describe characteristics, outcomes, and 60-day hospital mortality of patients with COVID-19 pneumonia and AKI in the intensive care unit (ICU). Methods: We conducted a retrospective study in which all adult patients with confirmed COVID-19 who were admitted to ICUs of Montefiore Medical Center and developing AKI were included. The study period ranged from March 10 to April 11, 2020. The 60-day follow-up data through June 11, 2020 were obtained. Results: Of 300 adults admitted to the ICUs with COVID-19 pneumonia, 224 patients (75%) presented with AKI or developed AKI subsequent to admission. A total of 218 (97%) patients required invasive mechanical ventilation for moderate to severe acute respiratory distress syndrome (ARDS). A total of 113 (50%) patients had AKI on day 1 of ICU admission. The peak AKI stages observed were stage 1 in 49 (22%), stage 2 in 35 (16%), and stage 3 in 140 (63%) patients, respectively. Among patients with AKI, 114 patients (51%) required RRT. The mortality rate of patients requiring RRT was 70%. Of the 34 patients who were survivors, 25 (74%) were able to be weaned off RRT completely before hospital discharge. Nonsurvivors were older and had significantly higher admission and peak creatinine levels, admission hemoglobin, and peak phosphate levels compared with survivors. The 60-day hospital mortality was 67%. Conclusions: COVID-19 requiring ICU admission is associated with high incidence of severe AKI, necessitating RRT in approximately half of such patients. The majority of patients with COVID-19 and AKI in ICU developed moderate to severe ARDS, requiring invasive mechanical ventilation. Timing or severity of AKI did not affect outcomes. The 60-day hospital mortality is high (67%). Patients with AKI requiring RRT have high mortality, but survivors have good rates of RRT recovery. Podcast: This article contains a podcast at https://www.asn-online.org/media/podcast/K360/2020_12_31_KID0004282020.mp3.

Nanoparticle Based Treatment for Cardiovascular Diseases.

Nanotechnology has gained increased attention for delivering therapeutic agents effectively to the cardiovascular system. Heart targeted nanocarrier based drug delivery is a new, effective and efficacious approach for treating various cardiac related disorders such as atherosclerosis, hypertension, and myocardial infarction. Nanocarrier based drug delivery system circumvents the problems associated with conventional drug delivery systems, including their nonspecificity, severe side effects and damage to the normal cells. Modification of physicochemical properties of nanocarriers such as size, shape and surface modifications can immensely alter its invivo pharmacokinetic and pharmacodynamic data and will provide better treatment strategy. Several nanocarriers such as lipid, phospholipid nanoparticles have been developed for delivering drugs to the target sites within the heart. This review summarizes and increases the understanding of the advanced nanosized drug delivery systems for treating cardiovascular disorders with the promising use of nanotechnology.

Septic pulmonary emboli causing recurrent bilateral pneumothoraces in a patient with right sided endocarditis: A case report and review of literature.

Patients with a history of drug abuse and right sided endocarditis are prone to develop septic pulmonary emboli. Pneumothorax is a rare complication of septic pulmonary emboli reported in the literature, likely due to the rupture of thin-walled septic cavitary lesions resembling pneumatoceles into the pleural space. Only seven cases (including our case) of pneumothorax from septic pulmonary emboli due to right sided endocarditis have been described in the literature. Our patient is the first reported case of recurrent bilateral pneumothorax due to septic pulmonary emboli and tricuspid valve endocarditis.

"Sacred Pause" in the ICU: Evaluation of a Ritual and Intervention to Lower Distress and Burnout.

BACKGROUND: Increased exposure to deaths in the intensive care unit (ICU) generate grief among ICU staff, which remains unresolved most of the time. Unresolved grief becomes cumulative and presents a risk factor for burnout. "sacred pause" is a ritual performed at patient's death to honor the lost life and recognize the efforts of the health-care team. OBJECTIVE: To study the impact of the ritual of sacred pause on the attitudes and behaviors of the ICU physicians and nurses. METHODS: Ten-question online anonymous survey was sent to ICU physicians and nurses in the medical ICU of a tertiary care hospital in July 2017. RESULTS: Thirty-four ICU team members completed the survey including 12 physicians and 22 nurses. Seventy sacred pause rituals were performed from July 2016 to June 2017. Seventy-nine percent respondents believed that the ritual brought closure and helped them overcome the feelings of disappointment, grief, distress, and failure after the death of their patient in ICU. Seventy-three percent agreed that the ritual has instilled and encouraged a sense of team effort. Eighty-two percent responded that the ritual makes their efforts feel appreciated. Many felt that the ritual should be a universal phenomenon in all ICUs. Only 55% respondents felt that the practice has a potential to decrease ICU burnout, many of them (42%) were undecided. CONCLUSION: Sacred pause brings closure, prevents cumulative grief and distress, builds resilience, promotes team effort, and improves professional satisfaction of ICU team. It may lower burnout syndrome in ICU, but further studies are warranted.

Intensive care unit complications and outcomes of adult patients with hemophagocytic lymphohistiocytosis: A retrospective study of 16 cases.

AIM: To study the management, complications and outcomes of adult patients admitted with hemophagocytic lymphohistiocytosis (HLH) in the intensive care unit (ICU). METHODS: We performed a retrospective observational study of adult patients with the diagnosis of "HLH" admitted to the two academic medical ICUs of Baylor College of Medicine between 01/01/2013 to 06/30/2017. HLH was diagnosed using the HLH-2004 criteria proposed by the Histiocyte Society. RESULTS: Sixteen adult cases of HLH were admitted to the medical ICUs over 4 years. Median age of presentation was 49 years and 10 (63%) were males. Median Sequential Organ Failure Assessment (SOFA) score at the time of ICU admission was 10. Median ICU length of stay (LOS) was 11.5 d and median hospital LOS was 29 d. Septic shock and acute respiratory failure accounted for majority of diagnoses necessitating ICU admission. Septic shock was the most common ICU complication seen in (88%) patients, followed by acute kidney injury (81%) and acute respiratory failure requiring mechanical ventilation (75%). Nine patients (56%) developed disseminated intravascular coagulation and eight (50%) had acute liver failure. 10 episodes of clinically significant bleeding were observed. Multi system organ failure was the most common cause of death seen in 12 (75%) patients. The 30 d mortality was 37% (6 cases) and 90 d mortality was 81% (13 cases). There was no difference in mortality based on age (above or less than 50 years), SOFA score on ICU admission (more than or less than 10), immunosuppression, time to diagnose HLH or direct ICU admission versus floor transfer. CONCLUSION: HLH is a devastating disease associated with poor outcomes in ICU. Intensivists need to have a high degree of clinical suspicion for HLH in patients with septic shock/multi system organ failure and progressive bi/pancytopenia who are not responding to standard management in ICU.

Diffuse Large B-Cell Lymphoma with Secondary Hemophagocytic Lymphohistiocytosis Presenting as Acute Liver Failure.

Hemophagocytic lymphohistiocytosis (HLH) and newly diagnosed malignant infiltration of liver are rare presentations of acute liver failure associated with poor prognosis. We report a case of a patient with acute liver failure caused by malignant infiltration by diffuse large B-cell lymphoma and secondary HLH.

Critical care management and intensive care unit outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

AIM: To study the early postoperative intensive care unit (ICU) management and complications in the first 2 wk of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: Our study is a retrospective, observational study performed at Icahn School of Medicine at Mount Sinai, quaternary care hospital in New York City. All adult patients who underwent CRS and HIPEC between January 1, 2007 and December 31, 2012 and admitted to ICU postoperatively were studied. Fifty-one patients came to the ICU postoperatively out of 170 who underwent CRS and HIPEC therapy during the study period. Data analysis was performed using descriptive statistics. RESULTS: Of the 170 patients who underwent CRS and HIPEC therapy, 51 (30%) came to the ICU postoperatively. Mean ICU length of stay was 4 d (range 1-60 d) and mean APACHE II score was 15 (range 7-23). Thirty-one/fifty-one (62%) patients developed postoperative complications. Aggressive intraoperative and postoperative fluid resuscitation is required in most patients. Hypovolemia was seen in all patients and median amount of fluids required in the first 48 h was 6 L (range 1-14 L). Thirteen patients (25%) developed postoperative hypotension with seven requiring vasopressor support. The major cause of sepsis was intraabdominal, with 8 (15%) developing anastomotic leaks and 5 (10%) developing intraabdominal abscess. The median survival was 14 mo with 30 d mortality of 4% (2/51) and 90 d mortality of 16% (8/51). One year survival was 56.4% (28/51). Preoperative medical co morbidities, extent of surgical debulking, intraoperative blood losses, amount of intra op blood products required and total operative time are the factors to be considered while deciding ICU vs non ICU admission. CONCLUSION: Overall, ICU outcomes of this study population are excellent. Triage of these patients should consider preoperative and intraoperative factors. Intensivists should be vigilant to aggressive postop fluid resuscitation, pain control and early detection and management of surgical complications.

Plasmapheresis for Refractory Pruritus due to Drug-Induced Cholestasis.

Pruritus can be a distressing symptom seen in various cholestatic disorders. It is treated with medications like bile acid sequestrants. Drug-induced cholestasis usually resolves with withdrawal of the causative medication. We describe a case of refractory pruritus due to drug-induced cholestasis, not improved with withdrawal of the drug, managed effectively with multiple sessions of plasmapheresis.

A US Multicenter Study of Safety and Efficacy of Fully Covered Self-Expandable Metallic Stents in Benign Extrahepatic Biliary Strictures.

BACKGROUND: Endoscopic therapy is considered first line for management of benign biliary strictures (BBSs). Placement of plastic stents has been effective but limited by their short-term patency and need for repeated procedures. Fully covered self-expandable metallic stents (FCSEMSs) offer longer-lasting biliary drainage without the need for frequent exchanges. AIMS: The aim of this study was to assess the efficacy and safety of FCSEMS in patients with BBS. METHODS: A retrospective review of all patients who underwent ERCP and FCSEMS placement at five tertiary referral US hospitals was performed. Stricture resolution and adverse events related to ERCP and/or stenting were recorded. RESULTS: A total of 123 patients underwent FCSEMS placement for BBS and 112 underwent a subsequent follow-up ERCP. The mean age was 62 years (±15.6), and 57% were males. Stricture resolution occurred in 81% of patients after a mean of 1.2 stenting procedures (mean stent dwell time 24.4 ± 2.3 weeks), with a mean follow-up of 18.5 months. Stricture recurrence occurred in 5 patients, and 3 patients required surgery for treatment of refractory strictures. Stent migration (9.7%) was the most common complication, followed by stent occlusion (4.9%), cholangitis (4.1%), and pancreatitis (3.3%). There was one case of stent fracture during removal, and one stent could not be removed. There was one death due to cholangitis. CONCLUSIONS: Majority of BBS can be successfully managed with 1-2 consecutive FCSEMS with stent dwell time of 6 months.

Theophylline toxicity leading to suicidal ideation in a patient with no prior psychiatric illness.

Suicidal behavior is a common psychiatric emergency and is associated with psychiatric illness and history of prior suicide attempts. Neuropsychiatric manifestations related to theophylline toxicity are well described in literature. We report a case of theophylline toxicity manifesting as suicidal ideation in a patient with no prior psychiatric illness.

Poor compliance with ACG guidelines for nutrition and antibiotics in the management of acute pancreatitis: a North American survey of gastrointestinal specialists and primary care physicians.

CONTEXT: Despite recent updates in the treatment of acute pancreatitis emphasizing enteral nutrition over parenteral nutrition as well as minimizing antibiotic usage, mortality rates from acute pancreatitis have not improved. Data has been limited regarding physician compliance to these guidelines in the United States. METHODS: A 20 question survey regarding practice patterns in the management of acute pancreatitis was distributed to physicians at multiple internal medicine and gastroenterology conferences in North America between 2009 and 2010. Responses were analyzed using the chi-square test and multivariate logistic regression. RESULTS: Out of 406 available respondents, 43.3% of physicians utilize total parenteral nutrition/peripheral parenteral nutrition (TPN/PPN) and 36.5% utilize nasojejunal (NJ) feedings. The preferred route of nutrition was significantly related to practice type (P<0.001): academic physicians were more likely to use NJ tube feeding than private practice physicians (52.1% vs. 19.9%) while private practitioners were more likely to utilize TPN/PPN than academic physicians (70.2% vs. 20.5%). Gastroenterologists and primary care physicians were equally non-compliant as both groups favored parenteral nutrition. Multivariate logistic regression demonstrated that practice type (P<0.001) was the only independent predictor of route of nutrition. Most survey respondents appropriately do not routinely utilize antibiotics for acute pancreatitis, but when antibiotics are initiated, they are for inappropriate indications such as fever and infection prophylaxis. CONCLUSIONS: Many North American physicians are noncompliant with current ACG practice guidelines for the use of artificial nutrition in the management of acute pancreatitis, with overuse of TPN/PPN and underutilization of jejunal feedings. Antibiotics are initiated in acute pancreatitis for inappropriate indications, although there are conflicting recommendations for antibiotics in severe acute pancreatitis. Improved compliance with guidelines is needed to improve patient outcomes.