Increased Incidence, Morbidity, and Mortality in Human Coronavirus NL63 Associated with ACE Inhibitor Therapy and Implication in SARS-CoV-2 (COVID-19).

BACKGROUND: The endemic human coronavirus NL63 strain (HCoV-NL63) employs angiotensin-converting enzyme 2 (ACE-2) receptors on cell surfaces to infect hosts in the same manner as SARS-CoV and the novel SARS-CoV-2. It has been proposed that patients on angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin receptor blockers (ARB) therapy infected with SARS-CoV-2 have a higher mortality rate due to over-expression of ACE-2 receptors. AIM: We sought to evaluate the impact of ACE-I/ARB on infectivity of various endemic coronavirus strains, hypothesizing that rates of ACE-I use among patients with HCoV-NL63 would be higher compared to other endemic coronavirus strains that do not utilize the ACE-2 receptor. DESIGN/METHODS: A retrospective cohort study was designed to evaluate a total 466 subjects with a positive respiratory pathogens panel for one of the endemic coronavirus strains. Rate of ACE-I/ARB use among each coronavirus strain and clinical outcomes from the 88 HCoV-NL63 positive subjects was collected. RESULTS: Analysis revealed a higher rate of ACE-I (p=0.006) use among the HCoV-NL63 positives compared to the other three endemic coronavirus strains. The rate of invasive mechanical ventilation (p=0.007) and 90-day mortality (p=0.045) among HCoV-NL63 positives on ACE-I therapy was higher compared to those HCoV-NL63 positives not on ACE-I therapy. CONCLUSION: Concurrent therapy with an ACE-I was associated with an increased rate and severity of infection with the HCoV-NL63. This association was not found in infected patients on concurrent ARB therapy. These findings support the importance of further evaluation in patients on these therapies who are infected with the novel coronavirus SARS-CoV-2.

Patient Perception of Vaping in the Midst of the Electronic Cigarette and Vaping Product Associated Lung Injury (EVALI) Epidemic.

PURPOSE OF STUDY: EVALI has reached epidemic proportions. With the increasing prevalence, new information has come to light regarding the safety of electronic cigarettes. We investigate the impact of the recent EVALI epidemic on patient perception surrounding vaping. METHODS: An anonymous survey was developed to evaluate patient perception regarding vaping. The survey was administered to adult patients at various clinics at University of Missouri. A total of 287 survey responses were analyzed. RESULTS: In all, 81.5% of respondents reported that e-cigarettes are unsafe, 73.2% did not feel that the absence of THC oils or vitamin E acetate made e-cigarettes safer, and 55.1% felt that e-cigarettes are less safe than traditional cigarettes. A majority (76%) felt that e-cigarettes/vaping products should be more regulated and pose a public health concern. Most surprising, 67.6% of participants answered that they knew somebody who was negatively affected by EVALI. CONCLUSION: The survey responses suggest that the current EVALI epidemic is changing the public's perception and the narrative surrounding safety of e-cigarettes and vaping products.

A Pregnant Woman Presenting With Progressively Worsening Dyspnea and Pneumothorax.

CASE PRESENTATION: A 29-year-old Ukrainian woman presented to the obstetric clinic at 28 weeks' gestation with pregnancy complicated by intrauterine growth restriction. She reported progressively worsening dyspnea during her pregnancy and was found to have significant hypoxia with an oxygen saturation of 84% on room air prompting admission for further evaluation. Oxygen saturation improved to 92% on 10 L of supplemental oxygen. On further questioning, she was found to have a history significant for pleurodesis as a treatment for recurrent pneumothoraces and nephrectomy for a benign renal mass several years prior while living in Ukraine.

Understanding the Knowledge Gap and Assessing Comfort Level among Healthcare Professionals Who Provide Inhaler Education.

Inhaled medications play a pivotal role in the management of COPD and asthma. Provider knowledge and ability to teach various devices is paramount as poor inhaler technique directly correlates with worse disease control. The goal of our survey was to assess the knowledge and comfort level with various inhaled devices among providers involved in patient inhaler education. We constructed a 20-question survey consisting of a five-question Likert scale-based comfort assessment and a 15-question multiple-choice inhaler knowledge test that was distributed both internally and nationwide. Groups surveyed included internal medicine residents, family medicine residents, pulmonary fellows, respiratory therapists, nursing staff, and pharmacists. A total of 557 providers responded to the survey. The overall correct response rate among all respondents was only 47%. There was no significant difference between correct response rates among prescribers (internal medicine residents, family medicine residents, and pulmonary fellows) and non-prescribers (respiratory therapists, nursing staff, and pharmacists), 47% and 47%, respectively (p = 0.6919). However, respiratory therapists had the overall highest correct response rate of 85%. Over 72% of respondents indicated that they educate patients on inhaler technique as part of their clinical duties. Furthermore, the correct response rates for various inhaler devices varied with 55% among metered dose inhalers, 52% among dry powder inhalers, and 34% among soft-mist inhalers. Our study reveals that there is a continued need for education on the subject of inhaler devices among providers given their overall poor knowledge, particularly in an era of fast-changing inhaler devices. We continue without knowing what we teach.

The case of a 72-Year-Old Male with Hematemesis and Pneumomediastinum due to Acute Bacterial Esophageal Necrosis.

Acute esophageal necrosis (AEN) is a relatively uncommon presentation of esophagitis. AEN is characterized by black necrotic esophageal tissue and is associated with high mortality rates. We discuss the case of a 72-year-old Caucasian male who was admitted to the medical intensive-care unit (MICU) for evaluation of pneumomediastinum. CT of the chest revealed a right lower lobe consolidation, pneumomediastinum, and marked thickening of the distal esophagus. Vital signs on arrival revealed a temperature of 38.3° Celsius, heart rate of 92 beats per minute, respiratory rate of 30 breaths per minute, blood pressure of 144/65, and oxygen saturation of 97% on 15 liters of supplemental oxygen via non-rebreather. Laboratory studies on arrival were remarkable for a white blood cell (WBC) count of 19.75 x109/L, procalcitonin of 3.53 ng/mL, and C-reactive protein (CRP) level 43.95 mg/dL. The patient was intubated for acute hypoxemic respiratory failure and started on intravenous (IV) pantoprazole as well as broad-spectrum antibiotics for possible pneumonia. Bedside bronchoscopy showed no obvious airway deformities or perforations on inspection but did reveal thick copious secretions that were sent for culture. Thoracic surgery was consulted, and an esophagogastroduodenoscopy (EGD) was performed, which demonstrated no obvious tear or perforation. However, it did show swollen and black mucosa primarily involving the distal esophagus. Tissue cultures from the EGD grew Klebsiella pneumoniae, which was also grown from the bronchial wash and bronchoalveolar lavage. EGD findings were consistent with AEN. Despite extensive supportive care, the patient ultimately expired. We propose that people with AEN who present with pneumomediastinum and those in whom AEN is found to be secondary to a bacterial cause require not only supportive measures but also prompt surgical consultation.

Avoiding Unnecessary Repeat Laboratory Testing.

We present a 44-year-old Caucasian female with a history of diabetes mellitus admitted to the intensive care unit (ICU) for refractory hypoglycemia with an initial blood glucose of 39 mg/dl. The initial evaluation included a random insulin level, C-peptide, Hemoglobin A1c, and a sulfonylurea screen that were ordered when the patient's blood sugar was 39 mg/dL. She was discharged after demonstrating euglycemia. The test results for sulfonylurea screen, insulin, and C-peptide levels were obtained one day after discharge. The insulin level was elevated, and C-peptide was inappropriately low, establishing the diagnosis of surreptitious exogenous insulin use. Four days after discharge, the patient was readmitted to the same ICU with a similar presentation of refractory hypoglycemia. Once again, the sulfonylurea screen, along with the insulin and C-peptide levels were ordered as there was no mention of the previously obtained results in the discharge summary. The discrepancy between random insulin and C-peptide levels reaffirmed the diagnosis of surreptitious exogenous use of insulin. As high-value medical care becomes a focal point in medicine, the costs, root causes, and impacts of inappropriate laboratory testing must be understood. Upwards of 25% of ordered laboratory tests are unnecessary. Physicians' failure to follow-up on results of correctly ordered tests and repeat testing despite established diagnosis is a significant cause of unneeded laboratory testing. Best practice guidelines recommend a reduction in unnecessary laboratory testing by implementing computer-based solutions to maximize the identification of duplicate requests and to promote clinical education at the time of laboratory test ordering.

Diffuse Alveolar Hemorrhage: An Uncommon Manifestation of Vaping-associated Lung Injury.

Vaping involves the use of a device to deliver aerosolized nicotine and tetrahydrocannabinol (THC) oils to the lungs. Vaping continues to increase in popularity; however, because it is a novel drug delivery system there is little evidence regarding its safety and long-term consequences. Here, we present a 22-year-old Caucasian male who was admitted with acute hypoxic respiratory failure and massive hemoptysis. Contrasted computed tomography of the chest demonstrated ground glass opacities throughout all lung fields and bilateral pulmonary emboli. Bronchoalveolar lavage revealed increased red blood cell counts in serial aliquots, consistent with the diagnosis of diffuse alveolar hemorrhage (DAH). An extensive workup did not reveal an etiology for the DAH. However, further history was obtained, and the patient divulged daily vaping of THC. E-cigarette, or vaping, product use associated lung injury (EVALI) consists of a myriad of different lung injury patterns. Our case illustrates an uncommon presentation of EVALI with DAH and multiple pulmonary emboli.