Bilateral Pulmonary Edema Research Articles

Is the female sex a risk factor for heart failure after myocardial infarction?

Abstract Background In previous observations, female sex was associated with heart failure after myocardial infarction (MI). However, women were older and had more risk factors and were not treated the same as men. Purpose Our aim was to investigate the differential impact of sex on heart failure (including cardiogenic shock) and outcome in a propensity score matched population with MI who had undergone percutaneous coronary intervention (PCI) and the association between sex, heart failure and long-term mortality. Methods Data from 3624 (30.6% women) MI patients who underwent PCI at our institution were analyzed. Propensity-score matching analysis was performed to adjust for differences in baseline characteristics between men and women. After propensity matching, the sample comprised 2170 patients (1085 women and 1085 men). Heart failure was defined by clinical criteria (bilateral pulmonary rales, S3 gallop, edema or cardiogenic shock) and/or pulmonary edema on chest X-ray and/or ejection fraction <30%. The data were analyzed using descriptive statistics. The median follow-up time was 27 months (25th, 75th percentile: 9,48). Results In hospital, 329 (16.4%) patients developed heart failure, with a similar incidence in men and women (156(15.5%) vs. 173(17.2%);p=0.33) (Figure 1). Furthermore, female sex was not associated with heart failure either univariately (OR 1.13;95%CI 0.89-1.43;p=0.31) or after adjustment for confounding factors (aOR 1.27;95% CI 0.96-1.66;p=0.093). Age, hypertension, hyperlipidemia, ST- elevation MI, and P2Y12 receptor inhibitors were associated with heart failure. We followed the patients for up to six years. At the end of the observation period, 330(16.4%) patients had died. The mortality rate was similar in both sexes (159(15.8%) men died compared to 171(17.0%) women; p=0.51) (Figure 2). In addition, sex was not associated with long-term mortality (aHR 1.11;95%CI 0.88-1.40;p=0.38) after adjusting for confounders. In-hospital heart failure was independently associated with long-term mortality (aHR 2.64;95%CI 2.04-3.41;p<0.0001). Hyperlipidemia, age, ST- elevation MI, radial access, P2Y12 receptor inhibitor and GFR were also associated with long-term mortality. Conclusions Our results suggest that sex itself is not associated with heart failure after MI when women are treated similarly to men, have similar risk factors, and are of similar age. It is more likely that women are more frequently affected by heart failure because they are older, have more risk factors, are less likely to be revascularized, and are less likely than men to be treated with guideline-recommended therapy,Heart failure in men and womenLong-term all-cause mortality

An Adult with Acute Breathlessness and Unilateral Diffuse Alveolar Opacities

Abstract Cardiogenic pulmonary edema is typically bilateral and results from the accumulation of excessive fluid in the interstitial and alveolar spaces of the lungs caused by left ventricular failure. Cardiogenic unilateral pulmonary edema (CUPE) is uncommon and most often documented in severe mitral regurgitation. CUPE in other cardiac diseases such as coronary artery disease is rare and occasionally associated with prolonged lateral decubitus position or vascular perfusion mismatch between lungs either congenital such as pulmonary artery agenesis or acquired due to preexisting lung conditions such as compensatory emphysema following lobectomy. The radiologic opacities of CUPE does not have characteristic features as described with bilateral pulmonary edema. The possibility of CUPE is often not considered initially as its clinical/radiologic features often resemble or are mistaken as pneumonia resulting in diagnostic delay and higher mortality.

Natural Infection with H5N1 Highly Pathogenic Influenza (HPAI) Virus in 5- and 10-Day-Old Commercial Pekin Ducklings (Anas platyrhynchos domesticus).

Highly pathogenic avian influenza (HPAI) has resulted in catastrophic economic losses globally in poultry. This case report describes the diagnostic detection and pathology of HPAI H5N1 in 5-day-old commercial ducklings, which is an atypical age for detection of natural infection of HPAI in poultry. The pathology observed at 5 days of age was also compared to lesions observed in ducklings from the same flock evaluated at 10 days of age before depopulation. The California Animal Health and Food Safety (CAHFS) Laboratory, Tulare, received ten 5-day-old Pekin duckling (Anas platyrhynchos domesticus) carcasses for diagnostic evaluation due to mortality that started increasing at 3 days of age. The most common gross findings included bilateral pulmonary edema with congestion and enlarged, mottled livers and spleens. Microscopically, cerebral neuronophagia, pancreatic necrosis, and interstitial pneumonia with pulmonary edema were observed in the 5-day-old ducklings. Oropharyngeal and cloacal swabs were positive for avian influenza virus (AIV) by real-time reverse transcriptase PCR. The AIV was typed as HPAI, EA/AM 2.3.4.4b H5N1 goose/Guangdong clade lineage by the National Veterinary Services Laboratory. Ducks at the affected premises were depopulated 4 days after the 5-day-old ducklings were submitted to the CAHFS lab, at which time additional tissue samples were collected for comparison to 10-day-old ducklings on the same premises. Differences in microscopic lesions and AIV tissue distribution were observed between the 5-day and 10-day tissues collected. Notably, microscopic lesions were more severe in the brain and pancreas at 10 days of age. Findings in 10-day-old ducklings included cerebral lymphoplasmacytic perivascular cuffing, gliosis, neuronal degeneration, and pancreatic necrosis. AIV antigen distribution and intensity was greatest in the cerebral tissue of the brains at 10 days and in the lungs at 5 days of age. To the authors' knowledge, published studies are limited on AIV natural infection in domestic ducks less than 9 days of age.

Advances and Applications of Lung Organoids in the Research on Acute Respiratory Distress Syndrome (ARDS).

Acute Respiratory Distress Syndrome (ARDS) is a sudden onset of lung injury characterized by bilateral pulmonary edema, diffuse inflammation, hypoxemia, and a low P/F ratio. Epithelial injury and endothelial injury are notable in the development of ARDS, which is more severe under mechanical stress. This review explains the role of alveolar epithelial cells and endothelial cells under physiological and pathological conditions during the progression of ARDS. Mechanical injury not only causes ARDS but is also a side effect of ventilator-supporting treatment, which is difficult to model both in vitro and in vivo. The development of lung organoids has seen rapid progress in recent years, with numerous promising achievements made. Multiple types of cells and construction strategies are emerging in the lung organoid culture system. Additionally, the lung-on-a-chip system presents a new idea for simulating lung diseases. This review summarizes the basic features and critical problems in the research on ARDS, as well as the progress in lung organoids, particularly in the rapidly developing microfluidic system-based organoids. Overall, this review provides valuable insights into the three major factors that promote the progression of ARDS and how advances in lung organoid technology can be used to further understand ARDS.

Mirror syndrome associated with fetal cardiomyopathy

Mirror syndrome is a rare condition of generalized maternal oedema caused by fetal hydrops. A 37-year-old patient was admitted to our hospital because of suspected mirror syndrome caused by fetal cardiomyopathy. At 26th week of gestation patient developed bilateral pulmonary oedema as her condition rapidly deteriorated. Consequently, preterm labor was induced, percutaneous evacuation of fetal ascites was performed, and the patient finally vaginally delivered stillborn fetus. Although the initial postpartum period was severely complicated by hemorrhage, the condition of the patient significantly improved later, and she was discharged seven days after delivery. We believe this case is worth presenting due to its rarity and significant perinatal and obstetric challenges in treatment of those patients. Furthermore, preimplantation genetic testing could be performed to prevent at least some of the cases.

Subphenotypes of Acute Respiratory Distress Syndrome: Advancing Towards Precision Medicine.

Acute respiratory distress syndrome (ARDS) is a common cause of severe hypoxemia defined by the acute onset of bilateral non-cardiogenic pulmonary edema. The diagnosis is made by defined consensus criteria. Supportive care, including prevention of further injury to the lungs, is the only treatment that conclusively improves outcomes. The inability to find more advanced therapies is due, in part, to the highly sensitive but relatively non-specific current syndromic consensus criteria, combining a heterogenous population of patients under the umbrella of ARDS. With few effective therapies, the morality rate remains 30% to 40%. Many subphenotypes of ARDS have been proposed to cluster patients with shared combinations of observable or measurable traits. Subphenotyping patients is a strategy to overcome heterogeneity to advance clinical research and eventually identify treatable traits. Subphenotypes of ARDS have been proposed based on radiographic patterns, protein biomarkers, transcriptomics, and/or machine-based clustering of clinical and biological variables. Some of these strategies have been reproducible across patient cohorts, but at present all have practical limitations to their implementation. Furthermore, there is no agreement on which strategy is the most appropriate. This review will discuss the current strategies for subphenotyping patients with ARDS, including the strengths and limitations, and the future directions of ARDS subphenotyping.

Acute coronary events in SARS-CoV-2 - causal or incidental?

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus can damage respiratory, cardiovascular system by various mechanism which can lead to increased morbidity and mortality. Aims and Objectives: The aim of the study was to assess incidence of acute coronary syndrome (ACS) in moderate to severe cases of infection with SARS-CoV-2. Materials and Methods: This was an observational cross-sectional study including 60 patients of age ≥18 years of either gender presenting to GTB Hospital diagnosed as positive for SARS-CoV-2 by RT-PCR and/or Rapid Antigen Test and belonging to moderate and severe category without any prior history of respiratory, cardiac, gastrointestinal, renal illness, long-term corticosteroid, or immunomodulator use. The cardiac involvement was assessed by history, clinical examinations, and investigations. Results: Cardiovascular involvement was present in 25% patients. Cardiac involvement included ACS including ST elevation myocardial infarction (STEMI) (3.3%), non-STEMI (10%), unstable angina (1.67%), left ventricular hypertrophy (8.3%), bundle branch block (3.3%), atrial fibrillation (1.67%), and bradycardia (1.67%). Raised cardiac enzyme levels positively correlated with ECG abnormalities. Respiratory involvement was seen in 85% of patients. among which 56.7% patients in severe category, 41.67% patients in moderate category, and 1.67% patients in mild category as per CTSI scoring. There was lung parenchymal involvement with ground glass opacities in bilateral lungs (68.3%), lobar consolidation (6.7%), cavitatory lesion (5%), pulmonary edema (5%), pneumothorax (3.3%), emphysematous changes (3.3%), and bilateral pleural effusion (3.3%). Conclusion: ACS occurs frequently in patients with SARS-CoV-2 and it is associated with complications such as congestive heart failure, bundle branch block, atrial fibrillation, bradycardia, and heart block.

A salvaged case of severe pulmonary edema related to type A acute aortic dissection requiring preoperative ECMO

Preoperative utilization of ECMO in type A aortic dissection (TAAD) patient is a rare situation with limited reports. A 51-year-old man presenting with acute aortic insufficiency and coronary malperfusion induced by TAAD was referred to our hospital for surgical repair. After arrival at the Emergency Department, oxygenation of the patient was deteriorated due to ongoing severe bilateral pulmonary edema related to aortic insufficiency and left coronary artery (LCA) obstruction. Following the introduction of preoperatively veno-arterial ECMO support as a “bridge to surgery,” emergent ascending aortic repair was carried out. Closure of the false lumen was performed with BioGlue® (Cryolife, Kennesaw, GA, USA). Gluing of the left coronary sinus was carefully accomplished under the insertion of catheter into the LCA. Adequate aortic valve coaptation was confirmed by water test after closure of the false lumen. Construction of the proximal and distal aortic stump was simply done with our Hydrofit®-gluing (Terumo Corporation, Tokyo, Japan) felt strip method to minimize the bleeding. Evaluation by TEE before CPB weaning revealed disappearance of valve insufficiency. Postoperative course of the patient was uneventful. We successfully salvaged the severe pulmonary edema patients related to TAAD required preoperative ECMO support.

Unilateral Pulmonary Edema in Patients With Acute Mitral Regurgitation Caused by Chordal Rupture.

Background: Cardiogenic unilateral pulmonary edema (UPE) has been reported as an unusual condition and to occur in association with severe mitral regurgitation (MR). However, the prevalence of UPE in patients with severe MR remains unknown. Methods and Results: Among 143 consecutive patients with chordal rupture and significant MR, 38 patients with acute severe MR were studied. The prevalence of UPE was 50% (19 patients); all these patients had right-sided UPE. Eight (21%) patients had bilateral pulmonary edema (BPE). All 8 patients with BPE and 18 of 19 patients with UPE had chordal rupture of the posterior leaflet. All patients with UPE and BPE had severe MR with similar left atrial size. Chest radiographs taken ≤48 h from symptom onset diagnosed UPE in 15 of 19 (79%) patients and BPE in 3 of 8 (38%) patients (P=0.037). Chest radiographs taken >48 h from symptom onset diagnosed UPE in 4 (21%) patients and BPE in 5 (62%) patients (P=0.037). Conclusions: The prevalence of UPE was estimated as 50%; it was most frequently right sided and almost always associated with chordal rupture of the posterior leaflet. UPE is not rare, but common, particularly shortly after the development of acute severe MR caused by chordal rupture.

ODP390 Metastatic Gestational Trophoblastic Neoplasia Masquerading as Thyroid Storm in a Girl with Molar Pregnancy and Hyperthyroidism

Abstract The Case Patient is a 16-year-old female with molar pregnancy, admitted for D&C, referred for hyperthyroidism, concern for thyroid storm. A month prior, she presented with heavy vaginal bleeding, morning sickness. Ultrasound showed blighted ovum. HCG was significantly elevated, 668,123 mIU/mL. TSH was low at 0. 01 mIU/L, Free T4 elevated 2.3 ng/dL. No family history of thyroid dysfunction. She was for was noted to have respiratory distress, hypoxia, and tachycardia in the 120s post-operatively. LFTs normal, no fever, jaundice or CNS manifestations. Chest CT showed bilateral lower lobe localized pulmonary edema concerning for trophoblastic fluid embolism vs thyroid storm. BWPS = 40. She was placed on PTU, beta blockade, Lugol's iodine, and hydrocortisone. Repeat chest CT showed diffuse pulmonary nodules consistent with gestational trophoblastic neoplasm (GTN). No other metastasis on further imaging (chest, abdomen, pelvis, brain). Clinical status improved, FT4 normalized 5 days after starting treatment. TRAbs negative. She was discharged on Methimazole and Atenolol, which were eventually discontinued. HCG levels significantly decreased after D&C but remained detectable on follow-up. Endocervix/uterine curettage showed intraplacental choriocarcinoma arising within a complete hydatidiform mole. She is followed by Oncology and currently undergoing chemotherapy. Discussion HCG-mediated hyperthyroidism include gestational transient thyrotoxicosis, hyperemesis gravidarum, and trophoblastic hyperthyroidism (TH). Due to significant homology between TSH and the beta-subunit of HCG, HCG can cause hyperthyroidism. 2-60% of women with trophoblastic disease may have symptomatic hyperthyroidism at time of diagnosis which can be severe. Patients with GTN (choriocarcinoma in our case) have a higher likelihood of TH, as HCG exceeds 100,000 mIU/mL. Choriocarcinoma is the most aggressive type of GTN characterized by vascular invasion and widespread metastases, of which the most common sites are vagina and lungs. Patients with pulmonary metastasis my present with respiratory distress, chest pain, cough or hemoptysis. Our patient was initially thought to have impending thyroid storm mainly from findings of pulmonary edema, respiratory distress, tachycardia, and precipitant history (D&C), and was managed as such while further workup was being undertaken. Realization that the initial chest CT findings of pulmonary edema were actually related to multiple pulmonary nodules and GTN made thyroid storm less likely. Hyperthyroidism typically resolves with decreasing HCG levels in TH. Indeed, our patient no longer needed ATD once her HCG levels subsided s/p D&C. Conclusion One of the most common sites of metastasis in GTN is the lungs. An acute presentation of respiratory distress and pulmonary findings on chest imaging upon simultaneous discovery of TH may complicate management as thyroid storm needs to be considered. Although a higher index of suspicion for metastatic GTN should be made in this situation, a conservative management approach of treating for possible impending thyroid storm until definitive diagnosis has been established is prudent. Presentation: No date and time listed

UNDERSTANDING THE NEED FOR A BROAD DIFFERENTIAL DIAGNOSIS: A CASE OF PNEUMONIC TULAREMIA

UNDERSTANDING THE NEED FOR A BROAD DIFFERENTIAL DIAGNOSIS: A CASE OF PNEUMONIC TULAREMIA

USE OF POINT-OF-CARE ULTRASONOGRAPHY (POCUS) TO PREVENT DILTIAZEM-INDUCED CARDIOGENIC SHOCK

USE OF POINT-OF-CARE ULTRASONOGRAPHY (POCUS) TO PREVENT DILTIAZEM-INDUCED CARDIOGENIC SHOCK

S3143 Rare Case of Plasma Cell Infiltration-Induced Cirrhosis

Introduction: Multiple myeloma (MM) is a type of malignancy that arises from the unorganized replication of plasma cells within the bone marrow. The overproduction of these cells damages systems throughout the body leading to early asymptomatic symptoms that can rapidly progress to systemic signs of disease. Liver involvement with MM is less common and generally occurs through plasma cell infiltration, light chain/amyloid deposition, and biliary obstruction. Though it can occur, the probability of it presenting near the time of diagnosis of MM is very rare and associated with poorer outcomes. Case Description/Methods: A 59-year-old male presented with generalized weakness, shortness of breath and weight gain. Physical exam showed sign of ascites and hepatomegaly. PMH was significant for esophageal cancer and a recent diagnosis of MM. No history of acute or chronic liver disease or cirrhosis risk factors. CT scan showed cardiomegaly, bilateral pleural effusions, pulmonary edema, and cirrhosis with abdominal ascites. Labs was unremarkable other than normocytic anemia. An echocardiogram showed mild reduced ejection fraction (47%) with speckle tracking suggestive of cardiac amyloidosis. Abdominal ultrasound confirmed appearance of cirrhosis, ascites, and right pleural effusion. Cirrhosis work up revealed negative hepatitis panel, normal alpha-1 antitrypsin, and normal ceruloplasmin. EGD was performed and ruled out extracellular vesicles (EV) but noted type I isolated gastric varices. Liver biopsy confirmed cirrhosis and showed portal tract damage with severe extensive plasma cell infiltration. Additionally, fragments of hepatic parenchymal showed disrupted lobular architecture by septal fibrosis and nodular formation. Immunohistochemistry was positive for CD3, CD20, CD5, BCL2, CD79a, and CD138 as well as increased lambda light chain compared to free kappa light chain. Despite extensive treatment including repeated thoracentesis and paracentesis, patient eventually developed in to decompensating liver cirrhosis (Figure 1). Discussion: In previous studies, plasma cell infiltration of the liver was seen in about 40% of cases of MM, but rarely lead to cirrhosis. This case is unique in that the patient had liver failure caused by cirrhosis and that it was some of the presenting symptoms. Whether due to masked signs or aggressive onset, the outcome for this diagnosis is poor and more specific factors observing liver function could have provided a more favorable outcome.Figure 1.: Cirrhosis secondary to plasma cell infiltration. Table 1. - Total Protein 5.0 g/dL Serum Ascites Albumin Gradient (SAAG) 1.9 g/dL Left Hepatic Vein Pressure 25 Hg Left Portal Vein Pressure 29 Hg Portosystemic Pressure Gradient 5 Hg EUS Guided Shear Wave Elastography of Liver 27 kPa

BIOPROSTHETIC AORTIC VALVE FAILURE IN END-STAGE RENAL DISEASE AND REINTERVENTION

BIOPROSTHETIC AORTIC VALVE FAILURE IN END-STAGE RENAL DISEASE AND REINTERVENTION

Forensic veterinary diagnosis of dog’s fatal poisoning with anticoagulant rodenticide – bromadiolone

One of the objects of the forensic veterinary examination is the animal’s corpses, the death of which occurred suddenly, or from violent actions, including cruel treatment. A variation of the manifestation of cruelty to animals is their deliberate poisoning. Among the wide variety of toxic substances, pesticides, including rodenticides, occupy a significant place. The aim of the study was to develop an algorithm for forensic veterinary diagnostics and evaluation of dog corpses in case of their sudden death from poisoning with anticoagulant rodenticide – bromadiolone. The objects of the study were the seven dog’s corpses, on which a forensic veterinary examination was carried out for the period from 2010 to 2021 with a clinical diagnosis of acute poisoning with lethal fleeting consequences from poisoning with anticoagulant rodenticide – bromadiolone, established during life. The article shows that the general algorithm for the forensic veterinary examination of the corpse of an animal whose death occurred from poisoning includes the following steps: establishing a list of objects provided for research and information about their condition, conditions for conducting forensic veterinary research, applied methods of studies, their registration numbers (if any); study of the case and the animal’s death anamnesis circumstances; study of veterinary documents and individual case materials related to the examination or provided to the expert additionally at his request; forensic veterinary examination of an animal corpse; study of registration data; external examination of the corpse of an animal; internal examination of an animal corpse; additional studies of the corpse: chemical-toxicological, histological (cytological), microbiological, etc.; forensic veterinary diagnosis; synthesizing research; formulation of conclusions (results); formulation an expert opinion. The forensic veterinary diagnosis, established on the basis of the results of a forensic veterinary examination of the corpses of the dogs under examination, is formulated according to the established rubric structure: the main nosologicalunit and its fatal complication(internal bleeding – hematoperitoneum, hemothorax, bilateral pulmonary edema); accompanying nosological units (acute hemorrhagic gastroenterocolitis, acute hemorrhagic endocarditis, general anemia, congestive venous hyperemia of the kidneys, liver and spleen); background nosological units (undifferentiated hepatopathy and nephropathy, chronic pancreatitis, polyarthritis). The positions of the formulated forensic veterinary diagnosis indicate that they are generally characteristic of acute poisoning. The cytogram data analyzed in the article coincide with the data obtained during the forensic veterinary autopsy of animal corpses, indicating that the poison, from which the death of the dogs under examination occurred, belongs to the group of hemolytic toxins. A chemical-toxicological investigation of the contents of the stomach of the corpses of the dogs under expert identified the poisonous substance of the second generation of rodenticides – bromadiolone at a concentration of 10 mg/kg. A complex of investigations has proved that there is a direct necessary causal relationship between the dog’s death and the nature of the poisoning. Key words: forensic veterinary examination, animals, intoxication, poisonous substances, autopsy, chemical and toxicological research, algorithm.

Unexpected pulmonary edema and cardiac arrest following wedge resection of spontaneous pneumothorax -A case report-

BackgroundReexpansion pulmonary edema is a rare but potentially lethal complication. We report a case of suspected reexpansion pulmonary edema that led to cardiac arrest.CaseA 16-year-old male patient underwent wedge resection due to right pneumothorax. The patient showed pink frothy sputum three hours following surgery, and a chest x-ray showed right unilateral pulmonary edema. Thirteen hours following surgery, the patient continuously showed pink frothy sputum and presented with severe hypoxemia, tachypnea, and tachycardia. After transferring to the intensive care unit (ICU), he developed ventricular tachycardia. Cardiopulmonary resuscitation was performed for 32 min. Chest X-ray showed diffuse bilateral pulmonary edema. Extracorporeal membrane oxygenation was performed. During the 65 days of ICU care, the patient became mentally alert. However, follow-up echocardiography revealed severe heart failure.ConclusionsRexpansion pulmonary edema can rapidly progress to diffuse bilateral pulmonary edema. Therefore, careful observation is required for the patients who show signs of pulmonary edema after reexpansion.

Unilateral pulmonary oedema: a case report and literature review

Acute myocarditis is often secondary to an acute virus infection, which can be the first manifestation of upper respiratory tract symptoms, followed by chest tightness, shortness of breath, palpitations, chest pain and other non-specific symptoms. In severe cases, it can quickly progress to serious complications such as heart failure, shock and respiratory failure. Laboratory examinations can show an increase of myocardial injury markers, infection and inflammatory indicators. Cardiac ultrasound can detect the weakening of the myocardial contraction and valve regurgitation. On imaging, bilateral pulmonary oedema demonstrates symmetrical infiltration along the hilum of lung, called the “butterfly shadow”. This current case report describes a patient with unilateral pulmonary oedema caused by myocarditis that was initially misdiagnosed and treated as pneumonia. The patient was subsequently treated with the application of extracorporeal membrane oxygenation and he made a full recovery. A review of this case highlights that when a patient’s symptoms are not typical, a comprehensive examination and evaluation are required to avoid incorrect treatment.

Fatal Intoxication by the Novel Cathinone 4-Fluoro-3-methyl-α-PVP.

A 30 year old non-hispanic white male was found unresponsive at his workplace and admitted to the hospital in cardiac arrest. He was pronounced deceased shortly after arrival. At autopsy the pathologist noted a 176 pound, well-nourished, atraumatic, adult male with significant bilateral frothy pulmonary edema (right lung 930 g and left lung 1,130 g), cardiomegaly (430 g), dilated ventricles and slight cerebral edema. Upon completion of the systematic toxicological analysis scope for the Franklin County Coroner's Office Toxicology Laboratory, no known drugs were found. Further review of the gas chromatography--mass spectrometry (GC--MS) full-scan library summary reports showed an unknown peak in both the blood and urine solid phase extracts. An analogue of α-pyrrolidinovalerophenone (α-PVP) was identified, and a GC--MS selected ion monitoring method was developed to identify and quantitate the presence of 4-fluoro-3-methyl-α-PVP. This method quantified the drug at 26 ng/mL in gray top femoral blood, 30 ng/mL in purple top heart blood and 20 ng/mL in red top vitreous humor. Qualitative presence was also observed in the urine but was not detected in the liver. The decedent's cause of death was determined to be due to fluoro-methyl-PVP toxicity and the manner was ruled to be accidental. Investigational follow-up interviews corroborated drug use by the deceased with a preference of research chemicals and synthetic cannabinoids via the internet. No published literature is available currently, and to the author's knowledge this is the first incident of a fatal death solely attributed to this substituted cathinone.

Protocol for a systematic review and meta-analysis of studies on the use of brain natriuretic peptide and N-terminal brain natriuretic peptide levels in the diagnosis of cardiopulmonary edema in acute respiratory failure

BackgroundDyspnea with bilateral pulmonary edema is common among patients in emergency departments (EDs) or intensive care units (ICUs). For the initial management of patients with this condition, cardiopulmonary edema (CPE) must be differentiated from acute respiratory distress syndrome (ARDS) in clinical settings. Brain natriuretic peptide (BNP) and N-terminal brain natriuretic peptide (NT-proBNP) are useful in distinguishing these conditions. However, current data about the use of these indexes are limited. Hence, we planned to perform a systematic review and meta-analysis to determine the accuracy of the two indexes for the diagnosis of CPE.MethodsWe designed and registered a study protocol for a systematic review and meta-analysis. This study aims to determine the diagnostic accuracy of BNP and NT-proBNP based on the standards of the methodology of the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy and the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies in reporting the findings of this review. We will search PubMed (MEDLINE), Cochrane Library, Embase, www.ClinicalTrials.gov, International Clinical Trials Registry Platform, and Google Scholar. Randomized controlled trials, cross-sectional studies, and observational cohort studies reporting the accuracy in diagnosing CPE among adult patients with dyspnea and bilateral pulmonary edema will be included in the analysis. There will be no limits regarding language and publication date for this review. Two reviewers will independently screen articles, extract data, evaluate for quality and bias using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2), and use Grading of Recommendations Assessment, Development and Evaluation to summarize the strength of body of evidence. Then, a meta-analysis will be performed, and different statistical methods will be used to investigate heterogeneity among studies. A subgroup analysis of elderly patients with left ventricular dysfunction or chronic renal dysfunction will be performed. In the meta-analysis, a hierarchical summary receiver operating characteristic model or a bivariate model will be used in each index test, as appropriate.DiscussionA systematic review and meta-analysis of the accuracy of BNP and NT-proBNP for the diagnosis of CPE will be conducted. The result of this study can help clinicians to identify an appropriate initial treatment for patients with acute respiratory failure, including those with ARDS and CPE. To the best of our knowledge, this will be the first comprehensive systematic review focusing on ARDS management in a specific population.Systematic review registrationPROSPERO ID CRD42020201576

Suicide by ethylene glycol/brake oil poisoning\u2014a case report

BackgroundBrake fluid is used for automobiles. It is a mixture of different glycol derivatives including ethylene glycol and diethylene glycol (DEG) which are metabolized into various toxic metabolites. Fatalities following brake fluid ingestion are rare in forensic practice. Here, we report a case of suicide by brake fluid ingestion complicated with severe renal failure and esophageal and gastric erosions.Case presentationA 52-year-old male, with a history of alcohol dependence and comorbid moderate depression, ingested a bottle of brake fluid (100ml) mixed with alcohol. He had defaulted psychiatric follow-up. He developed severe metabolic acidosis and acute renal failure which necessitated intensive care, other supportive management, and the antidote; ethyl alcohol. On the 2nd day of admission, he developed upper gastrointestinal bleeding with melena. He also had seizures and cardiovascular complications. He died 12 days after hospital admission, and the manner of death was concluded as suicidal. The autopsy revealed congested and edematous brain, flabby and pale heart without evidence of infarction, erythematous trachea, bilateral diffuse pulmonary edema, congested liver, ulcer over the lower 1/3 of the esophagus, and few ulcers in the stomach. Also, the kidneys were edematous, diffusely necrosed, and there were adrenal hemorrhages.ConclusionsThis case report highlights the severity of effects of brake fluid poisoning including the corrosive effect on gastrointestinal mucosa which is rarely encountered in clinical practice.