Medical Floor Research Articles

COVID-19, Mucus Plug, and Immediate Postpartum: A Concerning Triad

<strong>Introduction:</strong> Infections with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can range from asymptomatic, to severe and critical COVID-19. Moreover, it can involve any organ system, thereby having various presentations. Little is known about the disease’s pathogenesis and even less regarding how pregnancy changes the disease’s course. We describe the first case of COVID-19 complicated by lung collapse in the immediate postpartum period. <strong>Case Presentation:</strong> A 29-year-old female was admitted for induction of labor (IOL) due to preeclampsia with severe features. She had no significant medical history, except for tobacco smoking in the past. The patient disclosed recent contact with a family member that tested positive for SARS-CoV-2 but denied any respiratory symptoms. A nasopharyngeal swab was sent. The positive test result became available only when the patient was taken to the operating room to undergo a cesarean section for failed IOL. In the immediate postoperative period, she developed fever, tachypnea, tachycardia, and hypoxia. Physical exam showed decreased breath sounds. A chest X-Ray (CXR) was performed and revealed complete opacification of the left lung (<em><strong>Figure 1</strong></em>). Oxygen supplementation was delivered initially via bilevel positive airway pressure. However, due to persistent hypoxia, the patient was transferred to the Intensive Care Unit (ICU), was intubated and was placed on mechanical ventilation. Bronchoscopy with the removal of mucus plug from the left mainstem bronchus was performed. The respiratory parameters improved. Post-bronchoscopy CXR showed interval partial re-expansion of the left lung (<em><strong>Figure 2</strong></em>). The patient continued to improve on corticosteroids and antibiotics. Subsequently, patient was extubated and transferred to the medical floor on postoperative day three. Five days later, the patient was discharged home with appropriate outpatient follow ups. <strong>Discussion:</strong> There is a lot yet to be known about the pathogenesis of hypoxic respiratory failure in critical COVID-19 patients. While older age, male sex, hypertension, diabetes, and obesity are associated with higher mortality, the pregnancy effect on the disease course is unclear [3]. One study reported a decreased risk of disease severity during pregnancy [4]. At the same time, several case reports described worsening of the disease in the postpartum period [12]. Our case is consistent with such a disease course. Whether pregnancy protects against critical COVID-19, or there are other factors that lead to deterioration postpartum requires further research, so that appropriate actions are taken in consideration for management purposes. <strong>Conclusions:</strong> Little is known regarding how pregnancy changes the course of COVID-19 infection. This clinical vignette describes the first case of COVID-19 complicated by lung collapse in the immediate postpartum period. The patient underwent bronchoscopy, and received steroids and antibiotics, with subsequent improvement in clinical status. Several case reports have described worsening of the disease in the postpartum period. Further research is needed to know what is the effect of pregnancy in the course of COVID-19 infection, so that appropriate management guidelines are developed in these patients.

ARE EARLY WARNING SYSTEMS EFFECTIVE AT PREDICTING CLINICAL DETERIORATION IN PATIENTS WITH COVID-19? A RETROSPECTIVE, SINGLE CENTER STUDY

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Covid-19 affects multiple organs creating a propensity for rapid and fatal deterioration. Previous studies have validated early warning systems as practical bedside tools to identify patients at risk for devastating clinical deterioration. However, few studies have evaluated the efficacy of these models in COVID 19 patients. The Modified Early Warning Score (MEWS) incorporates Respiratory rate, heart rate, systolic blood pressure, temperature, and mentation to tabulate a score. A MEWS cutoff of 5 and above has been proposed as having good sensitivity and specificity at predicting clinical deterioration. This study aims to see if the Modified Early Warning Score system effectively predicts clinical deterioration in the hospitalized COVID 19 population. METHODS: A retrospective electronic medical records review examining consecutive patients admitted to medicine floors with PCR confirmed COVID 19 infection in 2020. We collected patient demographics, Charlson co-morbidity index (CCI) and reviewed if a rapid response and/or transfer to the Intensive care unit (ICU) occurred. MEWS was then calculated at the time of the event, at 6 and 12 hours before the event. Patients who were directly transferred to the ICU from the emergency department were omitted. MDCalc online application was utilized to standardize calculations. RESULTS: 583 electronic medical records were reviewed. A group of 81 (n=81) patients with a median age of 75, 59% white, 59% female, and a median CCI of 5 were identified. Sixty-five patients were transferred to the ICU with a median MEWS of 2, 2, 2 at the transfer time, 6 hours prior, and 12 hours prior, respectively. 16 patients had rapid response codes with a median MEWS of 2, 2, 2 at the time of the code, 6 hours prior and 12 hours prior, respectively. These patients remained on the medical floors. A logistic regression model (OR 0.79 p= 0.25) and Kruskal-Wallis rank-sum test (p= 0.968) failed to show a statistically significant correlation between a MEWS score at any time and transfer to the ICU. CONCLUSIONS: In our patient population MEWS score was not effective in predicting clinical deterioration. The widely available MEWS calculators do not account for oxygen saturation levels or oxygen requirement, which was the most critical factor in determining clinical severity. This, in our opinion, is the limiting factor. We also found that as familiarity with the management of COVID 19 increased and as more resources became available, patients were more likely to remain on the floors rather than being transferred to the ICU. CLINICAL IMPLICATIONS: MEWS score is not valid for detecting clinical deterioration in COVID 19 patients in our study. It falsely underrepresents the severity of illness; therefore, clinicians should use clinical reasoning and objectivity to determine the need for higher level of care. Further studies should focus on determining other predictors of clinical deterioration based on demographic data, symptomology and co-morbidities. DISCLOSURES: No relevant relationships by Abdelrhman Abo-zed, source=Web Response No relevant relationships by Abasin Amanzai, source=Web Response No relevant relationships by Rahul Bollam, source=Web Response No relevant relationships by Leenah Chughtai, source=Web Response No relevant relationships by Bhagat Kondaveeti, source=Web Response No relevant relationships by Jamil Masood, source=Web Response No relevant relationships by Manasi Sejpal, source=Web Response No relevant relationships by Syed Arsalan Zaidi, source=Web Response

396 Objective Markers Associated With Early, Unplanned Transfer to the Intensive Care Unit Following a Rapid Response System Event

Unplanned transfer to the intensive care unit (ICU) within 24 hours of admission from the emergency department (ED) is a marker of unexpected clinical worsening in patients admitted to medical or surgical floors. Higher mortality rates have been seen in patients with delayed transfer to ICU, longer ED stays prior to ICU admission, and among similar groups of patients who developed sepsis on a medical ward compared to those developing sepsis in the ICU. Yet, identifying those patients at risk for clinical deterioration is a challenge and unplanned ICU transfer remains a common occurrence.

S1139 COVID-19 Experience in Patients With Cirrhosis and Clinically Significant Portal Hypertension

Introduction: Patients with underlying cirrhosis have increased mortality from Coronavirus disease 2019 (COVID-19) which correlates with their baseline MELD-Na and Child Turcotte Pugh (CTP) scores.1,2,3 Methods: We performed an institutional review board-approved retrospective review of medical records of all patients with cirrhosis and clinically significant portal hypertension (CSPH) defined by platelet count < 150,000/microL at our institution between 15 March and 15 May of 2020. Results: Of 119 patients with cirrhosis and CSPH, fifteen (12.6%) tested positive for SARS-CoV-2 (12 by nasopharyngeal PCR (GENEXPERT) within our institution; 3 tested positive at outside institutions per patient report). Among both uninfected patients and patients with SARS-CoV-2 infection, a majority of patients had CTP Class A cirrhosis (66.6% vs. 85.6%; p=0.144) (Table 1). Compared to uninfected patients, patients with SARS-CoV-2 infection were younger (median age 67 vs. 70 years; p= 0.010), less likely to be former smokers (20% vs. 49.3%; p=0.034) and had significantly higher MELD-Na scores (median 15 vs. 9; p= 0.001). Of the 12 patients diagnosed with SARS-CoV-2 at our hospital, 4 required supplemental oxygen via nasal cannula or nonrebreather mask on an inpatient medical floor, and 3 had severe disease requiring intubation and mechanical ventilation. Three patients died, two of which had preexisting decompensated liver disease (CTP B or C). None of the patients experienced hepatic decompensating events at the time of their diagnosis or within 90 days of diagnosis. Conclusion: Our single center cohort of patients with cirrhosis and CSPH is in line with previous reports of patients with higher MELD-Na scores being at increased risk of SARS-CoV-2 infection and suggests that patients with decompensated liver disease may have increased mortality from COVID-19.2,3 Compared to previous reports of hepatic decompensation rate of between 37% and 46%,2,3 a key difference in our experience is that no patient experienced hepatic decompensation at the time of their diagnosis or within 90 days of diagnosis. This difference may be explained by our single center experience and small sample size compared to multicenter international studies of larger cohorts.Table 1.: Percent Change in HBV and HCV Incidence from 2010 to 2019 (* p <0.05)

RISPERIDONE-INDUCED MODERATE CENTRAL HYPOTHERMIA

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Risperidone is a second-generation atypical antipsychotic medication (APD) commonly used to treat schizophrenia and bipolar disorder. An infrequent dangerous side effect of APDs is hypothermia, defined as a core body temperature < 35 Celsius (C) [1]. CASE PRESENTATION: A 61-year-old male with hypertension, epilepsy, and schizophrenia was transferred to the emergency department for bilateral lower extremity weakness and slow speech for two days. Medications included carbamazepine and risperidone. He denied being outside in the cold and stated he has a heater at home. A week prior, at a follow-up with his primary physician, his oral temperature was 35.5C. A clinical exam revealed dysphasia and right lower leg weakness. Core rectal temperature was 29.1C, indicating moderate hypothermia. Computed tomography of the head and neck with contrast displayed no acute intracranial abnormality. Blood work revealed a normal thyroid-stimulating hormone, cardiac enzymes, and lactic acid. Urinalysis was negative for infection. Chest x-ray showed no acute abnormalities. Carbamazepine level was in the therapeutic range. In the intensive care unit, he was given warmed intravenous fluids and placed on an external warmer with constant temperature monitoring. Due to central hypothermia concerns, risperidone was held, and external warming was applied. Gradually, core temperature increased to 36.5C over the next 14 hours. He had no signs of infection or metabolic derangements to increase his hypothermia risk. He improved quickly and was downgraded to the medical floor. DISCUSSION: Experimental animal model studies reveal a dose-dependent decline in temperature with risperidone [2]. The exact incidence is higher than reported medical literature based on reports submitted to Food and Drug Administration. Mild hypothermia was common and moderate hypothermia was rare after few years of therapy [3]. Mild hypothermia symptoms are inconspicuous and odd, like apathy, confusion, shivering, or hunger, and are often missed [1]. Clinical thermometers fail to register a temperature < than 34.4C. The risk is more in men and patients with schizophrenia and bipolar disorder. Risk factors such as age > 70 years, other APDs, and organic diseases amplify it [3]. APDs are highly antagonistic at serotonin receptors (5-HT2a) than dopamine (D2) and a2 adrenergic receptors. 5-HT2a and a2 receptors act to increase core temperature while D2 acts to decrease it [3]. APD use leads to an imbalance promoting lower core temperature. Monitoring temperature is essential at APDs initiation and dosage changes. Consideration of other medical comorbidities is a must. CONCLUSIONS: APDs induced moderate central hypothermia is a rare, reversible cause. Failure to recognize it by critical care providers can be fatal. REFERENCE #1: Polderman KH. Mechanisms of action, physiological effects, and complications of hypothermia. Crit Care Med. 2009;37(7 Suppl):S186-202 REFERENCE #2: Oerther S, Ahlenius S. Atypical antipsychotics and dopamine D(1) receptor agonism: an in vivo experimental study using core temperature measurements in the rat. J Pharmacol Exp Ther. 2000;292(2):731-736. REFERENCE #3: : Szota AM, Araszkiewicz AS. The risk factors, frequency and diagnosis of atypical antipsychotic drug-induced hypothermia: practical advice for doctors. Int Clin Psychopharmacol. 2019;34(1):1-8. DISCLOSURES: No relevant relationships by Dennis Chairman, source=Web Response No relevant relationships by Sahithi Katragadda, source=Web Response No relevant relationships by Parth Patel, source=Web Response No relevant relationships by Tarang Patel, source=Web Response No relevant relationships by SACHIN PATIL, source=Web Response

EYES DO NOT SEE WHAT MIND DOESN'T SEEK: A PUZZLING CASE OF METHEMOGLOBINEMIA

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Methemoglobinemia must be considered in the differential diagnosis of hypoxia not improving with supplemental oxygen. CASE PRESENTATION: An 84-year-old male patient with a past medical history of Atrial fibrillation, scleritis, hypertension presented with complaints of fever, chills, shortness of breath for 5 days. Medication history included triamterene/hydrochlorothiazide, Amiodarone, warfarin, ezetimibe, prednisone, and methotrexate. On presentation, the patient was saturating 79% on ambient air and was put on Hiflo nasal oxygen, and saturation improved to 95% on Fi02 100% at 35 l/min. The lab was significant for WBC count of 12.1, procalcitonin 1.06, a chest x-ray revealed bilateral opacities left greater than right with air bronchograms. Chest CT done showed bilateral ground-glass opacities with interposed consolidation. Bronchoscopy was deferred due to the clinical condition of the patient The patient was started on cefepime, doxycycline, methylprednisone, primaquine, and clindamycin for empiric treatment of PCP pneumonia with superimposed bacterial pneumonia and was transferred to ICU for hypotension secondary to sepsis. Pt initially improved clinically and Hiflo was weaned to Fi02 of 50% and maintained saturation above 95%. Over the course of 3-4 days after downgrading to the medical floor, the patient's oxygen requirement uptrend, though a repeat CT scan of the chest showed radiological improvement. An ABG with co-oximetry done showed Po2 of 302 mmHg, saturation of 91 % on Fi02 of 100%, and Methemoglobin content of 7.8%. IV methylene blue infusion was given and the patient's respiratory status improved with the Fio2 requirement coming down. Repeat ABG with co-oximetry showed a methemoglobin level of 2.4%. Repeat labs did not show evidence of hemolysis and G6PD levels were normal. The patient's increased susceptibility to methemoglobinemia would have been due to drug interaction as he is on thiazide diuretic and was started on primaquine increasing the oxidative stress coupled with oxidative stress secondary to sepsis. Primaquine was discontinued and started on atovaquone for PCP treatment. The patient continued to improve clinically. DISCUSSION: Methemoglobinemia can occur after exposure to a number of medications, including primaquine, sulfonamides, nitrates, topical anesthetics. Methemoglobin is the oxidized form of Hb, Oxygen does not bind as easily to the heme subunit with the ferric form of iron. The remaining heme sites have increased affinity for oxygen, resulting in decreased ability to release oxygen to tissues, causing left-shift of the oxygen-hemoglobin dissociation curve leading to tissue hypoxia. A clue to diagnosis is the cyanosis-saturation gap. CONCLUSIONS: An obvious mismatch between the PaO2 (which is >>100 mm) versus the pulse oximetry ( typically ~80-90%), known as the PaO2-saturation gap, is a clue to the diagnosis of methemoglobinemia REFERENCE #1: Gibson QH. The reduction of methemoglobin in red blood cells and studies on the cause of idiopathic methemoglobinemia. Biochem J 1948;42: 13-23. REFERENCE #2: Ohashi K, Yukioka H, Hayashi M, Asada A. Elevated methemoglobin in patients with sepsis. Acta Anaesthesiol Scand 1998;42: 713-716. REFERENCE #3: Beutler E. Methemoglobinemia and other causes of cyanosis. In: Beutler E, Lichtman MA, Coller BS, Kipps TJ, eds. Williams Hematology. 5th ed. New York: McGraw-Hill; 1994: 654-662. DISCLOSURES: No relevant relationships by Santhosh Bayambe, source=Web Response No relevant relationships by Nadish Garg, source=Web Response No relevant relationships by Killol Patel, source=Web Response No relevant relationships by ARCHANA SREEKANTAN NAIR, source=Web Response

Management of Common Psychiatric Illnesses on Pediatric Medical Floors

Pediatric consultation-liaison (CL) psychiatry focuses on the treatment of mental health difficulties in physically ill children. This article focuses on three diagnoses that a pediatric CL psychiatrist commonly encounters: delirium, somatic symptom and related disorders (SSRD), and pediatric medical traumatic stress (PMTS). Delirium is an acute cerebral dysfunction secondary to an organic cause and can present with agitation, sleep disruption, disorientation, inattention, perceptual disturbances or apathy, and withdrawal. The management of delirium involves the treatment of underlying medical causes by environmental modifications and pharmacological strategies. SSRDs present with medically unexplained symptoms in which physical examination and laboratory testing do not justify a diagnosis of a known medical illness. Cognitive-behavioral therapy has the most evidence for the treatment of SSRDs, whereas pharmacological interventions have insufficient evidence in improving core symptoms of SSRDs. PMTS is defined as a set of posttraumatic stress symptoms (PTSS) in response to pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences. Brief, focused cognitive-behavioral strategies delivered in a family-centered approach can prevent or reduce symptoms. [ Psychiatr Ann . 2021;51(10):473–481.]

BRONCHOPLEURAL FISTULA COMPLICATION OF INTRAPLEURAL TPA/DORNASE IN PRESENCE OF LUNG ABSCESS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: A short course intrapleural instillation of tissue plasminogen activator (tPA) and recombinant human deoxyribonuclease I (dornase alfa) is a highly safe and effective treatment for complicated parapneumonic effusions (CPE) and empyema. It improves drainage and reduces surgical referral as well as hospitalization length [1-3]. Clinical experiences of dual tPA/dornase therapy and ensuing rare complications are cumulating. CASE PRESENTATION: A 49 year old female with past medical history of hypertension, extensive tobacco use, and history of IV drug use presented with complaints of right sided chest pain, productive cough with blood tinged sputum, and weight loss for 2 weeks. Vitals were normal and physical exam only significant for decreased right chest breath sounds. An initial CT chest demonstrated right sided pleural effusion with air-fluid level and a cavitary lesion of 7 cm suggestive of lung abscess. She was admitted to the medical floor with antibiotics. On day 2, a 10F pigtail catheter was placed with frank pus evacuated. Pleural fluid analysis showed WBC >800K cells/μL, glucose 10 mg/dL, LDH >40K IU/L, protein 3.1 gm/dL. The cultures of the pleural fluid grew Streptococcus intermedius. Repeat CT demonstrated chest tube in position without communication between empyema and lung abscess.On day 4, two rounds of intrapleural 10mg tPA and 5mg dornase alfa were administered to facilitate drainage. The next day, an additional 250 mL of bloody output was noted from the pigtail catheter with development of a new air leak. A repeat CT chest revealed improvement in the right sided empyema and subcutaneous emphysema. The visualization of previously described cavitary lesion was noted to be open to the pleural cavity.She was transferred to the ICU for close observation and management due to development of a bronchopleural fistula (BPF). A larger 16F chest tube was placed to aid drainage and reduce subcutaneous emphysema. After 2 days, the patient was no longer experiencing air leak and subsequently had chest tube removed on hospital day 7. She was discharged home with an extended course of oral amoxicillin-clavulanic acid and to follow-up in clinic. DISCUSSION: This case describes a complication that can happen when using intrapleural tpa/dornase therapy in presence of lung abscess which can lead to BPF which can result from abscess rupture into the pleural cavity. As for our literature review, we could not find any reported cases of similar complications of fistula development, however, it was noted bleeding complication with prolonged tpa/dornase use. CONCLUSIONS: Standard 3 day treatment is effective in reducing surgical referral and intervention, however, it is important to appreciate complications that can arise from therapy in presence of lung abscesses. There should close monitoring of chest tube output upon utilization of tpa/dornase therapy. REFERENCE #1: Rahman, N.M., et al., Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med, 2011. 365(6): p. 518-26. REFERENCE #2: Majid, A., et al., Concurrent Intrapleural Instillation of Tissue Plasminogen Activator and DNase for Pleural Infection. A Single-Center Experience. Ann Am Thorac Soc, 2016. 13(9): p. 1512-8. REFERENCE #3: Piccolo, F., et al., Intrapleural tissue plasminogen activator and deoxyribonuclease therapy for pleural infection. J Thorac Dis, 2015. 7(6): p. 999-1008. DISCLOSURES: No relevant relationships by Mohammed Al-Ourani, source=Web Response No relevant relationships by Rami Batarseh, source=Web Response No relevant relationships by Belete Desimmie, source=Web Response No relevant relationships by Anup Kumar, source=Web Response No relevant relationships by Kelsey Marshall, source=Web Response

TISSUE IS THE ISSUE: CASE OF PRIMARY PULMONARY PERIPHERAL T CELL LYMPHOMA

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Primary pulmonary lymphoma is a rare disease. It accounts for 0.5-1% of all pulmonary malignancy and less than 1 % of all Non-Hodgkins Lymphoma (NHL) (1). Mostly they are of B cell origin; however, there are fourteen reported primary pulmonary peripheral T Cell Lymphoma cases (2). We report a case of a patient presenting with primary pulmonary peripheral T cell Lymphoma. CASE PRESENTATION: A 58-year-old woman presented with complaints of dyspnea, high-grade fever, and cough for the past 4-5 days. Physical exam was unremarkable except for the fever, tachycardia, tachypnea, and oxygen saturation of 87% on room air. Laboratory workup was unremarkable except for elevated ESR, CRP, LDH, and ferritin. Rheumatological workup was unremarkable. Infectious workup, including COVID-19 PCR, blood cultures, and respiratory viral panel, were unremarkable. Chest CT showed bilateral consolidation of lungs with hilar and mediastinal lymphadenopathy (fig 1). She was started on broad-spectrum antibiotics and admitted to the medical floor. Her dyspnea got progressively worse, and she was intubated a week after her admission. Bronchoscopy was done with bronchoalveolar lavage and transbronchial biopsy; however, results were unremarkable. Video-assisted thoracoscopic surgery ( VATS ) was done for mediastinal lymph node biopsy, and biopsy results came positive for peripheral T cell lymphoma(Fig 2, 3 ). Bone marrow biopsy was unremarkable. The patient started to desaturate even on the maximal ventilator setting and was placed on venovenous extracorporeal membrane oxygenation (V-V ECMO). She was given the first cycle of Gemcitabine and oxaliplatin. However, she developed multiorgan failure. She was transitioned to comfort care and expired. DISCUSSION: Primary pulmonary peripheral T cell lymphoma usually manifests with the symptoms of dyspnea, cough, and fever. The mean age of presentation is fifty-three years. Radiographically it presents with lung consolidation, atelectasis, pleural effusion, and multiple nodular lesions. (3) Our patient had bilateral lung consolidation with hilar and mediastinal lymphadenopathy. Diagnosis is made by lobectomy, open lung biopsy, transthoracic needle biopsy, and mediastinal lymph node biopsy. (3) There is still no recommended standard treatment for primary pulmonary T cell lymphoma due to the scarcity of cases (4). Resection, radiotherapy, and chemotherapy are the treatment options used in patients suffering from this disease. CONCLUSIONS: Primary pulmonary peripheral T cell lymphoma is a rare and aggressive cancer. It presents with pneumonia-like symptoms. We recommend clinicians to consider bronchoscopy for those patients with pneumonia who do not get better with antibiotics. REFERENCE #1: Cadranel J, Wislez M, Antoine M. Primary pulmonary lymphoma. Eur Respir J. 2002;20(3):750-762. doi:10.1183/09031936.02.00404102 REFERENCE #2: Zhang S, Liang B, Jiang S. Primary pulmonary peripheral T-cell lymphoma: A case report and review of the literature. Thorac Cancer. 2014;5(1):104-107. doi:10.1111/1759-7714.12042 REFERENCE #3: Sangho Lee, Bongkyung Shin, Hyungseok Yoon, Jung Yeon Lee, Gyu Rak Chon, A case of primary pulmonary NK/T cell lymphoma presenting as pneumonia, Respiratory Medicine Case Reports, Volume17,2016, Pages 1-4, ISSN 2213-0071, https://doi.org/10.1016/j.rmcr.2015.11.003. 4) Bernabeu Mora R, Sánchez Nieto JM, Nieto Olivares A. Bilateral pulmonary nodules as a manifestation of primary pulmonary T-cell lymphoma. Int J Hematol. 2009;90(2):153-156. doi:10.1007/s12185-009-0372-8 DISCLOSURES: No relevant relationships by Neil Amin, source=Web Response No relevant relationships by Olufunmilayo Folaranmi, source=Web Response No relevant relationships by Junaid mir, source=Web Response No relevant relationships by Salmaan Mumtaz, source=Web Response No relevant relationships by Ateeb Ur Rahman, source=Web Response

SPONTANEOUS PNEUMOMEDIASTINUM SECONDARY TO COVID-19 INFECTION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: SARS-CoV-2 (COVID-19) is a rapidly spreading virus that has resulted in a pandemic. Individuals impacted have varying symptoms and disease courses, ranging from asymptomatic carriers to severe respiratory illness. Pneumomediastinum, a rare complication of COVID-19 (where air is present in the mediastinum with or without pneumothorax) is presented here. CASE PRESENTATION: Our case is that of a 59-year-old man who presented to the emergency department with complaints of fever and chills for five days. His past medical history included hypertension, type 2 diabetes mellitus and hyperlipidemia. He endorsed associated dry cough, decreased appetite and shortness of breath. He denied recent travel or exposure to COVID-19. Initially the patient was hemodynamically stable, but hypoxic with oxygen saturation of 82%, requiring 4L nasal cannula (NC) – with improvement to 93-95%. Chest imaging revealed low lung volumes and patchy bilateral opacities. COVID-19 PCR was positive. He was admitted to the medical floor with acute COVID-19 pneumonia. He was treated with dexamethasone and remdesivir, and was encouraged to self-prone. Due to worsening hypoxia, he required a non-rebreather mask. Daily chest x rays were obtained, and on hospital day seven, imaging revealed air around the neck, suggesting pneumomediastinum without pneumothorax. CT chest and neck showed significant air dissecting up from the superior mediastinum, extending through the neck soft tissues bilaterally, confirming acute pneumomediastinum. With further pulmonary decompensation and respiratory failure, he required intubation and mechanical ventilation. A low PEEP strategy was employed to prevent worsening pneumomediastinum. In the subsequent week, although his pneumomediastinum resolved, the patient unfortunately developed ARDS and passed away. DISCUSSION: This presentation of acute pneumomediastinum in the setting of COVID-19 is an uncommon complication of the viral illness. Diffuse alveolar damage and/or complication of mechanical ventilation have been speculated to be possible causes. Pneumomediastinum is typically a benign diagnosis, but can sometimes progress to malignant mediastinum, where air compresses the trachea or venous return, which can in turn present as cardiac tamponade. In these cases, chest tube, VATS or thoracotomy may be indicated.1 CONCLUSIONS: Cases of pneumomediastinum in patients infected with COVID-19 are limited, hence its impact on worsening illness or outcome cannot be determined. Recommendations continue to focus on close monitoring with daily chest imaging. Should intubation be required, it is recommended to maintain a needle at bedside for needle thoracostomy in the event acute pneumothorax occurs.2 A low tidal volume, low PEEP strategy is also encouraged to mitigate risk of further barotrauma.3 Early paralysis may be beneficial to prevent coughing or ventilator dyssynchrony. REFERENCE #1: Kouritas VK, Papagiannopoulos K, Lazaridis G, et al. Pneumomediastinum. J Thorac Dis. 2015;7(Suppl 1):S44-S49. doi:10.3978/j.issn.2072-1439.2015.01.11 REFERENCE #2: Mousa S, Edriss H. Pneumomediastinum secondary to invasive and non-invasive mechanical ventilation. The Southwest Respiratory and Critical Care Chronicles. 2019;7(27), 36-42. https://doi.org/10.12746/swrccc.v7i27.524 REFERENCE #3: Wali A, Rizzo V, Bille A, Routledge T, Chambers A. Pneumomediastinum following intubation in COVID-19 patients: a case series. Anaesthesia. 2020;75: 1076-1081. https://doi.org/10.1111/anae.15113 DISCLOSURES: No relevant relationships by James McGee, source=Web Response No relevant relationships by Cilian White, source=Web Response No relevant relationships by Momina Zaman, source=Web Response

A CASE OF DISSEMINATED STRONGYLOIDIASIS DURING TREATMENT FOR COVID-19

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Strongyloides stercoralis is a parasitic infection that is endemic in subtropical and tropical climates. Due to the unique life cycle of this parasite, many hosts are asymptomatic. If a host becomes immunosuppressed, a hyperinfection syndrome caused by proliferation of these nematodes can ensue (1). CASE PRESENTATION: A 72-year-old Nicaraguan male was admitted to the hospital with dyspnea. A nasopharyngeal swab confirmed SARS-COV2 infection. He was admitted to the medical floor but was transferred to the intensive care unit due to worsening hypoxia. He was subsequently intubated and treated with intravenous dexamethasone and full dose anticoagulation. His course was complicated by acute respiratory distress syndrome ultimately necessitating tracheostomy, multi-drug resistant Escherichia coli pneumonia, prolonged shock requiring continuous vasopressor support and stress dose steroids, diarrhea, and persistent fevers despite broad antimicrobial coverage. His peripheral eosinophil count was noted to be elevated. This in combination with his Nicaraguan origin prompted a stool ova and parasite examination to evaluate for helminthic infection. Microscopic evaluation revealed rhabditiform larvae consistent with Strongyloides stercoralis. Review of a bronchoalveolar lavage gram stain demonstrated a larvae-like structure suspicious for Strongyloides stercoralis as well. He was diagnosed with disseminated strongyloidiasis and treated with ivermectin. His fevers and vasopressor requirements subsequently resolved. DISCUSSION: High dose glucocorticoid therapy has a known immunosuppressive effect on a host's response to infectious agents. In this case, the use of steroids for COVID-19 and shock resulted in strongyloides hyperinfection syndrome. The presence of an Escherichia coli pneumonia was, in retrospect, an important clue to the patient's presentation. Bacterial pneumonia from enteric organisms has been found to be a common co-infection in patients with pulmonary strongyloidiasis (2). Bacteria are transmitted from the intestine, where the larvae start their life cycle. They move into the bloodstream via penetration of the intestinal mucosa by the larvae. The larvae then carry the bacteria into the lungs by burrowing into the alveoli (2). Strongyloides is estimated to infect millions of people worldwide and thus there appears to be an increased risk for associated hyperinfection in the setting of steroid utilization for COVID-19 infections (3). It is important for clinicians to be aware of this risk and to delineate strategies for appropriate testing and initiation of treatment. CONCLUSIONS: Disseminated strongyloidiasis can be detrimental in patients with COVID-19. In the setting of a global pandemic during which one of the mainstays of treatment is high dose glucocorticoids, it is important to be cognizant of dormant infections like Strongyloides that may become unmasked during treatment. REFERENCE #1: Nutman TB. Human infection with Strongyloides stercoralis and other related Strongyloides species. Parasitology. 2017 Mar;144(3):263-273. REFERENCE #2: Nabeya, D., Haranaga, S., Parrott, G.L. et al. Pulmonary strongyloidiasis: assessment between manifestation and radiological findings in 16 severe strongyloidiasis cases. BMC Infect Dis 17, 320 (2017). REFERENCE #3: Stauffer WM, Alpern JD, Walker PF. COVID-19 and Dexamethasone: A Potential Strategy to Avoid Steroid-Related Strongyloides Hyperinfection. JAMA. 2020;324(7):623–624. DISCLOSURES: No relevant relationships by William Bender, source=Web Response No relevant relationships by Eliana Gonzalez, source=Web Response No relevant relationships by Anjali Patel, source=Web Response No relevant relationships by Margaret Williamson, source=Web Response

THE LEAKY LUNG: A CASE OF COVID-19 PNEUMONIA COMPLICATED BY LUNG ABSCESS, BRONCHOPLEURAL FISTULA, AND PNEUMOTHORAX

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lung abscesses develop when necrosis of lung tissue caused by underlying infections form cavitary spaces of the lung parenchyma. A bronchopleural fistula (BPF) is a complication of cavitary lesions where a sinus tract forms between the bronchus and pleural space. We present the first reported case of a patient with severe COVID-19 who developed a lung abscess with a BPF and spontaneous pneumothorax requiring video-assisted thoracoscopic surgery (VATS). CASE PRESENTATION: A 60-year-old male with a history of hypertension and dyslipidemia presented to the hospital with shortness of breath after a recent diagnosis of COVID-19. The patient was hypoxic on room air and his chest x-ray (CXR) revealed bilateral infiltrates. The patient was admitted to the medical floors and treated with methylprednisolone, Remdesivir, piperacillin/tazobactam and DVT prophylaxis doses of enoxaparin. Methylprednisolone was increased to higher doses over the next few days in response to worsening inflammatory markers and hypoxia, as high as 125mg IV 4 times a day and was subsequently tapered to 160mg IV daily in divided doses for 30 days. On day 40, a new cavitary lesion of the right middle lobe (RML) was seen on CXR, and blood cultures grew methicillin sensitive staphylococcus aureus (MSSA) for which linezolid, meropenem and micafungin were started. On day 42, the patient developed a right sided pneumothorax which required chest tube insertion. On day 47 the patient developed respiratory distress and worsening pneumothorax, the pleural drainage system demonstrated continuous air leak and the patient was subsequently intubated due to worsening respiratory failure. VATS was performed which revealed a RML abscess; the procedure was converted to open thoracotomy with RML wedge resection. Histopathological analysis showed organizing pneumonia, interstitial fibrosis, alveolar damage and a BPF. Cultures taken from the abscess grew MSSA. On day 49, the patient became hypotensive and required the initiation of vasopressors. In the following days he developed a new air leak noted on the pleural drainage system. He remained in the ICU for several days and did not exhibit clinical improvement, thus his family transitioned him to comfort measures and he passed away soon after. DISCUSSION: High dose corticosteroids are used to treat severe COVID-19 with the goal of preventing cytokine storm and subsequent ARDS. Immunosuppression is a complication of prolonged treatment with high dose corticosteroids and may result in bacterial superinfection. Lung abscesses are typically treated conservatively with broad spectrum antibiotics. In cases such as those with BPF and pneumothorax, treatment with surgical intervention may be required. CONCLUSIONS: While corticosteroids have been used widely in the treatment of COVID-19, clinicians should be cautious in the consequences of prolonged utilization and should monitor for related complications. REFERENCE #1: Kuhajda, I., Zarogoulidis, K., Tsirgogianni, K., Tsavlis, D., Kioumis, I., Kosmidis, C., . . . Kuhajda, D. (2015, August). Lung abscess-etiology, diagnostic and treatment options. Retrieved April 29, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4543327/ REFERENCE #2: Salik, I. (2020, August 27). Bronchopleural fistula. Retrieved April 29, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK534765/ DISCLOSURES: No relevant relationships by Arslan Chaudhry, source=Web Response No relevant relationships by Rajapriya Manickam, source=Web Response No relevant relationships by Christopher Millet, source=Web Response No relevant relationships by Sushant Nanavati, source=Web Response No relevant relationships by Sherif Roman, source=Web Response No relevant relationships by Anish Samuel, source=Web Response

A FATAL CASE OF PULMONARY HEMORRHAGE: RARE MANIFESTATION OF LEPTOSPIROSIS

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Leptospirosis can cause multi-organ failure and adult respiratory distress syndrome. Clinical suspicion is the key to diagnosis. A detailed social history is superior to serum and radiological investigation to prevent mortality. CASE PRESENTATION: A 41-year-old man presented to the hospital with diffuse muscle pain and chills for 3-weeks. He worked as a waste-water worker in New York City. On arrival, he had a temperature of 100.8 F, heart rate 94/min, blood pressure 102/67 mmHg, respiratory rate 21/min. Initial blood tests showed platelet count of 90,000 k/ul, serum creatinine 3.7 mg/dl, BUN 67 mg/dl, ALT 78 u/l, AST 101 u/l and total bilirubin of 6.9 mg/dl. Chest X-ray showed mild diffuse interstitial infiltrates. He was admitted to the medical floor for management of presumed bacterial pneumonia. Broad-spectrum antimicrobials therapy with intravenous vancomycin and cefepime was initiated. One week into inpatient stay, his clinical condition deteriorated with worsening hypoxemia along with worsening renal and liver function tests. Blood cultures, sputum cultures, and COVID-19 PCR tests were negative. CT Chest was performed which showed extensive ground-glass opacities with interstitial thickening in both lungs. He had worsening hypoxemia requiring mechanical ventilation and septic shock requiring vasopressors. Bronchoscopy was performed that showed diffuse endobronchial and alveolar hemorrhage. Based on his social history, empiric treatment with doxycycline was begun and serology for leptospirosis was ordered which resulted in positive. After 9-days of mechanical ventilation and renal replacement therapy, he recovered and was discharged home. DISCUSSION: Leptospirosis disease is caused by Leptospira interrogans which is transmitted from the urine of wild animals and it can cause multi-organ involvement by initiating a cytokine storm.(1) Severe pulmonary hemorrhage syndrome (SPHS) can present as cough, massive hemoptysis, and is associated with circulatory collapse.(2) Chest radiography can show a wide variety of nodular infiltrates, ground glass opacifications, or multifocal consolidations which make the diagnosis difficult.(3) In non-endemic areas, clinical suspicion and social history play a pivotal role in the diagnosis. Suspected cases should be confirmed with serology (microscopic agglutination test). Mild disease is treated with tetracycline, while IV penicillin or ceftriaxone are preferred for severe disease, however beneficial effects are limited once organ dysfunction is progressed.(1) CONCLUSIONS: Due to the severity of Leptospirosis, the diagnosis should be made based on social history and a disproportionate rise of bilirubin. The mortality rate is significantly high in cases of pulmonary hemorrhage. Early treatment with antimicrobials is needed while serology testing is being performed. REFERENCE #1: Haake DA, Levett PN. Leptospirosis in humans. Curr Top Microbiol Immunol. 2015;387:65-97. doi:10.1007/978-3-662-45059-8_5 REFERENCE #2: Gouveia EL, Metcalfe J, De Carvalho ALF, et al. Leptospirosis-associated severe pulmonary hemorrhagic syndrome, Salvador, Brazil. Emerg Infect Dis. 2008;14(3):505-508. doi:10.3201/eid1403.071064 REFERENCE #3: Marchiori E, Lourenço S, Setúbal S, Zanetti G, Gasparetto TD, Hochhegger B. Clinical and imaging manifestations of hemorrhagic pulmonary leptospirosis: A state-of-the-art review. Lung. 2011;189(1):1-9. doi:10.1007/s00408-010-9273-0 DISCLOSURES: No relevant relationships by Ahad Azeem, source=Web Response No relevant relationships by Manasa Velagapudi, source=Web Response

HEMORRHAGIC SHOCK: WHERE IS THE BLEED?

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Meckel diverticulum(MD), characterized as a common congenital malformation and is well studied in the pediatric population but less so in adults. Our case emphasizes MD as one of the possible diagnoses of gastrointestinal bleeding in adults when CT scans and endoscopic evaluations are unremarkable. Also, if the suspicion is high, the technetium 99m pertechnetate is also not often adequate to exclude the diagnosis. CASE PRESENTATION: 28 year old male with a history of Inflammatory bowel syndrome presented to the emergency department with lightheadedness and palpitations. Soon after, he experienced a large melanotic stool and was transferred to the ICU with hypovolemic shock. His labs were notable for normocytic normochromic anemia for which he was transfused with packed red blood cells. CTA abdomen and pelvis demonstrated no evidence for active extravasation. The patient continued to have massive melenic bowel movements requiring repetitive blood transfusion for his hemorrhagic shock. Bedside double endoscopy showed non-bleeding internal hemorrhoids with no obvious source of bleeding. Subsequently, workup was broadened to a tagged RBC scan which was positive in the mid to distal small bowel prompting small ileal branch embolization. However, bleeding persisted for which Meckel's scan was ordered and found to be suggestive of Meckel's diverticulum. Subsequently, he had a laparoscopic small bowel resection which led to the resolution of symptoms. DISCUSSION: Meckel's Diverticulum is a rare entity in adults with only 17 cases reported in literature in the last year. It usually presents in childhood with more than half of the patients being less than 10 years old.MD usually presents with intestinal obstruction, hemorrhage and inflammation ofthe diverticulum with or without perforation. Bleeding usually occurs from an ulcer due to ectopic gastric mucosa producing acid and damaging the intestinal mucosa. Clinical features are comparable to any other inflammatory condition and can be confused with more prevalent conditions like acute appendicitis. Meckel's nuclear scan proves to be the standard test in case of high suspicion with a sensitivity of 89.6% and specificity of 97.1%. Other testing modalities include X-ray, CT scan or an MRI in case of an obstruction. Mesenteric arteriography in case of GI bleeding, double-balloon enteroscopy or capsule endoscopy can be used in order to directly visualize the MD, or abdominal exploration can be done as required if the diagnosis remains unclear with high index of suspicion.The standard of treatment in case of a symptomatic patient is surgical resection by performing a diverticulectomy that our patient underwent and was discharged to medical floor after stabilization. CONCLUSIONS: Meckel's Diverticulum remains a diagnosis associated with pediatric population although should not be forgotten in cases of adults with unexplained gastrointestinal bleeding. REFERENCE #1: Lequet J, Menahem B, Alves A, Fohlen A, Mulliri A. Meckel's diverticulum in the adult. J Visc Surg. (2017) 154:253–9. 10.1016/j.jviscsurg.2017.06.006 [PubMed] [CrossRef] [Google Scholar] REFERENCE #2: Choi SY, Hong SS, Park HJ, Lee HK, Shin HC, Choi GC. The many faces of Meckel's diverticulum and its complications. J Med Imaging Radiat Oncol. (2017) 61:225–31. 10.1111/1754-9485.12505 [PubMed] [CrossRef] [Google Scholar] REFERENCE #3: Stone PA, Hofeldt MJ, Campbell JE, et al. Meckel diverticulum: ten-year experience in adults. South Med J 2004;97:1038-41. [PubMed] DISCLOSURES: No relevant relationships by Imama Ahmad, source=Web Response No relevant relationships by Anneris Estevez, source=Web Response No relevant relationships by Sneha Lakshman, source=Web Response

UTILITY OF DANTROLENE FOR HYPERPYREXIA IN THE MANAGEMENT SARS-COV-2 INFECTION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus Disease 2019 (COVID-19) continues to be a global pandemic with its management evolving as research continues to unveil innovative therapies. Dantrolene, approved in malignant hyperthermia, may have utility for hyperpyrexia in COVID-19 patients, given its cytoprotective effects (1). Here we present a COVID-19 case with persistent hyperpyrexia despite conventional antipyretic measures that abated after dantrolene administration. CASE PRESENTATION: A 57-year-old Hispanic male with no past medical history, presented with fever, palpitations, myalgias and worsening dyspnea. He denied other symptoms. His admission vitals were Temp 101.3F, BP 155/81, Pulse 106, Resp 22, SpO2 88% on RA and 98% on 50% Venturi Mask. Lung examination revealed decreased air entry throughout with scattered crackles. Laboratory investigations showed WBC of 5.61 with normal electrolytes. ABG showed pH 7.45, pCO2 36, pO2 59 with FiO2 0.35 which improved with increased oxygenation. CXR showed hallmark features for COVID-19 pneumonia. COVID-19 PCR was positive. Antibiotics and prophylactic anticoagulation were initiated. He was later admitted to the medical floor. His hospital course was unremarkable until day three when he developed acute hypoxic respiratory failure requiring high flow nasal cannula and intensive care transfer. Despite optimal oxygenation, PF ratio was 105F. Besides multiple positive COVID-19 tests, all other infectious investigations were negative. Antibiotics, antivirals and antifungals were started but pyrexia persisted. Intravenous dantrolene (2.5mg/kg then 1mg/kg) was given after which temperature abated. De-escalation of care ensued, with removal of antimicrobials, intubation and ECMO. Patient had an uneventful transfer from MICU and discharge from the hospital. DISCUSSION: Hyperpyrexia is an extreme elevation of core body temperature usually >106.7 °F due to an elevated hypothalamic thermo-regulatory threshold. It has been reported in COVID-19 patients and portends a poor outcome with up to 100% mortality. Proposed mechanisms include immune dysfunction, direct brain injury from SARS-CoV-2 and vascular thrombosis (2). Dantrolene has been shown to inhibit multiple cell damage induced by SARS-CoV-2 infection (1). In our index case, all conventional antipyretic measures failed, while dantrolene achieved normothermia. CONCLUSIONS: Our case had a favorable outcome juxtaposing those previously reported (1,2). The proposition that dantrolene can be repurposed in COVID-19 patients with hyperpyrexia is novel and hopefully will stimulate and unearth more research. REFERENCE #1: Jiang, B., Liang, S., Liang, G., & Wei, H. (2020). Could dantrolene be explored as a repurposed drug to treat COVID-19 patients by restoring intracellular calcium homeostasis?. European review for medical and pharmacological sciences, 24(19), 10228–10238. https://doi.org/10.26355/eurrev_202010_23247 REFERENCE #2: Suwanwongse, K., & Shabarek, N. (2020). Hyperpyrexia in patients with COVID-19. Journal of medical virology, 92(11), 2857–2862. https://doi.org/10.1002/jmv.26154 DISCLOSURES: No relevant relationships by Sneha Adidam, source=Web Response No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Lorenzo Leys, source=Web Response No relevant relationships by Alicia Thomas, source=Web Response

NOT FOR VETERINARIANS ONLY: A VERY RARE CASE OF PYOMETRA IN AN ELDERLY FEMALE

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Pyometra is a very rare but serious and potentially life threatening condition. It is defined as an accumulation of purulent material within the uterine cavity. It is a common presentation in the veterinary world however exceedingly rare in humans. CASE PRESENTATION: This is a 72-year-old female who presented to the emergency room with complaint of suprapubic abdominal pain and fullness. She reports having mild abdominal pain and fullness for 3 months however it progressively became worse over 2 weeks prior to presentation. She reported the pain to be very severe and sharp in nature. She denied any fever, chills, weight loss, dysuria, or vaginal discharge. In the ER CT of the abdomen and pelvis was obtained which revealed an intrauterine mass measuring 9.7x9.8x10.5 cm. Laboratory workup revealed leukocytosis with white blood cell count of 17.05x10^3. All other pertinent labs were within normal limits. She was transferred to our hospital and admitted to the medical floor. A pelvic ultrasound was then obtained which again revealed an enlarged uterus with a complex cystic appearing lesion. Ob/Gyn was consulted and she underwent a Pap smear and endometrial biopsy with culture. Pathology was negative for any malignancy however culture did grow streptococcus viridans. Patient was started on clindamycin and levofloxacin per infectious disease recommendations. She was then transferred to the intensive care unit as she became hypotensive and was then started on norepinephrine drip. Patient then underwent a dilatation and curettage which revealed copious amounts of purulent drainage in the uterus. Cultures again grew streptococcus viridans and she was continued on antibiotics. A repeat CT abdomen and pelvis was obtained which showed resolution of lesion. Patient remained in the ICU for monitoring and on postoperative day 4 went into cardiac arrest and subsequently deceased. DISCUSSION: Pyometra is reported to occur in 0.1-0.2% of all gynecologic patients [1]. The condition is commonly caused by malignant or benign tumors, radiation cervicitis, atrophic cervicitis or with the use of an intrauterine device. The classic triad of symptoms are vaginal discharge, postmenopausal bleeding and lower abdominal pain, however >50% of patients can be asymptomatic [2]. Pubmed literature review will reveal only a handful of such cases that have been reported. Most common microorganisms causing pyometra are E.coli and bactericides fragilis. A recent case report with literature review revealed a mortality rate of 22.2% [3]. Most suggest a CT scan and a pelvic ultrasound to obtain an accurate diagnosis and prompt initiation of antibiotics along with drainage of the pyometra. CONCLUSIONS: Pyometra is exceedingly rare however life threatening. This case illustrates the severity of the condition requiring prompt recognition and treatment. REFERENCE #1: Khan A, Prasad J. Perforated Pyometra Presenting As A Pelvic Abscess: A Case Report. International Journal of Case Reports and Images. 2012;3(2):10-14 REFERENCE #2: Schmiech K, Woods C, Hylton J, et al. Case Report: Recurrent Pyometra in an Adolescent. Journal of Pediatric and Adolescent Gynecology. 2020 October;33(5):574-576 REFERENCE #3: Uno K, Tano S, Yoshihara M, et al. A Case Report and Literature Review of Spontaneous Perforation of Pyometra. Journal of Emergency Medicine. 2016 May;50(5):231-236 DISCLOSURES: No relevant relationships by Mohammed Ali, source=Web Response No relevant relationships by Rahul Dadhwal, source=Web Response No relevant relationships by Jared Head, source=Web Response No relevant relationships by Aisha Mujahid, source=Web Response No relevant relationships by Salim Surani, source=Web Response

Thiol-Disulphide Homoeostasis in COVID-19: Evaluation of its Relationship with Complete Blood Count Parameters

Objective: In this study, we aimed to evaluate the relationship between thiol-disulfide homoeostasis and hemogram parameters in COVID-19 patients.&#x0D; Methods: Total thiol(TT), Native thiol(NT), dynamic disulfide status(DDS), DDS/NT, DDS/TT, NT/TT ratio and CBC parameters were analyzed in 68 patients with positive COVID-19 and 31 healthy individuals.&#x0D; Results: TT, NT, DD, hemoglobin and hematocrit levels were higher in the control group than in patient groups. TT, NT, DD and lymphocyte levels of COVID-19 patients treated in medical floor were higher than those treated in intensive care unit; WBC, neutrophil and NLR were low(P

Standardization of Nonverbal Report

<h3>Background Information</h3> Transfer of care of patients travelling from PACU to medical surgical floors can be inconsistent and frustrating to both sending and receiving parties. This transfer usually involves faxing a written report and/or calling the floor to give a verbal report to the receiving nurse. Nurses in the PACU complain of multiple attempts in contacting floor nurses to confirm proper handoff, spending valuable time away from the patients' bedsides. In turn, floor nurses state that report isn't always thorough. <h3>Objectives of Project</h3> The objective of this project is to standardize the handoff between PACU and ED to all eleven medical surgical floors. Since both units transfer patients to these floors, our goal was to develop a standardized <i>nonverbal</i> report that maximizes the quality of information given while minimizing time spent trying to pass information along. <h3>Process of Implementation</h3> Teaming up with representatives from all units involved, we worked to streamline a template that every nurse would use in our electronic medical record. All involved were educated on the expectations. The nonverbal portion of report relies on a series of texts, using hospital provided staff cellular phones. Once the report is reviewed, the sending nurse receives a text response from the receiving charge nurse. The amount of time between bed assigned to bed occupied was measured monthly. <h3>Statement of Successful Practice</h3> The national benchmark of bed assigned to bed occupied is 60 minutes. Before the start of this project, the average time for PACU was 85-94 minutes, using the two most utilized floors. Although we hadn't met the benchmark yet, the average time decreased 7-17% (71-87 minutes). There is some positive feedback from both sides, stating that "report is more thorough" and that "there's more accountability". <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> As technology advances in healthcare, it is imperative that nursing keeps pace. By utilizing the electronic advances available, safe transfer of care can occur more expeditiously. This will enhance flow of patients to their target destination and increase the patient and nurse experience. PACU nurses feel they can use their time more judiciously in the hands-on care of their patients rather than spending long amounts of time, tethered to the telephone, away from the bedside.

Adapting the SAFETY-Acute Intervention to Improve Quality of Care for Suicidal Youth in Emergency Rooms and Medical Floors

ABSTRACT Hospitals and emergency departments (ED) are experiencing an increased number of youths with suicidality. Safety interventions used in the ED and on medical floors have not been systematically examined. In this paper, we present the implementation and feasibility of the brief SAFETY-Acute intervention (SAFETY-A), adapted for use by our consultation – liaison psychiatry service. SAFETY-A is a cognitive-behavioral therapy (CBT) family intervention for youth, developed for an ED setting. We implemented SAFETY-A in the ED and on medical floors to determine disposition of a patient to an inpatient hospital versus a lower level of care. We adapted SAFETY-A to use clinically with youths in the ED and medical floors at the Children’s Medical Center in Dallas, Texas. In this report we analyze clinical outcomes of SAFETY-A with patients 10–17 years old (N = 333), who presented to the ED and medical floors with suicide ideations (SI) or suicide attempts (SA). SAFETY-A proved to be feasible and acceptable based on clinicians’ reporting. Safety planning and home safety education were reported as the most effective components of the intervention. Patients who completed SAFETY-A were more likely to be recommended to lower levels of care than patients who did not complete all components of SAFETY-A. SAFETY-A implemented in our consultation-liaison service was associated with reduced inpatient referrals and disposition to a lower level of care. SAFETY-A shows positive outcomes as an acceptable and feasible intervention in a pediatric hospital consultation-liaison program.

The experience of family carers of children with incurable cancer: a qualitative study from the occupied Palestinian territory

BackgroundTreatments for childhood cancers have raised the survival rate, however different forms of malignancy continue to cause untimely deaths, and cancer remains a leading cause of death among children. Global research on paediatric cancer is limited for several reasons. Most research has focused on specific methodologies, including questionnaires with heterogeneous samples. In addition, many studies have covered a broad range of cancer diagnoses, and a wide range of children's ages and periods between diagnosis and treatment. These methods are unable to capture the essence of experiences and cultural differences. This study aimed to explore the experience of family carers of children with incurable cancer in occupied Palestinian territory. MethodsThe study was conducted in the Paediatric Cancer Department of Beit Jala Hospital, which is the first public cancer department for children in the West Bank. The family carers of children aged 1–18 years with any type of incurable cancer in this hospital were considered eligible for participation, and the individual most involved in the care of the child was selected. To recruit participants, head nurses of medical and surgical paediatric floors provided assistance in approaching the carers of eligible children. The main objectives of the study were then discussed with the family carers. Semi-structured interviews were conducted with participants, and an interpretative phenomenological analysis approach was used to analyse the collected information. Ethical approval was obtained from the Beit Jala Hospital ethical review board and written informed consent was obtained from all participants. Findings14 interviews were conducted. Participants were nine mothers, four grandmothers, and one father. Family carers discussed their caring experiences, including their experiences in administering special treatments, their suffering due to treating irritable children, and the information given to them about their children's illness. Family carers reported that they changed the focus of their care from an initial emphasis on normalising their children's lives to relieving their physical and psychological discomfort. This change of focus accompanied changes in carers’ understanding of their child's disease over time. As carers became more realistic regarding the future of their children, they attempted to make their lives as comfortable as possible. Finally, carers discussed the support system around them; they found several resources to support them in the care of their children, including the experiences of other parents of children with similar diseases, the hospital environment, and their religious beliefs. Nevertheless, they stated that they needed more support during this difficult time of their lives. InterpretationThere is a need to support parents of children with incurable cancer in the occupied Palestinian territory. Suggestions to improve the quality of care provided for these parents include the education and recruitment of health care professionals, including social workers and psychologists, to provide emotional and spiritual support. FundingNone.