Room Air Oxygen Saturation Research Articles

No Remdesivir Resistance Observed in the Phase 3 Severe and Moderate COVID-19 SIMPLE Trials.

Remdesivir (RDV) is a broad-spectrum nucleotide analog prodrug approved for the treatment of COVID-19 in hospitalized and non-hospitalized patients with clinical benefit demonstrated in multiple Phase 3 trials. Here we present SARS-CoV-2 resistance analyses from the Phase 3 SIMPLE clinical studies evaluating RDV in hospitalized participants with severe or moderate COVID-19 disease. The severe and moderate studies enrolled participants with radiologic evidence of pneumonia and a room-air oxygen saturation of ≤94% or >94%, respectively. Virology sample collection was optional in the study protocols. Sequencing and related viral load data were obtained retrospectively from participants at a subset of study sites with local sequencing capabilities (10 of 183 sites) at timepoints with detectable viral load. Among participants with both baseline and post-baseline sequencing data treated with RDV, emergent Nsp12 substitutions were observed in 4 of 19 (21%) participants in the severe study and none of the 2 participants in the moderate study. The following 5 substitutions emerged: T76I, A526V, A554V, E665K, and C697F. The substitutions T76I, A526V, A554V, and C697F had an EC50 fold change of ≤1.5 relative to the wildtype reference using a SARS-CoV-2 subgenomic replicon system, indicating no significant change in the susceptibility to RDV. The phenotyping of E665K could not be determined due to a lack of replication. These data reveal no evidence of relevant resistance emergence and further confirm the established efficacy profile of RDV with a high resistance barrier in COVID-19 patients.

Paediatric Bronchiectasis in a Resource-Constrained Centre: A Case Series

Bronchiectasis denotes fixed and often irreversible dilatation of the bronchial wall caused by persistent inflammation and infection. Children with bronchiectasis in developing countries suffer recurrent hospitalisation and poor quality of life and usually succumb to the condition. These children are poorly recognised, misdiagnosed, and under-reported. We report five cases of computerised tomography-diagnosed paediatric bronchiectasis managed at the Edward Francis Small Teaching Hospital (EFSTH), Banjul, The Gambia. The ages of the children at presentation ranged from 3 to 14 years, and they all had recurrent chest infections. Four out of the five cases had Pulmonary Tuberculosis, among whom two cases had HIV/TB co-infections, and the only non-TB, non-HIV case had features of Down syndrome with congenital heart lesions. All the cases had growth impairment; digital clubbing was observed in four, and low peripheral oxygen saturation in room air in three of the five children. These cases are reported to increase the index of suspicion among clinicians working in resource-limited settings to consider the diagnosis of bronchiectasis in children with recurrent chest infections. Early diagnosis and prompt management, including appropriate follow-up care, will improve the quality of life of these children and ensure better management outcomes.

Alveolar Hemorrhage in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Results of an International Randomized Controlled Trial (PEXIVAS).

Rationale: Diffuse alveolar hemorrhage (DAH) is a life-threatening manifestation of antineutrophil cytoplasmic antibody-associated vasculitis (AAV). The PEXIVAS (Plasma Exchange and Glucocorticoids in Severe Antineutrophil Cytoplasmic Antibody-Associated Vasculitis) (NCT00987389) trial was the largest in AAV and the first to enroll participants with DAH requiring mechanical ventilation. Objectives: Evaluate characteristics, treatment effects, and outcomes for patients with AAV with and without DAH. Methods: PEXIVAS randomized 704 participants to plasma exchange (PLEX) or no-PLEX and reduced or standard-dose glucocorticoids (GC). DAH status was defined at enrollment as no-DAH, nonsevere, or severe (room air oxygen saturation of ⩽ 85% as measured by pulse oximetry, or use of mechanical ventilation). Measurements and Main Results: At enrollment, 191 (27.1%) participants had DAH (61 severe, including 29 ventilated) and were younger, more frequently relapsing, PR3 (proteinase 3)-ANCA positive, and had lower serum creatinine but were more frequently dialyzed than participants without DAH (n = 513; 72.9%). Among those with DAH, 8/95 (8.4%) receiving PLEX died within 1 year versus 15/96 (15.6%) with no-PLEX (hazard ratio, 0.52; confidence interval [CI], 0.21-1.24), whereas 13/96 (13.5%) receiving reduced GC died versus 10/95 (10.5%) with standard GC (hazard ratio, 1.33; CI, 0.57-3.13). When ventilated, ventilator-free days were similar with PLEX versus no-PLEX (medians, 25; interquartile range [IQR], 22-26 vs. 22-27) and fewer with reduced GC (median, 23; IQR, 20-25) versus standard GC (median, 26; IQR, 25-28). Treatment effects on mortality did not vary by presence or severity of DAH. Overall, 23/191 (12.0%) with DAH died within 1 year versus 34/513 (6.6%) without DAH. End-stage kidney disease and serious infections did not differ by DAH status or treatments. Conclusions: Patients with AAV and DAH differ from those without DAH in multiple ways. Further data are required to confirm or refute a benefit of PLEX or GC dosing on mortality. Original clinical trial registered with www.clinicaltrials.gov (NCT00987389).

Small Bowel Perforation at the Duodeno-Jejunal Junction from a Migrated Biliary Stent: A Case Report

Background: The most common sites of reported bowel perforation secondary to migrated biliary stents were duodenal or colonic. However, small bowel perforations were reported in a few cases. Herein we present a case of small bowel perforation secondary to migrated biliary plastic stent at the duodeno-jejunal junction (DJ). We think this peculiar site is the first to be reported as a perforation site secondary to migrated biliary stent. Case Presentation: We present the case of female Egyptian patient with severe abdominal pain and air under diaphragm after Endoscopic Retrograde Cholangiopancreatography (ERCP) for Klatskin tumor. The patient underwent a midline laparotomy. A moderate collection of enteric fluid was encountered with migrated stent causing perforation of the small intestine at DJ. The stent was removed, and primary closure was done. The patient could not be extubated due to bad chest condition and admitted to ICU for 48 hours then extubated after improvement of the chest condition and ability of the patient to maintain good oxygen saturation in room air. Unfortunately, the patient developed massive pulmonary embolism on the fifth postoperative day and died. Conclusion: Suspicion of stent migration should be put in mind in any patient presented with abdominal pain with history of previous ERCP and biliary stenting. Endoscopic removal and mucosal repair are possible in select cases. This is still not available for DJ or small bowel. Further research and future innovations may overcome this challenge.

Evaluation of feasibility phase of adaptive version of locally made bubble continuous positive airway pressure oxygen therapy for the treatment of COVID-19 positive and negative adults with severe pneumonia and hypoxaemia.

Bubble continuous positive airway pressure (bCPAP) oxygen therapy has been shown to be safe and effective in treating children with severe pneumonia and hypoxaemia in Bangladesh. Due to lack of adequate non-invasive ventilatory support during coronavirus disease 2019 (COVID-19) crisis, we aimed to evaluate whether bCPAP was safe and feasible when adapted for use in adults with similar indications. Adults (18-64 years) with severe pneumonia and moderate hypoxaemia (80 to <90% oxygen saturation (SpO2) in room air) were provided bCPAP via nasal cannula at a flow rate of 10 litres per minute (l/min) oxygen at 10 centimetres (cm) H2O pressure, in two tertiary hospitals in Dhaka, Bangladesh. Qualitative interviews and focus group discussions, using a descriptive phenomenological approach, were performed with patients and staff (n = 39) prior to and after the introduction (n = 12 and n = 27 respectively) to understand the operational challenges to the introduction of bCPAP. We enrolled 30 adults (median age 52, interquartile range (IQR) 40-60 years) with severe pneumonia and hypoxaemia and/or acute respiratory distress syndrome (ARDS) irrespective of coronavirus disease 2019 (COVID-19) test results to receive bCPAP. At baseline mean SpO2 on room air was 87% (±2) which increased to 98% (±2), after initiation of bCPAP. The mean duration of bCPAP oxygen therapy was 14.4 ± 24.8 hours. There were no adverse events of note, and no treatment failure or deaths. Operational challenges to the clinical introduction of bCPAP were lack of functioning pulse oximeters, difficult nasal interface fixation among those wearing nose pin, occasional auto bubbling or lack of bubbling in water-filled plastic bottle, lack of holder for water-filled plastic bottle, rapid turnover of trained clinicians at the hospitals, and limited routine care of patients by hospital clinicians particularly after official hours. If the tertiary hospitals in Bangladesh are supplied with well-functioning good quality pulse oximeters and enhanced training of the doctors and nurses on proper use of adapted version of bCPAP, in treating adults with severe pneumonia and hypoxaemia with or without ARDS, the bCPAP was found to be safe, well tolerated and not associated with treatment failure across all study participants. These observations increase the confidence level of the investigators to consider a future efficacy trial of adaptive bCPAP oxygen therapy compared to WHO standard low flow oxygen therapy in such patients. s Although bCPAP oxygen therapy was found to be safe and feasible in this pilot study, several challenges were identified that need to be taken into account when planning a definitive clinical trial.

Mechanical ventilation and outcomes in COVID-19 patients admitted to intensive care unit in a low-resources setting: A retrospective study

Objective: To describe the strategies and outcomes of mechanical ventilation in a poorly equipped facility. Methods: This retrospective descriptive study included patients with COVID-19 who were admitted to the intensive care unit (ICU) and mechanically ventilated between September 1, 2020, and May 31, 2021. Data were collected from medical records and databases. Results: 54 Patients aged (62.9±13.3) years were included. Among these cases, 79.6% had at least one comorbidity. On admission, all patients had hypoxia. The median peripheral oxygen saturation in room air was 76% (61%, 83%). Non-invasive ventilation (NIV) was performed in 75.9% of the patients, and invasive mechanical ventilation (IMV) in 68.5%. IMV was performed on patients due to severe coma (8.1%), failure of standard oxygen therapy (27.0%), and failure of NIV (64.9%). An arterial blood gas test was performed in 14.8% of the patients. NIV failed in 90.2% of cases and succeeded in 9.8%. IMV was successful in 5.4% of cases, vs. 94.6% of mortality. The overall mortality rate of patients on ventilation in the ICU was 88.9%. The causes of death included severe respiratory distress syndrome (85.2%), multiple organ failure (14.8%), and pulmonary embolism (13.0%). Conclusions: The ventilation management of COVID-19 patients in the ICU with NIV and IMV in a scarce resource setting is associated with a high mortality rate. Shortcomings are identified in ventilation strategies, protocols, and monitoring. Required improvements were also proposed.

Hypoxemia in School Age Children Undergoing One-Lung Ventilation: A Retrospective Cohort Study from the Multicenter Perioperative Outcomes Group (MPOG).

Risk factors for hypoxemia in school age children undergoing one-lung ventilation remain poorly understood. We hypothesize that certain modifiable and non-modifiable factors may be associated with increased risk of hypoxemia in school age children undergoing one-lung ventilation and thoracic surgery. The Multicenter Perioperative Outcomes Group database was queried for children 4 to 17 years of age undergoing one-lung ventilation. Patients undergoing vascular or cardiac procedures were excluded. The original cohort was divided into two cohorts: 4-9 and 10-17 years of age inclusive. All records were reviewed electronically for the primary outcome of hypoxemia during one-lung ventilation defined as an oxygen saturation (SpO2)<90% for≥3 minutes continuously and severe hypoxemia, SpO2<90% for ≥5 minutes. Potential modifiable and non-modifiable risk factors associated with these outcomes were evaluated using separate multivariable least absolute shrinkage and selection operator regression analyses for each cohort. Covariates evaluated included: age, extremes of weight, American Society of Anesthesiologists Physical Status≥3, duration of one-lung ventilation, preoperative SpO2<98%, approach to one lung ventilation, right operative side, video assisted thoracoscopic surgery, lower tidal volume ventilation defined as tidal volume≤6ml/kg + positive end expiratory pressure ≥ 4cmH2O >80% of the duration of one-lung ventilation, and procedure type. The prevalence of hypoxemia in the 4-9 and 10-17 year old cohorts was 24/228 (10.5%, 95%CI[6.5%-14.5%]) and 76/1012 (7.5%, 95%CI[5.9%-9.1%]) respectively. The prevalence of severe hypoxemia in both cohorts was 14/228 (6.1%, 95%CI[3.0%-9.3%]) and 47/1012 (4.6%, 95%CI[3.3%-5.8%]). Initial SpO2<98% was associated with hypoxemia in the 4-9 year old cohort, OR 4.20 [95%CI(1.61 - 6.29)]. Initial SpO2<98%, OR 2.76[95%CI(1.69-4.48)], extremes of weight, OR 2.18[95%CI(1.29-3.61)], right sided cases, OR 2.33[95%CI(1.41-3.92)], were associated with an increased risk of hypoxemia in the older cohort. Increasing age (1 year increment), OR 0.88[95%CI(0.80-0.97)] was associated with a decreased risk of hypoxemia. An initial room air oxygen saturation <98% was associated with an increased risk of hypoxemia in all children 4-17 years of age. Extremes of weight, right sided cases, and decreasing age were associated with an increased risk of hypoxemia in children 10-17 years of age.

Factors Associated with Elevated Transcranial Doppler Ultrasound Velocities in Children With Sickle Cell Anemia in Mwanza, Tanzania

Background: Stroke occurs in 11% of patients with SCA before 20 years of age. In Northwestern Tanzania, the prevalence of stroke among children living with SCA under the age 15 years is 16.9%, of which might be attributed to the absence of routine screening for the risk of stroke by using Transcranial Doppler Ultrasound (TCD). Screening with TCD allows preventive measures such as chronic blood transfusion to be done which has led to the reduction of stroke by 92%. Methods: This was a prospective analytical cross sectional study which enrolled 267 SCA children aged 2 to 16 years attending Bugando Medical Centre Pediatric Sickle Cell Clinic from July 2019 to June 2020. Assessment of factors associated with elevated TCD included a clinical history of stroke in sibling, death in sibling, temperature, oxygen saturation in room air, blood pressure, hemoglobin level and total white blood cell count. TCD was done by accessing transtemporal window and recording the highest time average mean of maximum velocity (TAMMV) of major vessels mainly, middle cerebral artery (MCA) and distal internal carotid artery (dICA). Results: The median age of enrolled was 6.6 (IQR: 4-9) years. The prevalence of elevated TCD (&gt; 170 cm/s) was found to be 21% (56/267). By multivariate logistic regression, low oxygen saturation in room air, p - value = 0.037, OR 1.08 [95% CI 1.00-1.17] and low hemoglobin level, p - value = 0.001, OR 1.76 [95% CI 1.26-2.45] were statistically significantly associated with elevated TCD among children living with SCA. Conclusion: The high prevalence of elevated TCD velocity, with low hemoglobin and low oxygen saturation in room air as associated factors under multivariate logistic regression, warrants routine TCD screening for children with SCA aged 2 to 16 years.

Captive Black Mamba (Dendroaspis Polylepis) Bite Leading to Respiratory Failure

BackgroundOf the 8000–10,000 snake envenomations evaluated in U.S. emergency departments (ED) annually, approximately 1% are due to non-native snakes. We describe a 26-year-old man who was bitten by his captive black mamba (Dendroaspis polylepis) as he was packing it up for transport to another snake collector. Case ReportThe patient presented to the ED 1 h after being bitten on the forearm, complaining of left arm pain, oral paresthesias, and dyspnea. His vital signs: heart rate 96 beats/min, blood pressure 167/101 mm Hg, temperature 36.7°C (97.9°F), respiratory rate 20 breaths/min, and room air oxygen saturation 100%. Two mildly tender puncture wounds without swelling or ecchymosis were found on the posterior aspect of the forearm. Over the ensuing 30 min his dyspnea worsened, and he developed objective weakness. He was intubated and placed on mechanical ventilation. He was treated with atropine 2 mg for bronchorrhea. Five vials of South African Vaccine Producers (Johannesburg, South Africa) polyvalent antivenom were administered 2.5 h post-bite and the patient was admitted to the intensive care unit. He was extubated 18 h post-envenomation and discharged the following day. He has remained asymptomatic since leaving the hospital. Why Should an Emergency Physician Be Aware of This?The primary manifestations of D. polylepis envenomings are neurological. Initial signs may include paresthesias, dysarthria, dysphagia, and ptosis. Progressive descending paralysis leading to respiratory failure develops within 60 min. Muscarinic features are frequently observed. Cardiotoxicity and hematologic laboratory abnormalities may be present. Although pain is common, significant local tissue injury does not occur. In addition to supportive care, several non-native antivenoms are indicated for D. polylepis envenomations. Black mamba envenomings differ from the native snakebites with which U.S. physicians are familiar. Rapid, progressive neurological toxicity and muscarinic features are most common. Treatment consists of supportive care and appropriate antivenom administration.

Arrhythmia in a COVID-19 patient: A case report

In this study, we considered an 83-year-old male patient admitted to the Al-Zahra hospital emergency department in Isfahan. He complained of fatigue, weakness, headache, and cough. In addition, he had hallucinations and delusions for two days; but he had no fever and chill. His physical examination showed a blood pressure of 170/100 mm Hg, heart rate of 142 beats per minute (bpm), respiratory rate of 23 pbm, oxygen saturation (in room air) of 83%, and oxygen bag reserve mask of 93%. We realized cardiac involvement during hospitalization, including sinus bradycardia, first-degree atrioventricular (AV) block, recurrent premature ventricular from tricuspid ring, atrial tachycardia (AT) rhythm with variable AV conduction block, increased heart rate with functional bundle branch block, and negative troponin. The patient was treated with medicines to control heart rate and admitted to the cardiac care unit (CCU). Next, the patient was intubated due to a worsening lung condition. Afterward, he was admitted to the intensive care unit (ICU) and died the next day. According to the literature, compromised cardiac vascular is the most common complications in hospitalized patients due to COVID-19 infection and has a higher mortality risk. Cardiac arrhythmias are additionally common clinical manifestations. These arrhythmias seem to be caused by inflammatory responses in the myocardium, electrolyte disorders, and hypoxia. Our patient showed that the COVID-19 virus might induce different types of arrhythmias.

The effect of vitamin D and magnesium supplementation on clinical symptoms and serum inflammatory and oxidative stress markers in patients with COVID-19: a structured summary of a study protocol for a randomized controlled trial

ObjectivesThis study aims to evaluate the effect of vitamin D and magnesium supplementation on clinical symptoms and serum inflammatory and oxidative stress markers in patients with COVID-19.Trial designThis study is a 4-arm randomized, double-blind, placebo-controlled clinical trial with a factorial design and the intervention period is 3 weeks.ParticipantsThis study is conducted on COVID-19 patients admitted to the Shahid Mohammadi hospital in Bandar Abbas, Iran, who are eligible for inclusion in the study. Patients are included only if they meet all of the following criteria: (1) aged from 18 to 65 years old; (2) confirmation of COVID-19 by RT-PCR test; (3) completing informed consent; (4) passing less than 48 h since the patient's hospitalization; (5) no skin or gastrointestinal allergies due to taking multivitamin supplements, vitamin D, and magnesium; and (6) having more than 30 breaths per minute and less than 93% oxygen saturation in room air and sea level. Patients are excluded if they have any of the following conditions: (1) pregnancy or lactation; (2) taking a daily multivitamin or take a vitamin D or magnesium supplement in the last month; (3) participating in other clinical trials; (4) renal failure or dialysis, severe liver disease or cirrhosis; (5) known diagnosis of hypercalcemia; (6) discharging from the hospital less than 24 h after the start of the intervention; (7) history of kidney stones in the last year; (8) transfer the patient to the ICU; (9) baseline vitamin D levels above 80 ng/ml; (10) baseline magnesium levels above 2.6 mg/dl; and (11) unwillingness of the patient to continue the study.Intervention and comparatorParticipants will be randomly allocated to one of the four following groups: (A) vitamin D (two 50,000 IU capsules at the beginning of the study, two 50,000 IU capsules on the 4th day, one 50,000 IU capsule on the 11th day, and one 50,000 IU capsule on the 17th day) and magnesium supplement (300 mg/day); (B) vitamin D capsule and magnesium placebo; (C) magnesium supplement and vitamin D placebo; and (D) vitamin D placebo and magnesium placebo.Main outcomesThe resolution of clinical symptoms (fever, dry cough, shortness of breath, headache, myalgia, oxygen saturation, and mortality rate) and interpretation of laboratory assays (CRP, MDA, TAC, WBC, neutrophils count, lymphocytes count, ratio of neutrophils to lymphocytes, levels of 25 hydroxyvitamin D and magnesium) will be assessed in the study groups.RandomizationA computer-generated block randomization list is used for randomization.Blinding (masking)Investigators and patients are blinded to group allocation and treatment. A double-blind design is achieved using matched placebos.Numbers to be randomized (sample size)A total of 104 eligible patients are randomized into four groups of 26 subjects (1:1:1:1 allocation ratio).DiscussionWith the rapid prevalence of COVID-19 in recent years, more attention has been paid to effective dietary supplementation to improve clinical symptoms and biochemical parameters in these patients. To our knowledge, this is the first study to evaluate the effects of vitamin D supplementation in combination with magnesium or alone with respect to this infectious disease. The findings of the current RCT will provide evidence regarding the effectiveness of dietary supplementation strategies to improve COVID-19 outcomes.Trial statusEthical approval of the first version of the study protocol was obtained from the medical ethics committee of Hormozgan University of Medical Sciences, Bandar Abbas, Iran on May 30, 2021 (IR.HUMS.REC.1400.085). Currently, the recruitment phase is ongoing since August 23, 2021, and is anticipated to be complete by the end of August 2022.Trial registrationThe study protocol was registered in the Iranian Registry of Clinical Trials (https://www.irct.ir; IRCT20210702051763N1) on August 14, 2021. https://www.irct.ir/trial/57413Full protocolThe full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol.

Which trial do we need? Management of elderly, fragile, fully vaccinated patients hospitalized for SARS-CoV-2 infection

An 81-year-old male is admitted to the hospital because of progressive confusion. The family cannot precisely tell when symptoms started, possibly one week ago or a few days before. The patient has early Alzheimer's disease but has been independent in the activities of daily living until two days ago when the family reports increased confusion. The patient received four doses of the BNT162b2 mRNA SARS-CoV-2 vaccine, the last dose two months ago. He is afebrile. Room air oxygen saturation is 93%.

Minimal important difference in childhood interstitial lung diseases

BackgroundMonitoring disease progression in childhood interstitial lung diseases (chILD) is essential. No information for the minimal important difference (MID), which is defined as the smallest change in a parameter that...

A Woman With Fever and Abdominal Pain

A 77-year–old woman with underlying diabetes mellitus presented to the emergency department with a 3-day history of fever and right upper abdominal pain. She had a blood pressure of 115/72 mmHg, a pulse rate of 125 beats/min, a room air oxygen saturation of 93%, and a body temperature of 37.7 °C. On examination, she appeared lethargic and mildly dyspneic. Her abdomen was soft; however, marked tenderness to percussion was noted on her right flank and subcostal area. Laboratory examination was noteworthy for an elevated WBC count of 19.6 × 109/L.

REACTIVATION MILIARY TB IN THE SETTING OF POSTINFECTIOUS COVID-19 LUNGS

REACTIVATION MILIARY TB IN THE SETTING OF POSTINFECTIOUS COVID-19 LUNGS

Predictors of atrial fibrillation in patients with COVID-19

Early diagnosis of atrial fibrillation (AF) predictors in coronavirus disease 2019 (COVID-19) and the appointment of additional therapy to prevent arrhythmias will improve the prognosis of patients.Aim. To identify predictors of AF in patients with COVID-19.Material and methods. This retrospective study included 1473 patients hospitalized with COVID-19. Depending on AF occurrence, the patients were divided into 2 groups as follows: group I included 95 patients with AF episodes during hospitalization; group II consisted of 1378 patients who did not have AF during hospitalization. All patients underwent a complete blood count and urine tests, a biochemical and coagulation blood tests, 12-lead electrocardiography, chest computed tomography (CT), and echocardiography.Results. Chest CT found that lung tissue involvement in patients of group I was significantly greater than in group II (p&lt;0,05). The number of patients with significant lung involvement &gt;50% (CT-3 and CT-4) was significantly higher in the AF group than in the control group. The average room air oxygen saturation upon admission to the hospital were significantly lower in patients with AF than in the comparison group (p&lt;0,05). Multivariate analysis showed that following factors have a significant effect on AF development in COVID-19 patients: age &gt;60 years, hypertension, coronary artery disease, heart failure, increased left atrial volume, large lung tissue involvement, and increased interleukin- 6 level.Conclusion. There are two following groups of predictors initiating AF in COVID-19: generally known (older age, cardiovascular disease, increased left atrial volume) and those that determine the severe COVID-19 course (large lung damage and high interleukin-6 levels).

Respiratory distress and tracheal deviation secondary to sigmoid volvulus

Introduction: The trachea is a semiflexible tube of 1.5 to 2 cm in width and 10 to 13 cm in length. Its deviation might be caused by not only diverse thoracic but also abdominal pathologies, which may compromise the airway. We present a case of a severe tracheal deviation due to an abdominal pathology causing displacement of mediastinal structures. Clinical Case: A 78-year-old woman presents with difficulty breathing. History of chronic bedridden and frequently constipated, last stool 5 days prior. On physical examination, cachectic complexion, dry mucous membranes, breathing superficially with scarce wheezing, SatO2 82% on room air. Abdomen distended with an absence of bowel sounds. Chest x-rays show severe tracheal deviation and abdominal x-ray with coffee bean sign. A laparotomy evidences a large sigmoid volvulus. A sigmoidectomy and descending colon colostomy is performed. Room air oxygen saturation improved after extubation to 96%. Conclusion: Desaturation and tracheal deviation were caused by a large sigmoid volvulus. Although these pathologies were thoracic, clinicians should suspect different underlying pathologies, in this case, abdominal.

Provider-Only Patients: A Novel Approach to ED Volume Surge and Covid-19

Summary To address changes in the health care landscape precipitated by the Covid-19 pandemic, particularly the lack of health care personnel, the ED at Inova Fairfax Hospital developed a process to evaluate and treat patients under a Provider-Only Patients (POP) protocol involving only physicians or advanced practice providers (APPs). In this article, Inova reports on the development of the POP process and the outcomes of a cohort of patients with suspected Covid-19 who were seen in the ED as POP patients between December 1, 2021, and January 15, 2022. All of the POP patients had Covid-19–related complaints, had an Emergency Severity Index (ESI) of 4 or 5 (on a scale where 1 is most urgent and 5 is least urgent), required limited nursing intervention, were discharged, and were 21–64 years of age. Any patients who exhibited signs of hemodynamic instability (e.g., hypo- or hypertensive), had non–Covid-19 complaints, had room air oxygen saturation below 96%, were pregnant, had difficulty ambulating, and/or had inadequate social support were not considered to be a POP patient and were seen in the regular queue of patients. Inova developed a designated area in the ED where patients were seen and discharged directly by the provider. Patients were first triaged by a triage nurse or physician to determine POP status. As of January 2022, Inova’s ED had seen 640 POP and 2,386 non-POP ESI 4 and 5 subjects (4.4% of the total ED census). Although the mean time from ED arrival to bed favored non-POP patients by approximately 9 minutes, the mean time from initially being seen by a provider to the discharge disposition and the mean time from discharge disposition placement to leaving the ED significantly favored POP by 48 minutes and 66 minutes, respectively. No POP patients returned within 72 hours for admission to the hospital, which supports the integrity of the POP triage and care delivery process. The authors estimate that the 640 patients who were part of the POP process saved approximately 1,892.27 nursing and 705.1 provider hours during that 46-day study period. No additional physician or APP hours were required, which suggests that POP is a safe, efficient, and effective process that can significantly reduce provider-to-disposition times and overall discharge length of stay. In addition to its value in mitigating the pandemic-related staff shortage, the POP model may also be considered to address nonpandemic-related staffing challenges.

Efficacy of nebulized magnesium sulfate in moderate bronchiolitis

Background: Bronchiolitis is a common cause of illness and hospitalization in infants and young children. The effectiveness of various bronchodilators remains unclear. This study was conducted to assess the efficacy of nebulized magnesium sulfate in hospitalized children with moderate bronchiolitis in the age group of 1–24 months. Subjects and Methods: This was a prospective observational study done from December 2018 to June 2020. All children with moderate bronchiolitis (clinical severity score [CSS]-4–8) meeting inclusion/exclusion criteria were enrolled. A detailed history, demographic profile, CSS and oxygen saturation in room air, and heart rate were recorded. They were given two doses of magnesium sulfate in the form of nebulization for 10 min each, at 30 min apart. The children were assessed for CSS at 0 h, 1 h, and 4 h after nebulization. The children were considered improved if CSS &lt;4 at the end of 4 h. The children were monitored for adverse reactions of magnesium sulfate. Results: Sixty children were enrolled. The mean age was 7.5 ± 6.47 months. Most children (51.7%) were in 1–6 months. The mean CSS scores at 0 h, 1 h, and 4 h were 6 ± 1.008, 2.95 ± 1.395, and 2.40 ± 1.564, respectively (P = &lt; 0.001). Fifty-three (88.3%) children improved and seven (11.7%) children did not improve. In nonimproved group, subanalysis was done and found hypoxia (odds ratio − 12.6) as a significant risk factor. Flushing was the most common adverse effect noticed in eight (13.3%) children. Conclusions: Children with moderate bronchiolitis were improved with nebulized magnesium sulfate.

May 2022 Imaging Case of the Month: Asymmetric Apical Opacity–Diagnostic Considerations

No abstract available. Article truncated after 150 words. Clinical History: A 64–year–old woman presented to the emergency room with complaints of right arm pain for 2 months accompanied by subjective low-grade intermittent fevers. The patient’s past medical history was unremarkable and she had never had surgery. She had been a smoker for most of her life, at least 25-pack-years. She denied allergies, admitted to moderate daily alcohol use, and denied illicit drug use. The patient’s physical examination showed no clear focal abnormalities and she was afebrile. She did have some right scapular tenderness to palpation, although there were no abnormal skin changes over this region. Her pulse rate and blood pressure were within normal limits, and her room air oxygen saturation was 96%. Basic laboratory data, including a complete blood count and electrolytes were largely within the normal range. The patient’s white blood cell count was technically abnormal at 9.7 x109 (normal, 3.4 - 9.6 x …