Supplemental Oxygen Requirement Research Articles

COVID-19 Is Associated with Endothelial Dysfunction and Enhanced Plasma Thrombin Generation Despite Pharmacological Thromboprophylaxis

BackgroundHospitalised patients with severe COVID-19 (requiring critical care level support) appear to be at increased risk of thrombosis despite standard pharmacological thromboprophylaxis. The magnitude of thrombotic risk in patients with COVID-19 of moderate severity (not requiring critical care) is less clear. The optimal approach to thromboprophylaxis (and the role of intensified thromboprophylaxis) remains to be determined.Evidence of endothelial dysfunction has been widely reported in COVID-19 (particularly in severe COVID) and this may contribute to hypercoagulability.AimTo assess differences in patterns of hypercoagulability and endothelial dysfunction between a group of patients with moderate COVID-19 and a group of age-matched hospitalized patients (SARS-CoV-2 PCR negative) receiving low molecular weight heparin (LMWH) thromboprophylaxis.MethodsBlood was collected from individuals admitted to hospital with COVID-19 of moderate severity (not requiring critical care level support) and a group of age-matched patients admitted with infective/inflammatory illness (SARS-CoV-2 PCR negative). All subjects received standard-dose LMWH thromboprophylaxis, with blood drawn at 12 hours post-dose (and with measurement of anti-FXa activity levels). Circulating levels of endothelial & fibrinolytic markers including ICAM, PAI-1, VCAM, soluble thrombomodulin (sTM), and tissue plasminogen activator (tPA) were determined by ELISA. Thrombin generation (TG) in platelet-poor plasma was assessed by calibrated automated thrombography in the presence of tissue factor (Final concentration, 1pM & 5pM), thrombomodulin (TM) (Final concentration, 6.25nM), and an inhibitory anti-tissue factor pathway inhibitor antibody (anti-TFPI; Final concentration 100μg/mL).Results14 COVID-19 positive subjects and 11 hospitalized controls were recruited. There were no differences in mean age (69.7±4.5 vs 61.6±4.7 years; p= 0.2) or mean Body mass index (25.7±1.1 vs 22.7±1.2 Kg/m2; p=0.1) between groups. No COVID-19 patient or control required critical care support. In the COVID group, radiological evidence of pneumonitis [diffuse (n=3) or peripheral infiltrates (n=7)] was present in the majority of cases. None of the COVID-19 cases were requiring supplemental oxygen at the time of recruitment.All controls were admitted with either respiratory or urinary infection [radiological evidence of pneumonia in 4/11; supplemental oxygen requirement in 2/11, (28-36% FiO2 via nasal cannula)].Plasma levels of sTM, ICAM, PAI-1 & VCAM were similar in both groups. Levels of t-PA were significantly higher in the COVID group (8.31±4.35 vs 4.91±2.37 ng/mL; p= 0.005). Despite similar plasma anti-Xa activity in both groups (0.06 vs 0.04 IU/mL; p=0.2), mean endogenous thrombin potential (ETP) was significantly higher in the COVID group (1929±119.7 vs 1528±138.9 nM*min; p=0.02), although peak thrombin was similar (173.6±26 vs 161.5±31nM). ETP-TM ratio was similar between groups (0.3±0.1 vs 0.2±0.1; p=0.3).Despite increased ETP, the lag time to thrombin generation was significantly prolonged in the COVID group (8.3±0.6 vs 5.8±0.5 mins, p= 0.006). This pattern has previously been observed in vascular diseases associated with altered plasma tissue factor pathway inhibitor (TFPI) activity. In the presence of an anti-TFPI antibody, the difference in lagtime between groups was attenuated (4.7±0.2 vs 3.5±0.1 mins; p= 0.002) and the difference in overall thrombin generation (delta TG) between both groups became significantly increased (Fig.1).ConclusionPlasma thrombin generation is enhanced in patients with non-severe COVID-19 despite pharmacological thromboprophylaxis. Endothelial dysfunction is also observed in this group and appears to modulate parameters of plasma thrombin generation. The clinical implications of these observations are not known although clinical studies of intensified thromboprophylaxis in attenuating thrombotic risk and other complications are ongoing.Fig 1. Inhibition of TFPI activity enhances thrombin generation in COVID-19.In the presence of an inhibitory anti-TFPI antibody, peak plasma thrombin generation was enhanced in COVID-19 in contrast to that observed among SARS-CoV-2 PCR negative hospitalised patients (339.6+25.2 vs 247.4+10.1, p=0.01). [Display omitted] DisclosuresMaguire: Actelion: Research Funding; Bayer Pharma: Research Funding. Ni Ainle: Daiichi-Sankyo: Research Funding; Actelion: Research Funding; Leo Pharma: Research Funding; Bayer Pharma: Research Funding. Kevane: Leo Pharma: Research Funding.

Oxygenation and Inflammatory Markers after Early Covid-19 Convalescent Plasma: A Comparison of Survivors and Non-Survivors

BackgroundAcute respiratory distress syndrome (ARDS) is a major complication in patients with severe coronavirus disease in 2019 (COVID-19). COVID-19 convalescent plasma (CCP) has been proposed as a specific therapy for patients with COVID-19. Our goal is to assess changes in oxygenation and inflammatory markers in patients after receiving CCP.MethodsThis is a retrospective, health system-based, a case-control study comparing hospitalized patients with COVID-19 who received CCP and were discharged (survivors) to patients who died after receiving CCP (non-survivors). We analyzed the severity of ARDS, oxygenation, and inflammatory markers of 295 patients, comparing 202 survivors to 93 non-survivors with COVID-19 who received CCP. Demographic information and laboratory data were collected on the day of the admission (initial), the day of the plasma infusion (D1), and post-infusion days 3, 7, 15, and 30 (when available).ResultsSurvivors were younger (52.48 y versus 64.02 y; p<0.001) with no pre-existing conditions (25.2% versus 13.9%; p=0.03) compared to non-survivors. Severe ARDS (PaO2/FiO2 <100) was predictive of increased mortality after CCP in non-survivors (p<0.001). Survivors with mild (20%) or moderate (46%) ARDS on D1 had a 54% resolution of ARDS on D7 after CCP (p<0.001). After 72 hours of transfusion, supplemental oxygen requirements decreased by 63% of the survivors, compared to 33% of non-survivors (p<0.001). Inflammatory markers, including white blood cells, absolute neutrophils, platelets, C-reactive protein (CRP), lactate dehydrogenase (LDH), and creatinine, improved within three days in survivors after CCP (p<0.05). Baseline findings associated with a poor prognosis on D1 include a lower platelet count (219.02 versus 281.64, p<0.001), higher blood urea nitrogen (BUN) (35.41 versus 21.48, p<0.001), higher creatinine (2.24 versus 1.26, p<0.001), higher D-dimer (5.88 versus 2.46, p<0.001) and elevated lactate dehydrogenase (LDH) (698.3 versus 464.51, p<0.001) when comparing non-survivors to survivors, respectively. After 72 hours post-transfusion, the following changes were remarkable: normalization of creatinine with a mean of 1.07 in survivors versus 1.92 in non-survivors (p<0.001), a significant decrease in CRP improving from 129.27 to 84.25 in survivors versus 139.11 to 130.0 in non-survivors (p<0.001), and lower lactate dehydrogenase (LDH) in survivors (459.47) versus non-survivors (674.56, p<0.001).ConclusionIn this retrospective, health system-based, case-control study, we found that the improvement in oxygenation, resolution of ARDS, and reduced inflammatory markers are seen in survivor patients after early COVID-19 convalescent plasma transfusion. These parameters can be used to assess response to COVID-19 convalescent plasma after 72 hours of the transfusion and could help physicians in the decision-making when administering CCP, especially if resources are scarce. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Analysis of Oxygen Blood Saturation/Respiratory Rate Index, NEWS2, CURB65, and quick Sequential Organ Failure Assessment Scores to Assess Prognosis in Patients with Mild Coronavirus Disease 2019.

Hospital bed saturation has been one of the problems to solve during the SARS-CoV-2 pandemic. However, not every patient who is admitted requires close monitoring or specific therapeutics. Mild cases could be managed in the outpatient setting. Our study aimed to analyze the accuracy of the oxygen saturation/respiratory rate (sat/RR) index, NEWS2, CURB65, and quick Sequential Organ Failure Assessment (qSOFA) scores to predict supplemental oxygen requirement and prolonged hospital stay in patients with mild coronavirus disease 2019 (COVID-19). A prospective cohort study in an academic medical center. We compared the values of these scores according to the occurrence or not of each outcome. When differences between groups were statistically significant, the discriminatory capacity of the score for that outcome was analyzed. We included 271 patients. Of them, 11.07% required supplemental oxygen, showing significantly higher values of NEWS2 score and qSOFA score, and lower values of Sat/RR index. About 38% presented prolonged hospital stay, with significantly higher values of NEWS2 score and lower values of sat/RR index. The ROC curve area under the curve (AUC) of sat/RR index to discriminate the requirement of supplemental oxygen was 0.72 (CI 95% 0.61-0.84). The ROC curve of NEWS2 and qSOFA for the same outcome was 0.75 (95% [95% CI 0.65-0.85]) and 0.66 (95% CI 0.57-0.76), respectively. The ability of the Sat/RR index to discriminate the requirement of prolonged hospitalization showed an AUC of 0.67 (95% [95% CI 0.60- 0.73]). The NEWS2 score showed an AUC of 0.63 (CI 95% 0.56-0.70) for the same outcome. sat/RR index and NEWS2 score have a good capacity to discriminate patients at risk of clinical worsening, being the Sat/RR index simpler and easier to calculate.

Remdesivir for the treatment of COVID 19: review of the pharmacological properties, safety and clinical effectiveness

ABSTRACT Introduction Remdesivir is a nucleoside analog that inhibits viral RNA replication by blocking RNA-dependent RNA polymerase. First developed and tested during the Ebola epidemic, repurposed, and gained prominence during the Coronavirus disease 19 (COVID-19) pandemic. Based on data from three major trials, remdesivir became the first and only medication to obtain approval from the Food and Drug Administration (FDA) to treat patients hospitalized with COVID-19 disease. Areas covered The purpose of the article is to review available preclinical, clinical, and post-marketing data to assess the safety and efficacy of remdesivir in the treatment of COVID-19 patients. We performed a comprehensive literature review of articles published on remdesivir until January 2021. Expert opinion The substantial evidence of its effectiveness in a few trials together with the favorable safety profile makes remdesivir a primary therapeutic candidate for treatment in adult and pediatric patients who are hospitalized with COVID-19 and requiring oxygen supplementation. While remdesivir does not improve mortality, it has been shown to reduce the recovery time and increase the odds for clinical improvement, specifically in patients with early presentation and moderate COVID-19 disease. Remdesivir is well tolerated and has an acceptable safety profile in the pediatric and adult populations.

An Abnormal Echocardiogram and Telemetry Tracing in a Late Preterm Infant.

An Abnormal Echocardiogram and Telemetry Tracing in a Late Preterm Infant.

Incidence of Atrioventricular Blocks and its Association with In-Hospital Mortality and Morbidity in Patients with Coronavirus Disease 2019

BackgroundCardiovascular sequelae of coronavirus disease 2019 (COVID-19) infection have been explored by clinicians and researchers all over the world. ObjectiveThe purpose of this study was to evaluate the incidence of atrioventricular block (AV) in patients hospitalized for COVID-19 and its association between in-hospital morbidity and mortality. MethodsIn-hospital electrocardiograms (ECGs) of 438 patients were compared with their prior or baseline ECGs to ascertain the development of new onset AV block. Patients who developed new AV blocks were then followed at 30 and 90 days post-discharge to check for resolution of AV block. Demographic characteristics, clinical characteristics, and complications during their hospital stay were evaluated. Major complications including respiratory failure requiring oxygen supplementation and mechanical ventilation, sepsis, deep vein thrombosis, elevated troponins, hospital and intensive care unit (ICU) length of stay, as well as death were compared between those who developed new onset AV blocks and those who did not. ResultsBased on our single center study, the incidence of new onset AV blocks among patients admitted for COVID-19 during the study period was 5.5 cases per 100 patients. New onset AV blocks were not associated with longer hospital and ICU length of stay, increased intubation rates, or increased mortality. ConclusionAlthough the development of a new onset AV block is most likely multifactorial and not solely due to COVID-19, it is still important for clinicians to be mindful about the possibility of developing symptomatic bradycardia and life-threatening arrhythmias in patients admitted for COVID-19. This can be achieved by appropriate rhythm monitoring in-patient but the need for a cardiac event monitor upon discharge is unlikely to be necessary. Careful history taking, including family and drug use history is also of great importance as emerging drug therapies for COVID-19 have potential arrhythmogenic effects.

Role of systemic corticosteroids in preventing hypoxia among patients with mild COVID-19: An observational study.

Use of systemic corticosteroids is well-established in COVID-19 patients with hypoxia; however, there is scant data on its role in patients with mild disease and prolonged symptoms as a measure to prevent disease progression. The aim of this study is to evaluate the role of systemic corticosteroids in preventing hypoxia (SpO2 ≤ 93% on room-air) among mild COVID-19 patients. An observational study was conducted among symptomatic COVID-19 patients taking oral corticosteroids and attending institute teleconsultation facility between 10th-30th June 2021. Patients who were already on corticosteroids for other indication or required oxygen supplementation before or within 24-hours of initiation of corticosteroids were excluded. A total of 140 consecutive symptomatic COVID-19 patients were included. Higher baseline C-reactive protein (OR: 1.03, 95% CI: 1.02-1.06, p < 0.001) and early systemic corticosteroid (within 7 days) initiation (OR: 6.5, 95% CI: 2.1-20.1, p = 0.001) were independent risk factors for developing hypoxia (SpO2 ≤ 93%). Progression to hypoxia was significantly higher in patients who received corticosteroids before day 7 of illness (36.7%, 95% CI, 23.4-51.7%) compared to ≥ 7 of illness (14.3%, 95% CI, 7.8-23.2%) for persistent fever. Systemic corticosteroids within 7 days from symptom-onset were harmful and increased the risk of progression to hypoxia, whereas it may decrease the risk of progression when administered on or beyond 7 days in patients with mild COVID-19 and persistent symptoms. A well-designed randomised controlled trial is required to validate the findings.

High altitude simulation testing in patients with congenital diaphragmatic hernia

Aim of studyCongenital Diaphragmatic Hernia (CDH) is associated with lung hypoplasia and pulmonary hypertension. Many patients receive care in specialty centers requiring air travel upon discharge and for subsequent follow-up care. Premature infants can experience significant hypoxia in flight, but this has not been studied in the CDH population. This report describes our center's experience with simulated altitude testing among CDH patients. MethodsIn a single center retrospective cohort study, CDH patients who underwent a High Altitude Simulation Test (HAST) from 2006 to 2019 were analyzed. HAST simulates increased altitude by reducing oxygen tension to an FIO2 of 0.15. Patients were tested only when flight was anticipated. Patients requiring oxygen were challenged on their baseline requirement. To pass, patients had to maintain oxygen saturation > 90%, and 94% if diagnosed with pulmonary hypertension. Supplemental oxygen was titrated as needed to achieve this goal. ResultsOf twenty patients tested, only six (30%) passed on their first attempt. Ten (50%) eventually passed, after an average of 3.2 additional attempts over 1.8 years. No patient passed initially who utilized ECMO support, diaphragmatic agenesis, or had elevated right ventricular pressure on echocardiogram. All patients achieved the targeted SpO2 with supplemental oxygen. ConclusionCDH patients experience hypoxia when exposed to the simulated hypobaric nature of air travel and therefore may become hypoxic in flight, requiring oxygen supplementation. Disease severity seems to correlate with risk of in-flight hypoxia. This data suggests that CDH patients should be screened to assess their need for supplemental oxygen to ensure safe air travel. Level of evidenceLevel 4 case series.

Feasibility of Implementing Thoracic Radiation Therapy for COVID-19 Pneumonia

Purpose/Objective(s)The value of low dose whole thoracic radiation therapy (LD-WTRT) for SARS-CoV-2 (COVID-19) pneumonia is unknown. Should ongoing clinical trials demonstrate LD-WTRT proves effective for COVID-19 pneumonia recovery, widespread rapid implementation will be helpful globally. Our aim was to outline a pragmatic process that could be implemented successfully in a community hospital.Materials/MethodsTo identify appropriate patients admitted to the hospital with COVID-19 pneumonia, we worked with Nursing Informatics to screen all currently admitted COVID+ patients requiring oxygen supplementation. For patients meeting criteria of the PreVent protocol per chart review, radiation oncologists contacted the hospitalist physician for telehealth consultation with the patient to discuss single dose LD-WTRT. After a patient had confirmed interest in treatment, at time of physical exam, we obtained consent and digitally transferred the signed consent form via secure text to avoid contaminated forms. Chest radiographs were used to estimate AP/PA field size and separation at the carina; diagnostic chest CT data was imported into the treatment planning system for field size and MU calculation before patient arrival, without using the department's CT simulator. Inpatient Nursing transported patients for treatment after clinic hours on a route pre-approved by Infection Control. The treating radiation oncologist and one ‘hot’ radiation therapist assisted with patient set-up supine or prone on the linear accelerator couch. After decontamination, the physician and a ‘cold’ therapist confirmed field size and MU calculations to prepare for treatment delivery. Nursing monitored patient O2 saturation and stayed gowned with the ‘hot’ therapist. After patient departure, Radiation Oncology contacted Facilities for decontamination of the vault before treating cancer patients the following day.ResultsFor the first treated patient, telehealth consultation lasted 40 minutes. In-person exam, evaluation and consent took 60 minutes, of which 30 were for the protocol-required consent form. With the diagnostic CT scan, field design and MU calculations took 20 minutes. Patient arrival to departure took 40 minutes. Once the patient was positioned on the couch, localization, MU confirmation and entry and treatment delivery took 16 minutes.ConclusionWe have developed a process to efficiently provide LD-WTRT for patients with COVID pneumonia that minimizes staff exposure, departmental equipment, and room contamination. Should clinical trials indicate that LD-WTRT helps treat COVID pneumonia patients, this process can work in most hospital-based radiation oncology departments to provide LD-WTRT efficiently and safely. Staff and cancer patient vaccination will further lower the risks of implementing LD-WTRT but is not necessary with careful planning and consultation with infection control.

Active surveillance of serious adverse events following transfusion of COVID-19 convalescent plasma.

BackgroundThe reported incidence of adverse reactions following Coronavirus disease 2019 (COVID‐19) convalescent plasma (CCP) transfusion has generally been lower than expected based on the incidence of transfusion reactions that have been observed in studies of conventional plasma transfusion. This raises the concern for under‐reporting of adverse events in studies of CCP that rely on passive surveillance strategies.Materials and MethodsOur institution implemented a protocol to actively identify possible adverse reactions to CCP transfusion. In addition, we retrospectively reviewed the charts of inpatients who received CCP at Stanford Hospital between May 13, 2020 and January 31, 2021. We determined the incidence of adverse events following CCP transfusion.ResultsA total of 49 patients received CCP. Seven patients (14%) had an increased supplemental oxygen requirement within 4 h of transfusion completion, including one patient who was intubated during the transfusion. An additional 11 patients (total of 18, 37%) had increased oxygen requirements within 24 h of transfusion, including 3 patients who were intubated. Six patients (12%) fulfilled criteria for transfusion‐associated circulatory overload (TACO).ConclusionUsing an active surveillance strategy, we commonly observed adverse events following the transfusion of CCP to hospitalized patients. It was not possible to definitively determine whether or not these adverse events are related to CCP transfusion. TACO was likely over‐diagnosed given overlap with the manifestations of COVID‐19. Nevertheless, these results suggest that the potential adverse effects of CCP transfusion may be underestimated by reports from passive surveillance studies.

Evaluation of role of remdesivir in covid-19 patients outcome: A retrospective analysis

Coronavirus disease 2019 (COVID-19) is a contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Remdesivir, a broad spectrum antiviral agent, is currently the only drug that is approved by the Food and Drug Administration for the treatment of COVID-19. It is recommended for use in hospitalized patients who require supplemental oxygen. There are insufficient data either for or against to recommend for routine use of Remdesivir in high risk patients who doesn’t require supplemental oxygen. To evaluate the efficacy of Remdesivir in covid positive patients. A retrospective analysis of 300 patients was done, out of which 150 patients belong to Group 1 and 150 patients belong to Group 2. Group 1-Elderly patients with comorbidities who doesn’t require supplemental oxygen Group 2- Patients requiring oxygen supplementation (SpO2 88% to 94% on room air).Group 1 patients were discharged earlier than Group 2 patients.Elective use of Remdesivir has a definitive role in prevention of progression of disease especially in high risk susceptible individuals.

BASELINE SUPPLEMENTAL OXYGEN REQUIREMENTS DO NOT INCREASE COMPLICATION RATES AFTER TRACHEOBRONCHOPLASTY FOR SEVERE SYMPTOMATIC EXCESSIVE CENTRAL AIRWAY COLLAPSE

TOPIC: Cardiothoracic Surgery TYPE: Original Investigations PURPOSE: Tracheobronchoplasty (TBP) is the treatment of choice for severe symptomatic Excessive Central Airway Collapse (ECAC). Currently, there have not been any studies that investigate the impact of baseline supplemental oxygen requirements on patients undergoing TBP. This study compares short-term postoperative complications in patients with baseline supplemental oxygen versus patients with no supplemental oxygen requirements that underwent TBP. METHODS: A retrospective, single-center analysis was conducted on consecutive patients that underwent TBP for severe symptomatic ECAC from 2004 to 2018. Baseline characteristics, comorbidities, and functional status variables were collected. Short-term postoperative complications (90 days) were recorded and stratified using the Comprehensive Complication Index (CCI). Complications were compared between patients with supplemental oxygen requirements and patients with no supplemental oxygen requirements using a t-test, Wilcoxon rank-sum test, or Chi2 as appropriate. Propensity score matching was used to control for age, sex, race, Charlson Comorbidity Index, and operative time. RESULTS: One hundred three patients that underwent TBP during the study period were included. Fourteen patients had supplemental oxygen requirements at baseline. When the two groups were compared, the patients with supplemental oxygen requirements had a lower prevalence of COPD (p=0.03), a higher prevalence of OSA (p<0.01), and lower mean values of DLCO (p=0.03) and FEV1 (p=0.05) at baseline. When the propensity score matching was used, nine patients remained in each group. Baseline differences in demographics and pulmonary function testing were not observed any longer. In both the matched and unmatched cohort, there were no differences in ICU length of stay, reintubation rates, prolonged ventilation rates, the incidence of any kind of complication, the incidence of major complications (Clavien Dindo Score > IIIb), or median CCI scores. CONCLUSIONS: Short-term 90-day postoperative complications after TBP for severe symptomatic ECAC were no different in patients with or without supplemental oxygen requirements at baseline. Our findings suggest that oxygen requirements should not be considered a cause of increased complication rates, increased length of stay in ICU, prolonged ventilation, or reintubation in ECAC patients that underwent TBP. CLINICAL IMPLICATIONS: Supplemental oxygen requirement should not be a decisive factor when considering the surgical candidacy of patients with ECAC. DISCLOSURES: No relevant relationships by Erick Flores, source=Web Response no disclosure on file for Sidhu Gangadharan; No relevant relationships by Fayez Kheir, source=Web Response Consultant relationship with Boston Scientific Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with olympus Please note: $5001 - $20000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with pinacle biologics Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with cook medical Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Removed 06/23/2021 by Adnan Majid, source=Web Response No relevant relationships by Daniel Ospina-Delgado, source=Web Response No relevant relationships by Mihir Parikh, source=Web Response no disclosure on file for Jennifer Wilson

INHALED NITRIC OXIDE VIA HIGH-FLOW NASAL CANNULA IN PATIENTS WITH ACUTE RESPIRATORY FAILURE RELATED TO COVID-19

INHALED NITRIC OXIDE VIA HIGH-FLOW NASAL CANNULA IN PATIENTS WITH ACUTE RESPIRATORY FAILURE RELATED TO COVID-19

PNEUMATOCELE FORMATION DUE TO SARS-COV2: A CASE REPORT

PNEUMATOCELE FORMATION DUE TO SARS-COV2: A CASE REPORT

DEXAMETHASONE-INDUCED HICCUPS IN A PATIENT WITH COVID-19 PNEUMONIA

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Dexamethasone has been shown to reduce 28-day mortality in patients with severe COVID-19 pneumonia who required oxygen supplementation or invasive mechanical ventilation according to the RECOVERY trial. With the global COVID-19 pandemic, we are seeing increasing use of dexamethasone. This may lead to increased incidence of side effects as well. One of the side effects of dexamethasone therapy is hiccups which can range in presentation from mild and transient to persistent, causing distress and impaired quality of life. CASE PRESENTATION: A 59-year-old male with past medical history of type 2 diabetes mellitus and hypertension presented to the hospital with chief complaint of shortness of breath. Vitals were remarkable for acute hypoxic respiratory failure, improved with oxygen supplementation. Computerized tomography (CT) of the chest with contrast both showed bilateral airspace opacities. COVID-19 PCR was positive. Patient was diagnosed with COVID-19 pneumonia and started on remdesevir and dexamethasone. On day 3 of therapy, patient endorsed having hiccups without aggravating or relieving factors. These hiccups were suspected to be secondary to dexamethasone after initial evaluation. Gabapentin therapy was planned for relief, but patient's hiccups resolved after 24 hours. Patient completed the remaining dexamethasone therapy without incident. DISCUSSION: This brief case highlights the importance of recognizing dexamethasone induced hiccups as a clinical entity that may increase in incidence given increasing utility of dexamethasone in patients with severe COVID-19 pneumonia. Previous studies described this phenomenon in patients who were prescribed dexamethasone for chemotherapy induced nausea. They noticed that rotating dexamethasone with prednisolone in patients who developed hiccups significantly reduced the hiccups intensity. The hiccups were thought to be due to dexamethasone being more permeable to and crossing the blood brain barrier to stimulate the hiccups reflex arc in the midbrain. For patients with COVID-19 who meet criteria for dexamethasone, it may be prudent to continue with dexamethasone despite hiccups if quality of life is not significantly impaired due to lack of convincing evidence regarding efficacy of other steroids in COVID-19. Therapies such as gabapentin, metoclopramide and baclofen have been proposed for hiccups that are significantly affecting quality of life. Dexamethasone induced hiccups usually resolve upon discontinuing the drug. As such, most patients usually require reassurance or brief pharmacotherapy for hiccups. CONCLUSIONS: Dexamethasone may cause hiccups during the course of therapy for severe COVID-19 pneumonia. These hiccups are usual transient and resolve upon discontinuation of the drug. REFERENCE #1: Lee GW, Oh SY, Kang MH, Kang JH, Park SH, Hwang IG, Yi SY, Choi YJ, Ji JH, Lee HY, Bruera E. Treatment of dexamethasone-induced hiccup in chemotherapy patients by methylprednisolone rotation. Oncologist. 2013;18(11):1229-34. doi: 10.1634/theoncologist.2013-0224. Epub 2013 Oct 9. PMID: 24107973;PMCID: PMC3825309. DISCLOSURES: No relevant relationships by Muhammad Hasib Khalil, source=Web Response

HAMMAN'S SYNDROME: A RARE CONSEQUENCE FOR A COMMON VICE

TOPIC: Disorders of the Mediastinum TYPE: Medical Student/Resident Case Reports INTRODUCTION: Roughly 42 million Americans have reported trying cocaine via myriad methods in their lifetime. Since the early 2000s, spontaneous pneumomediastinum as a result of intranasal cocaine use has been demonstrated though it remains a relatively rare occurrence. Though complications such as coronary vasospasm and thrombosis may prove a greater threat to life, it should remain a part of the clinician's differential when treating a patient with a history of cocaine abuse and chest pain. CASE PRESENTATION: A healthy 20-year-old male presented with chest pain, cough, and neck pain for 3 days. He was drinking with a friend and "snorted" cocaine a few times on the same night. A few hours into the evening, he experienced a sudden, sharp retrosternal chest pain, without radiation, and exacerbated by deep breathing. He denied trauma and denied vomiting, dry heaving, gagging, or other symptoms to cause concern for GI perforation as cause, despite drinking heavily that night.On evaluation, his oxygen saturation measured 98% on room air with normal pulse, blood pressure and temperature. Physical examination revealed extensive neck and chest wall subcutaneous emphysema. Electrocardiogram demonstrated normal sinus rhythm without arrhythmias or segmental changes. CT of the chest demonstrated large amounts of air in the superior mediastinum. Based on his history, severity of presentation, and laboratory investigations, there was no concern for mediastinitis or esophageal rupture. He did not require oxygen supplementation and his pain was well controlled, so he was discharged to his home. DISCUSSION: In 1939, Louis Virgil Hamman (1877–1946) described the co-occurrence of subcutaneous emphysema with spontaneous pneumomediastinum, thus coining the term Hamman's Syndrome for this particular malady. Subcutaneous emphysema occurs primarily within the head and neck due to anatomical proximity to the airway and pneumomediastinum as a result of cocaine insufflation is thought to be due to barotrauma, with rapid changes in intrathoracic and intra-alveolar pressures as the individual snorts and performs Valsalva maneuver. Though typically self-limited, complications of spontaneous pneumomediastinum to be aware of include airway compression, pneumopericardium, and mediastinitis. CONCLUSIONS: In a case of Hamman's Syndrome without a history of illicit drug use or trauma, it is prudent to investigate other secondary causes of spontaneous pneumomediastinum, such as esophageal or tracheobronchial rupture, that can prove fatal. Particularly in young males who abuse cocaine, the astute clinician must search for underlying causes of chest pain with recent drug use: coronary artery spasm or thrombosis, arrhythmia, pneumothorax, or pneumomediastinum. REFERENCE #1: Dadhwal R, Bulathsinghala C P, Choudhry I, et al. Cocaine-Induced Bronchial Laceration: A Rare Incidence. Cureus, 2021, 13(4): e14252. doi:10.7759/cureus.14252 REFERENCE #2: Jaensch, S.; Hwang, S.; Kuo, T. Spontaneous pneumomediastinum and subcutaneous emphysema following cocaine inhalation and ecstasy ingestion. Case Reports in Otolaryngology, 2019, Article ID 6972731: 1-4. https://doi.org/10.1155/2019/6972731 REFERENCE #3: Soares et al. Subcutaneous emphysema and pneumomediastinum following cocaine inhalation: a case report. Journal of Medical Case Reports, 2015, 9(195): 1-4. DOI 10.1186/s13256-015-0683-8 DISCLOSURES: No relevant relationships by Kendall Creed, source=Web Response No relevant relationships by Navkiran Randhawa, source=Web Response No relevant relationships by Sabrina Siddiqui, source=Web Response No relevant relationships by Victor Test, source=Web Response

Prospective Clinical, Virologic, and Immunologic Assessment of COVID-19 in Transplant Recipients.

Several studies have described the clinical features of COVID-19 in solid-organ transplant recipients. However, many have been retrospective or limited to more severe cases (hospitalized) and have not routinely included serial virological sampling (especially in outpatients) and immunologic assessment. Transplant patients diagnosed with COVID-19 based on a respiratory sample PCR were prospectively followed up to 90 d. Patients provided consent for convalescent serum samples and serial nasopharyngeal swabs for SARS-CoV-2 antibody (antinucleoprotein and anti-RBD) and viral load, respectively. In the 161 SOT recipients diagnosed with COVID-19, the spectrum of disease ranged from asymptomatic infection (4.3%) to hospitalization (60.6%), supplemental oxygen requirement (43.1%), mechanical ventilation (22.7%), and death (15.6%). Increasing age (OR, 1.031; 95% CI, 1.001-1.062; P = 0.046) and ≥2 comorbid conditions (OR, 3.690; 95% CI, 1.418-9.615; P = 0.007) were associated with the need for supplemental oxygen. Allograft rejection was uncommon (3.7%) despite immunosuppression modification. Antibody response at ≥14 d postsymptoms onset was present in 90% (anti-RBD) and 76.7% (anti-NP) with waning of anti-NP titers and stability of anti-RBD over time. Median duration of nasopharyngeal positivity was 10.0 d (IQR, 5.5-18.0) and shedding beyond 30 d was observed in 6.7% of patients. The development of antibody did not have an impact on viral shedding. This study demonstrates the spectrum of COVID-19 illness in transplant patients. Risk factors for severe disease are identified. The majority form antibody by 2 wk with differential stability over time. Prolonged viral shedding was observed in a minority of patients. Reduction of immunosuppression was a safe strategy.

Respiratory Non-Invasive Venous Waveform Analysis for Assessment of Respiratory Distress in Coronavirus Disease 2019 Patients: An Observational Study.

Due to the rapid rate of severe acute respiratory syndrome coronavirus 2 transmission and the heterogeneity of symptoms of coronavirus disease 2019, expeditious and effective triage is critical for early treatment and effective allocation of hospital resources. A post hoc analysis of respiratory data from non-invasive venous waveform analysis among patients enrolled in an observational study was performed. Vanderbilt University Medical Center. Peripheral venous waveforms were recorded from admission to discharge in enrolled coronavirus disease 2019-positive patients and healthy age-matched controls. Data were analyzed in LabChart 8 to transform venous waveforms to the frequency domain using fast Fourier transforms. The peak respiratory frequency was normalized to the peak cardiac frequency to generate a respiratory non-invasive venous waveform analysis respiratory index. Paired Fisher exact tests were used to compare each patient's respiratory non-invasive venous waveform analysis respiratory index at admission and discharge. A nonparametric one-way analysis of variance was used for multiple comparisons between patients with coronavirus disease 2019 and healthy controls for respiratory non-invasive venous waveform analysis respiratory index. Fifty coronavirus disease 2019-positive patients were enrolled between April 2020, and September 2020, and 45 were analyzed; 34 required supplemental oxygen and 11 did not. The respiratory non-invasive venous waveform analysis respiratory index was significantly higher for the 34 patients with coronavirus disease 2019 who received supplemental oxygen (median, 0.27; interquartile range, 0.11-1.28) compared with the 34 healthy controls (median, 0.06; interquartile range, 0.03-0.14) (p < 0.01). For patients with coronavirus disease 2019 who received supplemental oxygen, respiratory non-invasive venous waveform analysis respiratory index was significantly lower at hospital discharge (p = 0.02; 95% CI, 0.10-1.9) compared with hospital admission (median = 0.12; interquartile range, 0.05-0.56). For patients with coronavirus disease 2019, a respiratory non-invasive venous waveform analysis respiratory index of 0.64 demonstrated sensitivity of 92%, specificity of 47%, and positive predictive value of 93% for predicting requirement of supplemental oxygen during the hospitalization. Respiratory non-invasive venous waveform analysis respiratory index represents a novel physiologic respiratory measurement with a promising ability to triage early care and predict the need for oxygen support therapy in coronavirus disease 2019 patients.

CRACK LUNG MIMICKING INFECTIOUS PNEUMONIA

TOPIC: Signs and Symptoms of Chest Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cocaine is responsible for innumerable visits to the emergency department and a frequent cause of death. It is the most used drug worldwide after marihuana. An estimated 1.9 million people over the age of 12 had used cocaine in the last month. Toxicity can affect multiple systems such as the cardiovascular, respiratory, and central nervous systems. Lung damage is caused by different mechanisms such as direct cellular toxicity, thermal airway injury, barotrauma, inflammatory damage, and vasospasm leading to ischemia that could lead to respiratory failure. Here is an intriguing case secondary to this highly addictive drug. CASE PRESENTATION: A 28-year-old inmate with a history of hypertension, bronchial asthma, and illicit drug abuse arrived at the emergency department with episodes of hemoptysis. Symptoms began the day before his arrival, accompanied by shortness of breath, dizziness, and cough. Vital signs were tachycardia, tachypnea, and desaturation requiring oxygen supplementation. Physical exam was notable for bilateral wheezing and rhonchi. Initial laboratories were remarkable for leukocytosis and hypoxemia. The drug screen test was negative. Chest radiograph showed multiple nodular densities distributed in both lungs and alveolar infiltrates with air bronchograms in the right upper lobe. Chest computerized tomography revealed diffuse patchy opacities and ground glass bilaterally. Respiratory therapies and empirical antibiotics were started. The next day, the patient's symptoms markedly improved, including shortness of breath, hypoxemia, and hemoptysis. Cultures and tuberculosis workup came back negative. After the complete amelioration of symptoms, the patient admitted to consuming cocaine the day the symptoms began and related it to his inhaled intake. A Follow-up chest x-ray showed resolution of previously visualized diffuse patchy pulmonary opacities. DISCUSSION: Crack-lung is an acute pulmonary syndrome induced by cocaine, characterized by diffuse alveolar damage and hemorrhagic alveolitis that occurs within 48 hours after its consumption. Diagnosis can be challenging since it can mimic many diseases, so it is essential to consider those patients with a history of drug abuse who come to the emergency room. Its incidence is still unknown. Laboratory tests are nonspecific, and negative toxicology tests do not rule out this disease. Diagnosis requires a temporal relationship of cocaine use within 48 hours of symptom onset, radiological evidence, and a consistent clinical course. REFERENCE #1: Forrester JM, Steele AW, Waldron JA, Parsons PE. Crack lung an acute pulmonary syndrome with a spectrum of clinical and histopathologic findings. Am Rev Respir Dis. 1990;142(2):462–467. doi:10.1164/ajrccm/142.2.462 DISCLOSURES: No relevant relationships by Gabriela Negron-Ocasio, source=Web Response No relevant relationships by Nicole Rassi, source=Web Response No relevant relationships by William Redondo, source=Web Response No relevant relationships by Nicole Rivera-Bobe, source=Web Response No relevant relationships by JORGE SANDELIS PEREZ, source=Web Response No relevant relationships by Juan Santiago, source=Web Response

A CASE OF VAPING-RELATED LUNG INJURY MIMICKING COVID-19

TOPIC: Tobacco Cessation and Prevention TYPE: Medical Student/Resident Case Reports INTRODUCTION: E-cigarette and vaping associated lung injury (EVALI) was first recognized in 2019 and can present with acute onset respiratory distress mimicking that of COVID-19. It is important to consider in a young patient with a significant vaping history. CASE PRESENTATION: A 19-year-old male with a history of anxiety, depression, and delusional disorder presented with worsening dyspnea, fever and productive cough, nausea, vomiting, diarrhea for 1 week. He had gone to urgent care where he had tested negative for COVID19 twice and was started on Azithromycin. He denied any exposure to COVID positive individuals but reported that his siblings' school had a recent outbreak. Vitals on admission were temperature 100.3F, Heart rate 121, Respiratory rate 24, Blood Pressure 157/97, pulse oximetry 81% on Room Air, improved after 6L supplemental oxygen. Labs significant for leukocytosis of 19.4K, normal procalcitonin, ESR >130, ferritin 443, LDH 694, CRP 358. Urine drug screen positive for THC (tetrahydrocannabinol). Urine was negative for Legionella and Strep pneumoniae. COVID testing were negative on 3 separate occasions. Chest x-ray showed mild-moderate pulmonary congestion, but no effusions. Chest CTA showed patchy parenchymal interstitial infiltrates bilaterally, suspicious for nonspecific pneumonitis/atypical viral pneumonia or pulmonary edema, but no pulmonary embolus. Blood cultures and sputum cultures negative.On further questioning, he attested to vaping and smoking marijuana through a bong; he had recently bought a new THC product off the street for vaping that contained vitamin E acetate. Given his history of vaping and his failed treatment with antibiotics, we considered EVALI. He was started on prednisone 40mg daily and 5 day course of Azithromycin and Ceftriaxone. On the 4th day of hospitalization, he showed significant clinical improvement and was no longer requiring oxygen supplementation. The patient was discharged on Day 5. Repeat chest xray 5 days after discharge showed no evidence of active disease. DISCUSSION: EVALI is a diagnosis of exclusion; it can mimic atypical and viral pneumonias, most notably COVID-19. Vitamin E acetate is the main causative agent, resulting in an acute lung injury with findings of acute fibrinous pneumonitis, diffuse alveolar damage, or organizing pneumonia. Patients are usually treated with supportive care, antibiotics, and systemic steroids. The COVID19 pandemic poses a diagnostic challenge to accurately diagnose cases of EVALI due to the similar presentation of both diseases: acute to subacute respiratory symptoms with gastrointestinal symptoms, ground-glass opacities on CT, and elevated inflammatory markers. CONCLUSIONS: Similar to COVID19, EVALI can also be fatal, and should not be overlooked as a diagnosis. A thorough history is imperative in reaching a diagnosis, and can save PPE use, and decrease hospitalization cost. REFERENCE #1: "Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products." Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 27 Nov. 2020, www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#overview. REFERENCE #2: Blount, Benjamin C., et al. "Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI." New England Journal of Medicine, vol. 382, no. 8, 2020, pp. 697–705., doi:10.1056/nejmoa1916433. REFERENCE #3: Hollingsworth, Helen. UpToDate, 9 Feb. 2021, www.uptodate.com/contents/e-cigarette-or-vaping-product-use-associated-lung-injury-evali?search=evali&source=search_result&selectedTitle=1~13&usage_type=default&display_rank=1#H4113759245. DISCLOSURES: No relevant relationships by Rebecca Greenspan, source=Web Response No relevant relationships by Areej Khan, source=Web Response No relevant relationships by Manpreet Mann, source=Web Response No relevant relationships by Krishnaveni Sirigaddi, source=Web Response