The Southwest Respiratory and Critical Care Chronicles

Texas accounts for 25% of national congenital syphilis cases in 2022

J. Drew Payne — 2024-01-16

Syphilis cases have increased dramatically, with a 500% rise in Lubbock County from 2019 to 2023. Texas, alone, reported approximately 25% of U.S. congenital syphilis cases in 2022, indicating a broader public health threat. This rise in congenital syphilis is particularly concerning and a harbinger for systemic issues with the healthcare system. Healthcare professionals must screen patients for risk factors, increase routine testing and administer effective treatment protocols.

Pulmonary rehabilitation in patients with prior COVID-19 infections

Avantika Mallik — 2024-01-29

Abstract

Background: Patients with prior COVID-19 infections can develop persistent dyspnea and physical limitation. This may reflect chronic lung disease, chronic heart disease, or neuromuscular disease. Treatment approaches include pulmonary rehabilitation. This study analyzed the benefits of conventional pulmonary rehabilitation in patients with chronic symptoms following COVID-19 infections.

Methods: Twenty-eight patients completed pulmonary rehabilitation at University Medical Center in Lubbock, Texas. The primary outcome was the time spent on four different types of exercise equipment during aerobic exercise sessions.

Results: This study included 15 women and 13 men, with a mean age of 54.4 years. The racial distribution included 12 White patients, 10 Hispanic patients, and 6 Black patients. Ten patients had a smoking history, 19 patients used supplemental oxygen, 14 patients had hypertension, and 11 patients had diabetes. The median COPD Assessment Test (CAT) score was 21.5 (Q1, Q3: 17.5,29), the median Patient Health Questionnaire-9 (PHQ-9) score was 8 (Q1, Q3: 4.5,15.5), and the median Medical Research Council (MRC) score was 2. Twenty-six patients had the abnormal chest x-rays within 3 months of starting the rehabilitation program; these included 5 patients with focal interstitial infiltrates, 9 patients with diffuse interstitial infiltrates, 6 patients with focal opacities, and 6 patients with bilateral opacities. These patients completed 22.9 (Q1, Q3: 6.8,36) exercise sessions. There were statistically significant increases in all machine times on all 4 machines.

Conclusion: This study indicates pulmonary rehabilitation can significantly increase aerobic activity levels in patients with prior COVID-19 infections. This improvement occurred in patients with important comorbidity, abnormal chest x-rays, and chronic oxygen supplementation requirements. Patients with prior COVID-19 infections and persistent respiratory symptoms should be referred to pulmonary rehabilitation.

Key words: COVID-19, long COVID, rehabilitation

Fluid management based on renal function considerations

Arunee Motes — 2024-01-29

Intravenous fluid administration is one of the most commonly used interventions in acutely ill patients. Almost all hospitalized patients receive intravenous fluids for either volume resuscitation or as diluents for drug administration. However, recent studies suggest that fluid overload is associated with acute kidney injury and that fluid administration beyond the volume needed to correct the fluid deficit is associated with increased morbidity, longer hospital stays, and mortality. The exact cause and effect underlying this association remains uncertain. Previous studies have reported a correlation between fluid overload and mortality in critically ill patients with acute respiratory distress syndrome, acute lung injury, sepsis, and acute kidney injury. In patients with acute kidney injury, a higher percentage of fluid overload has been associated with higher mortality and shorter ventilator-free days starting during the initial management in the intensive care unit. Similarly, in a large multicenter study, a positive fluid balance was an important factor associated with increased 60-day mortality in patients with acute kidney injury. This review analyzes the use of intravenous fluids and renal function, including types of intravenous fluid, cumulative fluid targets, endpoint hemodynamic indicators, and renal replacement therapy for acute kidney injury.

Key words: volume status, intravenous fluids, fluid balance, acute kidney injury, volume excess

Mechanical power during mechanical ventilation

Kenneth Nugent — 2024-01-29

Mechanical ventilation provides lifesaving support for patients with acute respiratory failure. However, the pressures and volumes required to maintain gas exchange can cause ventilator-induced lung injury. The current approach to mechanical ventilation involves attention to both tidal volume and airway pressures, in particular plateau pressures and driving pressures. The ventilator provides energy to overcome airway resistance and to inflate alveolar structures. This energy delivered to the respiratory system per unit time equals mechanical power. Calculation of mechanical power provides a composite number that integrates pressures, volumes, and respiratory rates. Increased levels of mechanical power have been associated with tissue injury in animal models. In patients, mechanical power can predict outcomes, such as ICU mortality, when used in multivariable analyses. Increases in mechanical power during the initial phase of ventilation have been associated with worse outcomes. Mechanical power calculations can be used in patients on noninvasive ventilation, and measurements of mechanical power have been used to compare ventilator modes. Calculation of mechanical power requires measurement of the area in a hysteresis loop. Alternatively, simplified formulas have been developed to provide this calculation. However, this information is not available on most ventilators. Therefore, clinicians will need to make this calculation. In summary, calculation of mechanical power provides an estimate of the energy requirements for mechanical ventilation based on a composite of factors, including airway resistance, lung elastance, respiratory rate, and tidal volume.

Key words: mechanical ventilation, mechanical power, ventilator-induced lung injury, energy, work

Teprotumumab-associated hearing-related adverse events

Amanda Key — 2024-01-29

This study aims to provide a review of the existing literature on teprotumumab (Tepezza)-associated hearing-related adverse effects. A review of PubMed and Embase was conducted using keywords “teprotumumab,” “tepezza,” “hearing disorder[s],” “hearing loss,” and “ototoxicity.” These search results were filtered to include all clinical trials, observational studies, case reports, and case series relevant to the topic of teprotumumab-associated hearing disorders. Data collection from the 15 included studies consisted of: sample size, number and percentage of hearing disorders reported, types of hearing disorders, remission rates, timeline of symptom onset, predisposing risk factors, suggested screening guidelines, and treatment proposals. Teprotumumab-associated hearing disorders are reported in 7-81.5% (median 12%) of clinical study participants. Symptoms described include sensorineural hearing loss (SNHL), hypoacusis, autophony, ear fullness/pressure/plugging, patulous eustachian tube, and tinnitus. Most symptoms improve with discontinuation of teprotumumab, but some symptoms persist after completion of treatment, most commonly SNHL. Symptoms have been reported occurring 3-37 (median 8.4) weeks after treatment initiation, with the majority reported 6 weeks after treatment initiation. Additional prospective studies are needed to clarify how frequently teprotumumab causes ototoxicity. There remains a need for both standardized audiologic screening guidelines and treatment for patients in whom ototoxicity persists post-treatment.

Key Words: teprotumumab, tepezza, hearing disorder[s], hearing loss, ototoxicity

The benefits of a closed ICU: a systematic review

Or Belkin — 2024-01-29

This study compared closed and open intensive care unit (ICU) models in terms of patient outcomes. Closed ICUs had reduced mortality rates, shorter lengths of stay, and lower healthcare-associated infection rates. Intensivists in closed ICUs contributed to better outcomes due to their expertise and competence. Enhanced interdisciplinary collaboration, improved communication, and coordination in closed ICUs led to higher patient and family satisfaction. In addition, closed ICUs were more cost-effective, with better resource use and reduced healthcare costs. Overall, closed ICU models have advantages in patient outcomes, better resource use, cost-effectiveness, and patient satisfaction compared to open ICU models.

Key words: Intensive care unit, ICU, patient outcomes, resource utilization, quality of care.

Cefepime-induced non-convulsive status epilepticus

Walter Duarte-Celada — 2024-01-29

Cefepime-induced non-convulsive status epilepticus (NCSE) can develop in patients with advanced age, renal impairment, and previous central nervous system disorders. Its clinical presentation varies from confusion, mutism, and decreased level of consciousness to coma. The typical electroencephalogram (EEG) findings are generalized spike and wave discharges of 1-3 Hz. We present a case series of 4 patients with cefepime-induced NCSE, including the clinical presentation and EEG findings. Electroencephalograms should be part of the workup of acute confusional state in patients on this antibiotic, and physicians should be aware of this uncommon complication.

Keywords: Non-convulsive status epilepticus, cefepime, confusion, mutism, electroencephalogram.

COVID-19 infection with serial bilateral pneumothoraces

Rosa Ragozzino — 2024-01-29

Background: Coronavirus disease 2019 (COVID-19) is most frequently associated with a mild presentation of fever, cough, and shortness of breath. Typical radiographic findings in severe COVID-19 infection are bilateral ground-glass opacities on computed tomography (CT) scans. Bilateral pneumothorax is a rare complication of COVID-19. Among observational studies, the incidence of pneumothorax is low at 0.3% in hospitalized COVID-19 patients. However, the incidence of pneumothorax increases to 12.8-23.8% in patients requiring invasive mechanical ventilation.

Case: This case report describes a previously healthy 52-year-old man who had recurrent pneumothoraces. He had five separate episodes of bilateral pneumothoraces during a two-month infection with SARS-CoV-2 during which he required mechanical ventilation. Chest x-rays revealed pneumothoraces, and bilateral chest tubes were inserted into the intrathoracic space for drainage five times. This case highlights the potential atypical clinical course in a COVID-19 infection and is the first reported case, to our knowledge, that features five bilateral spontaneous recurring pneumothoraces.

Conclusion: COVID-19-related pneumothorax is likely a sequela of COVID-19 disease progression due to the inflammatory insult from COVID-19 infection and the increased respiratory effort needed to maintain gas exchange. COVID-19- related pneumothoraces are associated with mechanical ventilation and resolved in prolonged hospitalization. The treatment of COVID-19 and its long-term consequences represents a relatively new challenge for clinicians and health care providers. A multidisciplinary approach during the posthospitalization management of COVID-19 survivors is strongly advised.

Keywords: SARS-CoV-2 infection, COVID-19 lung complications, pneumothorax

Robotic-assisted cholecystectomy in the third trimester of pregnancy

Marvelyn Iweh — 2024-01-29

Acute and chronic cholecystitis commonly occur during pregnancy. Hormonal changes during pregnancy put women at a higher risk of forming gallstones and biliary dyskinesia leading to disease. The standard of care for acute cholecystitis is to have an elective cholecystectomy within 48 hours. Extensive research exists on the current practice of performing a laparoscopic cholecystectomy in pregnancy. Based on our review of the current literature, there is only one report that details a robotic cholecystectomy performed on a pregnant patient. This report will detail the methods used to perform the surgery and steps taken to ensure the safety of mother and fetus. It will describe the unique circumstances surrounding the robotic technique used in this case and include the demographics and background of this patient, in an effort to promote this technique in future cases.

Key words: obstetrics, acute cholecystitis, symptomatic cholelithiasis, pregnancy, laparoscopic cholecystectomy, robotic-assisted cholecystectomy

Atypical presentation of herpes zoster: Zoster sine herpete

Maria Batchinsky — 2024-01-29

Herpes zoster dermatitis is a vesicular eruption occurring in a dermatomal distribution
secondary to the reactivation of varicella zoster virus. Prodromal symptoms of paresthesia,
hyperesthesia, and pruritus normally occur in the regions where the vesicular eruptions develop,
typically preceding the cutaneous eruptions. However, this reactivation can present atypically
with few to no cutaneous lesions, referred to as zoster sine herpete.

This case report describes a middle aged, immunocompetent man with zoster sine herpete,
who initially presented with a four-day history of severe migratory prodromal pain and hyperesthesia situated in dermatomal distributions. Physical exam revealed two groups of 2–4 mm
erythematous papules of the skin on the left posterior neck and left flank. However, the patient’s
sensory symptoms did not align with the dermatomes of his asymptomatic non-vesicular skin
lesions.

Herpes zoster dermatitis may present atypically, with prodromal neuralgia occurring in
differing dermatomes from where cutaneous findings occur, if any eruption occurs at all. In
such cases, it is important to rely on the patient’s history, timeline, and description of symptoms
in conjunction with a thorough skin examination to diagnose zoster sine herpete. In addition, if
no skin findings are present, serologic testing can be used to make the diagnosis.
Keywords: Herpes zoster, zoster sine herpete, varicella zoster virus, herpetic neuralgia

Rare solid pseudopapillary neoplasm in a Caucasian man

Atul Ratra — 2024-01-29

Pancreatic pseudopapillary neoplasms are rare pancreatic tumors and have a female predominance. Clinical manifestations include abdominal pain and/or an abdominal mass. Some patients are asymptomatic, and the tumors are found incidentally on imaging. Endoscopic ultrasound with fine needle biopsy with pathological tissue remains the gold standard for diagnosis. The malignant potential is low, and surgery remains the standard treatment.

Keywords: Solid pseudopapillary neoplasm, pancreatic tumor, pancreatic malignancy,
endoscopic ultrasound

Leishmaniasis is now considered an endemic pathogen in Texas

Barbara Mora — 2024-01-29

The sequential, multiple assignment, randomized trial (SMART) design

Shengping Yang — 2024-01-29

Chronic tophaceous gout in a woman with extensive allergic history to gout medications

Busara Songtanin — 2024-01-29