Muhammad Adrish

Vitamin D deficiency is associated with mortality in the medical intensive care unit

IntroductionThe incidence of vitamin D deficiency in critically ill patients has been reported to range from as low as 17% to as high as 79%. Data regarding the relationship between 25-hydroxyvitamin D levels and outcomes in the medical intensive care unit are sparse. The goal of the study was to evaluate the prevalence of 25-hydroxyvitamin D deficiency in the medical intensive care unit and its relationship with outcomes.MethodThis was a retrospective study in a medical intensive care unit (MICU) at an inner city community hospital. The study period was between October 2009 and February 2010.ResultsOf the 932 patients admitted during the study period, 25-hydroxyvitamin D vitamin D (25(OH)D) levels were available in 523 (53%); 86 of them were excluded from the study due to readmission to the intensive care unit. Deficiency was defined as 0 to 19.9 ng/dL 25(OH)D levels, insufficiency as 20 to 29.9 ng/dL, and normal levels as ≥30 ng/dL. Of the 437 patients studied, 25(OH)D deficiency was identified in 340 (77.8%), insufficiency in 74 (16.9%), and normal levels in 23 (5.3%) patients. Patients with 25(OH)D deficiency/insufficiency were younger (P = 0.015), were male (P = 0.001), and had kidney disease (P = 0.017) and lower total serum calcium levels (P = 0.003). Hospital mortality was higher in patients with 25(OH)D deficiency (P = 0.01). No differences in ventilator days or length of stay in the MICU were evident among the three groups. Analysis by multiple logistic regression demonstrated that acute physiology and chronic health evaluation (APACHE) IV score ((odds ratio (OR) 1.036; 95% confidence interval (CI) 1.024-1.048, P < 0.0001), ventilator requirement (OR 7.7; 95% CI 4.3-13.98, P < 0.0001), 25(OH) D levels(OR 0.942; 95% CI 0.942-0.904, P < 0.0005) and 25(OH) D deficiency (OR 8.7; 95% CI 1.03-72.8, P < 0.0469) showed statistical significance. There was no association between 25(OH)]D insufficiency and hospital mortality. The mean 25(OH)D level of survivors (27.9 ± 9.7 ng/dL) was higher than for non-survivors (9.7 ± 4.7 ng/dL; P < 0.0001).ConclusionsThe study results demonstrate an association between 25(OH)D deficiency and hospital mortality in MICU patients. A randomized prospective study to evaluate the effect of vitamin D replacement therapy on mortality is warranted.

Opioid overdose with gluteal compartment syndrome and acute peripheral neuropathy

Patient: Male, 42 Final Diagnosis: Gluteal compartment syndrome • acute peripheral nauropathy Symptoms: — Medication: — Clinical Procedure: — Specialty: Critical Care Medicine Objective: Management of emergency care Background: Heroin addiction is common, with an estimated 3.7 million Americans reporting to have used it at some point in their lives. Complications of opiate overdose include infection, rhabdomyolysis, respiratory depression and central or peripheral nervous system neurological complications. Conclusions: We present a 42-year-old male admitted after heroin use with heroin-related peripheral nervous system complication preceded by an acute gluteal compartment syndrome and severe rhabdomyolysis. Case Report: Early diagnosis and surgical intervention of the compartment syndrome can lead to full recovery while any delay in management can be devastating and can lead to permanent disability. The presence of peripheral nervous system injuries may portend a poor prognosis and can also lead to long term disability. Careful neurological evaluation for signs and symptoms of peripheral nervous system injuries is of paramount importance, as these may be absent at presentation in patients with opioid overdose. There is a potential risk of delaying a necessary treatment like fasciotomy in these patients by falsely attributing clinical symptoms to a preexisting neuropathy. Early EMG and nerve conduction studies should be considered when the etiology of underlying neurological weakness is unclear.

Significance of NT-pro-BNP in acute exacerbation of COPD patients without underlying left ventricular dysfunction

Background B-type natriuretic peptide (BNP) and the N-terminal fragment of pro-BNP (NT-pro-BNP) are established biomarkers of heart failure. Increased levels of natriuretic peptide (NP) have been associated with poor outcomes in acute exacerbation of COPD (AECOPD); however, most studies did not address the conditions that can also increase NT-pro-BNP levels. We aimed to determine if NT-pro-BNP levels correlate with outcomes of AECOPD in patients without heart failure and other conditions that can affect NT-pro-BNP levels. Methods We conducted a retrospective study in patients hospitalized for AECOPD with available NT-pro-BNP levels and normal left ventricular ejection fraction. We compared patients with normal and elevated NT-pro-BNP levels and analyzed the clinical and outcome data. Results A total of 167 of 1,420 (11.7%) patients met the study criteria. A total of 77% of male patients and 53% of female patients had elevated NT-pro-BNP levels (P=0.0031). NT-pro-BNP levels were not associated with COPD severity and comorbid illnesses. Log-transformed NT-pro-BNP levels were positively associated with echocardiographically estimated right ventricular systolic pressure (r=0.3658; 95% confidence interval [CI]: 0.2060–0.5067; P<0.0001). Patients with elevated NT-pro-BNP levels were more likely to require intensive care (63% vs 43%; P=0.0207) and had a longer hospital length of stay (P=0.0052). There were no differences in the need for noninvasive positive pressure ventilation (P=0.1245) or mechanical ventilation (P=0.9824) or in regard to in-hospital mortality (P=0.5273). Conclusion Patients with AECOPD and elevated NT-pro-BNP levels had increased hospital length of stay and need for intensive care. Based on our study, serum NT-pro-BNP levels cannot be used as a biomarker for increased mortality or requirement for invasive or noninvasive ventilation in this group of patients.

Concurrent lung squamous cell carcinoma and extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type.

The coexistence of primary lung cancer and lymphoma is a rare finding. We present a case of a 66-year-old woman with marginal B-cell lymphoma of mucosa-associated lymphoid tissue type with lung, mediastinal lymph node, and bone marrow involvement. Surveillance imaging after treatment for lymphoma revealed persistent uptake by positron emission tomography scan. A transbronchial biopsy revealed the marginal B-cell lymphoma and a well-differentiated invasive squamous cell carcinoma. Management was changed to address new pathologic findings.

Safety of Bronchoscopy in Patients with Echocardiographic Evidence of Pulmonary Hypertension

Background: Bronchoscopy with transbronchial and endobronchial biopsy and transbronchial needle aspiration is an important diagnostic tool in the pulmonologists armamentarium. Safety in patients with pulmonary hypertension is controversial and many bronchoscopists consider this as a contraindication for the procedure. Objectives: To evaluate safety of bronchoscopy in patients with echocardiographic pulmonary hypertension and to compare with patients without it. Methods: Retrospective analysis of patients who underwent bronchoscopic transbronchial biopsy, endobronchial biopsy and/or endobronchial ultrasound-guided transbronchial needle aspiration. Patients were divided into two groups based on echocardiographic results: control group with systolic pulmonary artery pressure <36 and a group with elevated systolic pulmonary artery pressure (eSPAP) ≥36. Results: One-hundred and ninety patients met the study criteria. Patients in the control group were younger with a lower incidence of chronic kidney disease. There was no difference in prevalence of congestive heart failure, obstructive airway disease, malignancy, liver disease, coagulopathy, use of antiplatelet agent or anticoagulant drugs. Incidence of minor bleeding due to bronchoscopic biopsies was 4.8% in both groups (p = 1.00). Incidence of major bleeding was similar in the groups (one patient in each group). In the control group, one patient had pneumothorax and another required prolonged mechanical ventilation (>4 h). In the eSPAP group, two patients required prolonged mechanical ventilation. There was no procedure-related mortality or sedation complications in the cohort. Conclusion: Our study provides additional support that in patients with echocardiographic evidence of pulmonary hypertension, transbronchial and endobronchial biopsies and endobronchial ultrasound-guided transbronchial needle aspiration are safe procedures.

Intracranial hemorrhage and extensive cerebral venous thrombosis associated with ulcerative colitis.

CVT is an uncommon disorder, with an annual incidence of three to four cases per million. Risk factors for CVT include thrombophilias, malignancies, hematological disorders, sinus infections, vasculatides, traumatic head injuries and inflammatory bowel diseases. Thrombosis of cerebral veins result in increased pressure in the venous system, which ultimately results in decreased cerebral perfusion, ischemic injury, disruption of the blood-brain barrier and vasogenic edema. Occasionally, this increased pressure can lead to venous and capillary rupture causing parenchymal hemorrhage. Clinical presentation of this entity is highly variable and can include headaches, seizures, encephalopathy or focal neurological signs. Diagnosis can be delayed for the same reason and, therefore, requires high clinical suspicion. Magnetic resonance venography is the most sensitive test for detection of CVT. Systemic anticoagulation is considered to be the primary

Higher Fluids in the First Three Hours of Sepsis Resuscitation? Too Soon to Conclude

Th e authors used electronic medical records (EMRs) to identify patients with severe sepsis and septic shock. “Sepsis onset time” was determined by fl uidresistant hypotension, vasopressor use, or a lactate level . 4 mmol/L. 1 Th e reliability and validity of the outcome data in EMR-based interventional studies depend on the accuracy of data collection, entry, and storage. A study conducted on the Veterans Administration’s EMRs, a highly integrated and standardized EMR system, showed that 60% of the patients had one or more input-related errors, with an average of 7.8 errors per patient. 2