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Respiratory disease is common in guinea pigs (Cavia porcellus). As obligate nasal breathers, disease of the upper airway can result in significant dyspnea. Nasopharyngeal stenosis is defined as a luminal narrowing of the nasopharynx, which extends from the choana to the caudal margin of the soft palate. This condition can be acquired or congenital and has been diagnosed in other species. However, nasopharyngeal stenosis has not been previously described in guinea pigs. Four guinea pigs were presented with chronic, recurrent upper respiratory signs including stertor, oculonasal discharge, tachypnea, and dyspnea. All four animals had signs suggestive of upper respiratory tract disease on examination. Nasopharyngeal stenosis was identified at the rostral aspect of the nasopharynx at the level of the choana via computed tomography (CT) in all cases. Otitis media was also present in three of the four cases. Antibiotic therapy was instituted for all animals. Two of the four guinea pigs were treated with prednisolone and two were treated with meloxicam to control associated inflammation. One animal died 2 months after diagnosis due to complications from severe otitis media. One individual was euthanized due to progressive disease after a year and a half of treatment. One guinea pig was lost to follow up after 6 months. The remaining guinea pig was alive at the time this case series was written (11 months after initial diagnosis) but continues to have signs of upper airway disease. Nasopharyngeal stenosis is an important differential diagnosis for persistent upper respiratory signs in guinea pigs. CT was diagnostic in all cases, identifying nasopharyngeal stenosis at the level of the choana, and allowed identification of comorbidities (otitis media and rhinitis). Medical management resulted in survival times from 2 months to a year and a half following diagnosis. Further investigation into minimally invasive interventions such as balloon dilation and stent placement are warranted for future cases.

Background Many patients with Coronavirus disease-2019 (Covid-19) present with radiological evidence of pneumonia. Because it is difficult to determine co-existence of bacterial pneumonia, many of these patients are initially treated with antibiotics. We compared the rates of bacterial infections and mortality in Covid-19 patients with pulmonary infiltrates versus patients diagnosed with ‘pneumonia’ the year previously. Methods We conducted a medical record review of patients admitted with Covid-19 and a pulmonary infiltrate and compared them with patients diagnosed with pneumonia admitted in the prior year before the pandemic. Data abstracted included baseline demographics, comorbidities, signs and symptoms, laboratory and microbiological results, and imaging findings. Outcomes were bacterial infections and mortality. Patients presenting with and without Covid-19 were compared using univariable and multivariable analyses. Results There were 1398 and 1001 patients admitted through the emergency department (ED) with and without Covid-19 respectively. Compared with non-Covid-19 patients, those with Covid-19 were younger (61±18 vs. 65±25 years, P

A 41-year-old male farmer was injured in a land mine explosion. After initial resuscitation, the emergency physician coordinated with the hospital and air medical crew for the patient's evacuation. The evacuation was started by a Bell 214C helicopter, and the patient's clinical condition deteriorated during flight with increased abdominal pain and distension, tachycardia, tachypnea, hypotension, and loss of consciousness. Intra-abdominal (vesical) pressure of 23 mm Hg, findings of in-flight bedside ultrasound, and echocardiography indicated intra-abdominal hypertension with abdominal compartment syndrome. The emergency physician started medical management quickly based on the World Society of Abdominal Compartment Syndrome, but after 15 minutes the intra-abdominal pressure was still > 20 mm Hg. Despite the in-flight difficult condition, the risk of vascular or neural damages, and infection, the emergency physician performed a midline decompression laparotomy and, when the intra-abdominal pressure reached about 11 mm Hg, temporarily covered the wound with a Bogota bag. After the patient's intra-abdominal pressure stabilized, permanent abdominal wound repair was performed by the surgeon, and he was discharged from the hospital.

Background Management of acute pulmonary hypertension in the Emergency Department(ED) can be challenging. The treatment is specialised, requires rapid identification and correction of the precipitating cause; failing which the patient enters a vortex of deterioration. We describe a lesser-known cause for the same, Thiamine responsive acute pulmonary hypertension (TRAPH) syndrome where timely appropriate treatment can result in dramatic improvement. Methodology Medical records with ICD code E51.12 (Wet Beriberi) from Mar 2018 to Mar 2020 were screened. The data regarding presenting symptoms, initial vitals, lab and radiological investigations, and treatment received were retrieved from patient files and the Hospital Informatics System, entered into an MS Excel sheet and compared. Results The study includes eight cases, which we believe to be TRAPH syndrome. Majority were young adult males, ethanol users. All patients presented with acute shortness of breath with tachypnea and shock index more than 0.9. Gross right atrioventricular dilatation, tricuspid regurgitation and mild to moderate pulmonary arterial hypertension was identified in echocardiography. The initial blood gas revealed median pH 6.98 (IQR 6.81–7.09), Bicarbonate 3.4 meq/L (IQR 2.5–5) and lactate 172 mg/dL (IQR 132–200) which improved within 12–16 h of admission. Patients received median 400 mg IV Thiamine. The mean duration of ICU stay was 2.5 days and total hospital stay was 7 days. Conclusion Thiamine Responsive Acute Pulmonary Hypertension (TRAPH) Syndrome is an under-recognised entity which should be included in differentials for acute right ventricular dysfunction in the ED. Early diagnosis and rapid protocolised management of the same can cause quick recovery of patients.

Background Malignant hyperthermia (MH) is a rare and potentially life-threatening pharmacogenetic disorder encountered during general anesthesia, with the incidence higher in children than in adults. Dantrolene is the specific antagonist of MH, but it is not readily available in China, thus developing alternative treatment protocols is of great practical importance. Case Presentation Herein, the authors report a two-month-old infant who underwent holmium laser epiglottis retrofitting through a bronchoscope, but developed limb muscular stiffness, tachypnea, tachycardia, and hyperthermia after sevoflurane exposure. After the diagnosis of MH, corresponding supportive treatment was implemented. Because there was no dantrolene available, continuous blood purification and mechanical ventilation were performed. A few days later, the boy recovered without any complications. Conclusion Based on the authors’ successful clinical practice, the authors consider continuous blood purification as a reliable treatment for MH. But its feasibility still needs to be clarified after multicenter clinical observations.

Background: Coronavirus disease 2019 (COVID-19) has resulted in millions of deaths, including more than 6000 deaths in the Kingdom of Saudi Arabia (KSA). Identifying key predictors of intensive care unit (ICU) admission and mortality among infected cases would help in identifying individuals at risk to optimize their care. We aimed to determine factors of poor outcomes in hospitalized patients with COVID-19 in a large academic hospital in Riyadh, KSA that serves as a Middle East Respiratory Syndrome coronavirus (MERS-CoV) referral center. Methods: This is a single-center retrospective cohort study of hospitalized patients between March 15 and August 31, 2020. The study was conducted at King Saud University Medical City (KSUMC). COVID-19 infection was confirmed using real-time reverse transcriptase polymerase chain reaction (RT-PCR) for SARS-COV-2. Demographic data, clinical characteristics, laboratory, radiological features, and length of hospital stay were obtained. Poor outcomes were, admission to ICU, need for invasive mechanical ventilation (IMV), and in-hospital all-cause mortality. Results: Out of 16,947 individuals tested in KSUMC, 3480 (20.5%) tested positive for SARS-CoV-2 and of those 743 patients (21%) were hospitalized. There were 62% males, 77% were younger than 65 years. Of all cases, 204 patients (28%) required ICU admission, 104 (14%) required IMV, and 117 (16%) died in hospital. In bivariate analysis, multiple factors were associated with mortality among COVID-19 patients. Further multivariate analysis revealed the following factors were associated with mortality: respiratory rate more than 24/min and systolic blood pressure 37 units/L in the first 48 h of presentation, while a RT-PCR cycle threshold (Ct) value ≤24 was a predictor for IMV. Conclusion: Variable factors were identified as predictors of different outcomes among COVID-19 patients. The only predictor of IMV was a low initial Ct values of SARS-CoV-2 PCR. The presence of tachypnea, hypotension, lymphopenia, and elevated AST in the first 48 h of presentation were independently associated with mortality. This study provides possible independent predictors of mortality and invasive mechanical ventilation. The data may be helpful in the early identification of high-risk COVID-19 patients in areas endemic with MERS-CoV.

Background Joubert syndrome is an autosomal recessive or X-linked genetic disease with a cerebellar vermis defect or hypoplasia, hypotonia, ocular dyskinesia, and mental retardation. In neonates, respiratory problems such as apnea and tachypnea are notable. Case report We report a patient Joubert syndrome with a homozygous NPHP1 variant, who had head titubation with irritability, including exaggerated jitteriness and a marked Morrow reflex appeared soon after birth without neonatal respiratory problems. These symptoms decreased gradually and disappeared until 1 year. Conclusion Irritability with head titubation may be an early clinical clue for the clinician to suspect Joubert syndrome.

To describe the emergency department (ED) triage of anaphylaxis patients based on the Emergency Severity Index (ESI), assess the association between ESI triage level and ED epinephrine administration, and determine characteristics associated with lower acuity triage ESI assignment (levels 3 and 4).We conducted a cohort study of adult and pediatric anaphylaxis patients between September 2010 and September 2018 at an academic ED. Patient characteristics and management were compared between Emergency Severity Index (ESI) triage level 1 or 2 versus levels 3 or 4 using logistic regression analysis. We adhered to STROBE reporting guidelines.A total of 1090 patient visits were included. There were 26 (2%), 515 (47%), 489 (45%), and 60 (6%) visits that were assigned an ESI triage level of 1, 2, 3, and 4, respectively. Epinephrine was administered in the ED to 53% of patients triaged ESI level 1 or 2 and to 40% of patients triaged ESI level 3 or 4. Patients who were assigned a lower acuity ESI level of 3 or 4 had a longer median time from ED arrival to epinephrine administration compared to those with a higher acuity ESI level of 1 or 2 (28 min compared to 13 min, p .001). A lower acuity ESI level was more likely to be assigned to visits with a chief concern of hives, rash, or pruritus (OR 2.33 [95% CI, 1.20-4.53]) and less likely to be assigned to visits among adults (OR, 0.43 [0.31-0.60]), patients who received epinephrine from emergency medical services (OR 0.56 [0.38-0.82]), presented with posterior pharyngeal or uvular angioedema (OR, 0.56 [0.38-0.82]), hypoxemia (OR, 0.34 [0.18-0.64]), or increased heart (OR 0.83 [0.73-0.95]) or respiratory (OR 0.70 [0.60-0.82]) rates.Patients triaged to lower acuity ESI levels experienced delays in ED epinephrine administration. Adult and pediatric patients with skin-related chief concerns were more likely to be to be assigned lower acuity ESI levels. Further studies are needed to identify interventions that will improve ED anaphylaxis triage.

Bronchiectasis patients may present a reduced functional capacity due to an increase in the ventilatory demand during exercise.To evaluate the effects of controlled voluntary hyperinflation and increased respiratory rate on the mechanics of the respiratory system, simulating what happens during exercise, in bronchiectasis and healthy subjects.Bronchiectasis (n=30) and healthy (n=16) subjects were evaluated by impulse oscillometry (IOS) during a baseline condition, and in controlled conditions with baseline (b) tidal volume (V) and hyperinflation (H), with respiratory rates at 30(R30) and 40(R40) bpm, in a random order. The mixed effects and a significance level at 0.05 were used for comparisons.Resistance at 5Hz (R5), and at minus 20Hz (R5-R20), in kPa/L/s, were higher in subjects with bronchiectasis in all experimental conditions (p0.05). For the bronchiectasis group, R5 and R5-20 increased with R increase at V (VRb versus VR30 and VR40; VR30 versus VR40; R5, R20 and R5-20 increased with R increase at H (HRb versus HR40; HR30 versus HR40). For the same R, there was a decrease with H compared to V (HRb versus VR30 and VR40; and HR30 versus VR30 and VR40). For the healthy group, only R20 showed differences (HR30 versus HR40; HR40 versus VR40).The tachypnea increases the resistance and reactance of the respiratory system in bronchiectasis patients, and the voluntary hyperinflation caused attenuates this increase. These results can guide the development of strategies to reduce the limitation of physical activity in patients with bronchiectasis.

Introduction Both paroxysmal high-grade second-degree and persistent third-degree atrioventricular block (AVB) are recognised in cats. Our aim was to document the presentation, echocardiographic data, comorbidities and outcome in affected cats from a single referral hospital, including those that underwent epicardial pacemaker implantation (EPI). Animals, materials and methods This retrospective study included 64 cats diagnosed with persistent third-degree or paroxysmal high-grade AVB, for which detailed patient history was available. Non-parametric testing, Kaplan-Meier curves and Cox proportional hazard testing were performed. Results Atrioventricular block was persistent in 43 cats (67%) and paroxysmal in 21 (33%). Forty-seven cats (74%) were referred for cardiac complaints (e.g. collapse, arrhythmia, tachypnea), 6 (9%) had non-specific complaints and AVB was an incidental finding in 11 cats (17%). Median duration of clinical signs prior to presentation was 21 days (1–1138 days). Thirty-nine (63%) cats had echocardiographic abnormalities; 13 (20%) presented with congestive heart failure. Forty-five (70%) cats had one or more comorbidities. Fifteen cats underwent EPI with immediate resolution of signs in 12 cats. Following EPI, two and four cats experienced major and minor complications, respectively. Forty-seven cats died; median survival time was 799 days (all-cause mortality). Cardiac-related death occurred in 17 cats (36%); median survival in these cats was 132 days. Heart failure on presentation was the only independent risk factor for cardiac death (p=0.002). Conclusions Outcome in cats with AVB was variable, although most had good medium- to long-term survival. Cardiac death occurred in a minority of cats. Pacemaker implantation was effective in relieving clinical signs.

The diagnosis and treatment of pediatric intrathoracic lymphatic-venous malformations (LVM) can be complex due to their rarity, variable presentation and confusing nomenclature in the literature. The International Society for the Study of Vascular Anomalies (ISSVA) has recently (2018) updated their classification to help guide the correct diagnosis, nomenclature and management of such cases. We present the case of a 12-month-old Caucasian female with a lymph-venous malformation (LVM) classified in the updated ISSVA classification as a combined vascular malformation (CLVM) defined as two or more vascular malformations found in one lesion, associated with an underlying “malformation of an individual named vessel”. The patient presented with tachypnea, tachycardia and fever. While all the previous cases underwent surgical treatment, our patient was successfully treated with rapamycin and sclerotherapy. Appropriate imaging can aid in the diagnosis of vascular anomalies and in the proper ISSVA classification, saving the patient the need for a biopsy and allow for proper referral to Multidisciplinary Vascular Anomalies centers. The accurate classification can identify cases that can be treated through Interventional Radiology with sclerosing agents and medical therapy as opposed to surgery.

Objective Sleep complaints are frequent after acute COVID-19. Aim of this study was to videopolysomnographically evaluate sleep and sleep disorders after SARS-Cov2 infection. Methods Patients with suspected sleep disorders after acute COVID-19 underwent video-polysomnography (v-PSG) at the Sleep Disorders Clinic, Department of Neurology, Medical University Innsbruck. V-PSG was conducted 4.2 (SD = 1.3) months after diagnosis of SARS-CoV-2 infection. Results Eleven patients [nine men, age 52.5 (SD = 11.7) years; BMI 29 (SD = 5.2) kg/m2] were included. At 60 days follow-up after diagnosis, persisting breathing complaints were present in 7/11 (64%) patients. After v-PSG four patients (36%) were diagnosed with obstructive sleep apnea (OSA). Respiratory frequency during sleep was normal and no tachypnea, thoracoabdominal asynchrony, or periodic deep sighing were detected. Four patients (36%) showed REM sleep without atonia (RWA), and two additional patients showed an RWA index within the highest range of normality. Conclusion We report videopolysomnographic findings in a series of eleven patients after acute COVID-19. A major finding of this study was the presence of isolated RWA, a recognized prodromal stage of RBD, in more than one third of the patients. Future videopolysomnographic investigations including quantification of RWA in patients after COVID-19 will give more insights into a possible acute or post-infectious CNS pathology related to the SARS-CoV-2 infection.

Background and objectives Mortality of patients with pulmonary tuberculosis (TB) admitted to emergency departments is high. This study was aimed at analysing the risk factors associated with early mortality and designing a risk score based on simple parameters. Methods This prospective case-control study enrolled patients admitted to the emergency department of a referral TB hospital. Clinical, radiological, biochemical and microbiological risk factors associated with death were compared among patients dying within one week from admission (cases) and those surviving (controls). Results Forty-nine of 250 patients (19.6%) experienced early mortality. Multiple logistic regression analysis showed that oxygen saturation (SaO2) ≤90%, severe malnutrition, tachypnoea, tachycardia, hypotension, advanced disease at chest radiography, severe anaemia, hyponatremia, hypoproteinemia and hypercapnia were independently and significantly associated with early mortality. A clinical scoring system was further designed to stratify the risk of death by selecting five simple parameters (SpO2 ≤ 90%, tachypnoea, hypotension, advanced disease at chest radiography and tachycardia). This model predicted early mortality with a positive predictive value of 94.88% and a negative predictive value of 19.90%. Conclusions The scoring system based on simple parameters may help to refer severely ill patients early to a higher level to reduce mortality, improve success rates, minimise the need for pulmonary rehabilitation and prevent post-treatment sequelae.

It is a frequent challenge for physicians to identify pneumonia in patients with acute febrile respiratory symptoms, particularly in stable pediatric patients without respiratory distress. A decision rule is required to assist judgement on the need of ordering a chest radiograph.This was a multicenter prospective study in 3 emergency departments. Children younger than 6 years old with an acute onset of fever and respiratory symptoms were recruited. Split sample method was adopted for derivation and validation of the Pediatric Acute Febrile Respiratory Illness rule (PAFRI Rule). PAFRI was derived from logistic regression with weighting based on adjusted odds ratios.Out of 967 children evaluated, 530 had taken chest radiograph examination, with 91 demonstrated evidence of pneumonia on radiograph. PAFRI Rule was derived from logistic regression with 5 weighed predictors: duration of fever3 days (0 points), 3-4 days (2 points), 5-6 days (4 points), ≥7 days (5 points), chills (2 points), nasal symptoms (-2 points), abnormal chest examination (3 points), SpOPAFRI rule can be used as a reference tool for guiding the need for taking Chest radiograph examination for pediatric patients. While promising, the PAFRI rule requires further validation.It is often a challenge for physicians to identify pneumonia in children acutely febrile with respiratory symptoms, particularly in those who are stable without respiratory distress. The decision to order chest radiograph was based on clinical assessment with heterogenous practice. A valid and verified clinical prediction rule for ordering chest radiograph examination for stable febrile children without signs of respiratory distress would therefore assist in management of this group of patients.The PAFRI rule, based on parameters from clinical bedside assessment, can be used as a reference tool for guiding the need for referral to emergency department or taking use of chest radiograph for pediatric patients, and triaging for higher priority of clinical care.

Background Postextubation complication rates vary among studies. It is necessary to standardize a method to identify postextubation complications and determine their potential association with extubation failure and reintubation in critically ill adult patients. Objectives To describe immediate (up to 60 min) endotracheal postextubation complications in critically ill adult patients and determine whether these complications are associated with extubation failure. Methods Secondary analysis of a Randomized Clinical Trial that included 240 critically ill adult patients, who were eligible for extubation. Overall complications include at least one major complication (upper airway obstruction, desaturation, vomiting, post-obstructive pulmonary edema) and/or minor complications (bronchospasm, severe cough, hypertension, tachycardia, tachypnea, poor respiratory mechanics). Results Incidence of overall, major and minor complications was 71.2%, 30.9% and 62.7%, respectively. Forty (16.9%) patients failed extubation, and thirty (12.7%) were reintubated. Of 168 patients who developed a postextubation complication, 137 (81.5%) were successfully extubated. Only major complications were significantly associated with reintubation after extubation failure (p Conclusion We have observed high incidence rates of overall, major and minor complications. The development of major complications was statistically significantly associated with extubation failure and reintubation. It is still unknown whether the identification and treatment of immediate postextubation complications have positive effects on patients' clinical course or whether the complications are a mere effect of the extubation procedure.

Histoplasmosis is the second most common fungal infection reported among domestic felines in the United States. Dissemination of the organism after inoculation is common and affected organ systems include the respiratory tract, gastrointestinal tract, reticuloendothelial organs, skeletal system, integument, and ocular system. However, histoplasmosis presenting as a discrete granulomatous mass identified on echocardiogram has never been reported in the veterinary literature. Here, we describe the first case of feline histoplasmosis presenting as a granuloma with cardiac involvement. The patient, a 6-year-old male neutered domestic longhair feline, was referred for tachypnea and dyspnea. A mass in the cranial mediastinum abutting the heart was diagnosed via two-dimensional echocardiography. Cytology of fine needle aspirates from the mass revealed round yeast structures consistent with Histoplasma spp. The patient was treated with oral fluconazole therapy, and subsequent rechecks have shown marked improvement in clinical parameters, lesion size, and antigen concentrations.

Introduction Mortality risk prediction for Intermediate Respiratory Care Unit's (IRCU) patients can facilitate optimal treatment in high-risk patients. While Intensive Care Units (ICUs) have a long term experience in using algorithms for this purpose, due to the special features of the IRCUs, the same strategics are not applicable. The aim of this study is to develop an IRCU specific mortality predictor tool using machine learning methods. Methods Vital signs of patients were recorded from 1966 patients admitted from 2007 to 2017 in the Jimenez Diaz Foundation University Hospital's IRCU. A neural network was used to select the variables that better predict mortality status. Multivariate logistic regression provided us cut-off points that best discriminated the mortality status for each of the parameters. A new guideline for risk assessment was applied and mortality was recorded during one year. Results Our algorithm shows that thrombocytopenia, metabolic acidosis, anemia, tachypnea, age, sodium levels, hypoxemia, leukocytopenia and hyperkalemia are the most relevant parameters associated with mortality. First year with this decision scene showed a decrease in failure rate of a 50%. Conclusions We have generated a neural network model capable of identifying and classifying mortality predictors in the IRCU of a general hospital. Combined with multivariate regression analysis, it has provided us with an useful tool for the real-time monitoring of patients to detect specific mortality risks. The overall algorithm can be scaled to any type of unit offering personalized results and will increase accuracy over time when more patients are included to the cohorts.

Case Presentation A previously healthy 22-month-old girl presented to the ED with a 3-week history of dyspnea on exertion. A chest radiograph showed a right upper-lobe opacity suspicious for pneumonia ( Fig 1 A). The patient was prescribed amoxicillin but returned to the ED 7 days later with cough and persistent dyspnea and tachypnea. At that time, a repeat chest radiograph was concerning for worsening pneumonia ( Fig 1 B). Treatment with azithromycin and albuterol was initiated, and amoxicillin was discontinued. Her symptoms briefly improved; however, she returned to the ED 10 days later because of worsening cough and tachypnea, and a 2-day history of increased irritability, decreased oral intake, decreased urine output, and intermittent perioral cyanosis. She was afebrile throughout this period per parent report and vital sign documentation at each ED visit.

Introduction Rapid eye movement (REM) sleep has an inhibitory effect on epileptiform EEG discharges, and seizures occur extremely rarely in REM sleep. Case study We present the case and video recordings of a 10-year-old boy, with sleep-related hypermotor seizures starting from REM sleep, identified from videoEEG recordings. The semiology comprised intense fear, tachycardia, tachypnea, followed by hypermotor manifestations. Further investigations included brain MRI and source localization of the EEG signals. Multiple antiepileptic drugs were tried, the patient obtaining a good control of the seizures in the last 2.5 years with eslicarbazepine. Discussion and conclusion The ictal EEG source imaging showed seizure onset in the anterior part of the right insula, with propagation to the orbitofrontal area, confirmed by the semiological sequence. Although rare, focal seizures can be triggered by REM sleep and our findings suggest that deficient maturation of brain areas involved in sleep modulation might induce insufficient desynchronization during REM sleep, thus allowing seizure emergence.

Background and objective Nursing and healthcare-associated pneumonia (NHCAP) is a category of healthcare-associated pneumonia modified for the healthcare system in Japan. To date, only a few studies have examined the prognostic factors of NHCAP in a prospective cohort. This study aimed to investigate the prognostic factors related to 30-day mortality in patients with NHCAP by analyzing prospective data. Methods We analyzed patients hospitalized for NHCAP who were enrolled between October 2010 and February 2017. Age, sex, comorbidities, vital signs and laboratory findings were used as prognostic variables. The primary outcome was 30-day mortality. Results Of 817 NHCAP patients identified, the mean age was 78.0 ± 11.1 years, 580 (71.0%) were men and 30-day mortality was 13.1% (107/817). On multivariate analysis, male sex (odds ratio [OR]: 2.07, 95% confidence interval [CI]: 1.18–3.63), malignancy (OR: 2.35, 95%CI: 1.38–4.01), performance status (PS) (OR: 1.55, 95%CI: 1.23–1.96), body temperature (OR: 0.77, 95%CI: 0.61–0.97), heart rate (OR: 1.02, 95%CI: 1.01–1.03), respiratory rate (OR: 1.04, 95%CI: 1.01–1.08), serum albumin (Alb) (OR: 0.45, 95%CI: 0.30–0.66) and blood urea nitrogen (BUN) (OR: 1.02, 95%CI: 1.01–1.03) were significantly related to 30-day mortality. On the other hand, the risk factors for involvement by drug-resistant pathogens predicted a better prognosis (OR: 0.39, 95%CI: 0.19–0.82). Conclusions Male sex, malignancy, poor PS, hypothermia, tachycardia, tachypnea, low serum Alb and high BUN are worse prognostic factors. Thus, the risk of drug-resistant pathogens is not necessarily related to poor prognosis.

Hemangioarcoma in the cat is an infrequently diagnosed tumor, and cardiac involvement is rare. We report a previously healthy, 8-year-old, domestic shorthair cat with acute collapse associated with pericardial effusion and cardiac tamponade. Following pericardiocentesis and removal of 15 mL of fluid, the cat improved rapidly. A massive, space-occupying, intrapericardial tumor adhered to and compressing the right atrium and ventricle was detected by echocardiography. Approximately 5 weeks following initial presentation, bicavitary effusion and tachypnea developed, and the cat was euthanized. Necropsy revealed a giant intrapericardial mass adhered to and impinging upon the right heart. Histologic and immunohistochemical examination confirmed hemangiosarcoma with no gross or histologic evidence of metastasis. To the authors' knowledge, this is the first account of a pericardial-occupying, primary feline cardiac hemangiosarcoma resulting in compression of the right heart and cardiac tamponade, Further, this report describes novel clinicopathological relationships between radiographic and echocardiographic findings and gross and microscopic pathology.

Background: Enterovirus-D68 (EV-D68) has been endemic in Taiwan for some years with a small number of positive cases. Detailed information about respiratory presentation is lacking. This study characterized the clinical course in children admitted to the medical center and regional hospital in Taichung during 2015. Methods: Retrospective chart review of patients with confirmed EV-D68 infection admitted to the medical center and regional hospital in Taichung with respiratory symptoms in the second half of 2015. Past medical history, clinical presentation, management, and course in hospital were collected and analyzed. Simple demographic data and clinical symptoms were also collected from patients confirmed with EV-D68 infection who visited clinics in Taichung. Results: Six children were included. Two patients had a prior history of asthma or recurrent dyspnea, and one had other preexisting medical comorbidities. One child was admitted to the pediatric intensive care unit. All the patients were cured. Cough, rhinorrhea, tachypnea and fever were the most common clinical symptoms among inpatients, while influenza-like illness (ILI) was prevalent in outpatients. Conclusion: EV-D68 infection resulted in respiratory presentations of asthma-like illness in the hospitalized pediatric population. Patients with a prior history of asthma or recurrent dyspnea appear to be more severely affected. Key Words: enterovirus D68, respiratory presentation, taiwan

Purpose To create a simplified ICU scoring system to predict mortality in critically ill patients that can be feasibly applied in resource limited setting with good performance of predicting hospital mortality. Materials and methods A retrospective study from prospective cohort was created consisting of adult patients who were admitted to an ICU of 17 centers across Thailand from 2013 to 2015. A development cohort (n = 3503) and a validation cohort (n = 1909) were randomly selected from the available enrollment data. Results In the development cohort, the predictors of the simplified score 6 variable model were low Glasgow coma score (GCS), low mean arterial pressure or need vasopressor, positive net-fluid balance, tachypnea, thrombocytopenia, and high blood urea nitrogen. In the validation study of THAI-ICU, AUC (95%CI) was 0.81(0.78–0.83). At the optimum cutoff value of 9; the sensitivity, specificity, positive likelihood ratio were 72%, 73%, and 2.72 respectively. The Hosmer-Lemeshow - C statistic was 13.5 (p = .2) and the Brier score 95% CI was 0.16 (0.15, 0.17). Conclusions The THAI-ICU score is a new simplified severity score for predicting hospital mortality. The simplicity of the score will increase the possibility to apply in resource limited settings.

Objectives To describe the clinical-radiological-pathological characteristics and treatment outcomes of children with suspected exogenous lipoid pneumonia (ELP). Design Systematic review. We searched electronic databases and reference lists published between 1967 and 2018, restricted to non-accidental cases. Results Forty-four studies including 489 participants aged 1 day to 17 years from 13 countries were included. Cultural, medical, and behavioural rationale for oil-use was described. The clinical-radiological presentation varied widely. Diagnostic certainty was deemed highest if ELP was confirmed on bronchoalveolar lavage/frozen section lung biopsy with documented extracellular lipid on cytological staining and/or fat analysis. Non-tuberculous mycobacteria infection was identified in six studies: Mycobacterium fortuitum/chelonei, Mycobacterium smegmatis and Mycobacterium abscessus. Treatment comprised supportive therapy, corticosteroids, stopping oil, therapeutic lung-lavage and surgical resection. Outcomes were reported inconsistently. Conclusion Paediatric ELP resulting from cultural and medical practices continues to be described globally. Preventive interventions, standardized reporting, and treatment efficacy studies for cases not averted, are lacking. Protocol registration: PROSPERO CRD42017068313.

Background Pulmonary embolism (PE) in children carries a significant morbidity and mortality. We examined previously described factors in 2 cohorts of children tested for PE and identified novel factors. Methods We combined data from 2 retrospective cohorts. Patients up to age 21 years were included who underwent imaging or D‐dimer testing for PE, with positive radiologic testing being the gold standard. Combined predictor variables were examined by univariate analysis and then forward stepwise multivariable logistic regression. Results The combined data set yielded 1103 patients with 42 unique predictor variables, and 93 PE‐positive patients (8.4%), with a median age of 16 years. Univariate analysis retained 17 variables, and multivariable logistic regression found 9 significant variables with increased probability of PE diagnosis: age‐adjusted tachycardia, tachypnea, hypoxia, unilateral limb swelling, trauma/surgery requiring hospitalization in previous 4 weeks, prior thromboembolism, cancer, anemia, and leukocytosis. Conclusion This combined data set of children with suspected PE discovered factors that may contribute to a diagnosis of PE: hypoxia, unilateral limb swelling, trauma/surgery requiring hospitalization in previous 4 weeks, prior thromboembolism, and cancer, age‐adjusted tachycardia, tachypnea, anemia, and leukocytosis. Prospective testing is needed to determine which criteria should be used to initiate diagnostic testing for PE in children.

Highlights • Adult hospitalized patients with RSV were advanced age and had comorbidities. • Cardiopulmonary complications were common. • Major complication was pneumonia with acute respiratory failure. • Pre-existing coronary arterial disease was a risk factor of cardiovascular complication. • Pneumonia and acute myocardial infarction were the major causes of death., Background Respiratory syncytial virus (RSV) is an important virus found in adult hospitalized patients. Objectives To study the clinical outcomes of hospitalized patients aged ≥ 15 years and diagnosed with RSV infection. Study design Both retrospective and prospective cohort studies were conducted at a university hospital between May 2014 and December 2015. Results: RSV was detected in 86 of 1562(5.5%) adult hospitalized patients suspected of respiratory viral infection. Sixty-nine patients were included in the study. RSV was detected by RT-PCR (82.6%), IFA (10.1%), and both RT-PCR and IFA (7.3%). Most patients (87.0%) were aged ≥ 50 years. Cardiovascular diseases, pulmonary diseases, immunocompromised hosts, and diabetes were the major comorbidities. The common manifestations were cough (92.8%), dyspnea (91.3%), sputum production (87.0%), tachypnea (75.4%), wheezing (73.9%), and fever (71.0%). Fifty- five patients (79.7%) were diagnosed with pneumonia. Hypoxemia (SpO2 ≤ 92%) was found in 53.6% patients. Twenty-five of 69(36.2%) patients developed respiratory failure and required ventilatory support. Cardiovascular complications were found in 24.6% of patients. Congestive heart failure, acute myocardial infarction (MI), new atrial fibrillation, and supraventricular tachycardia were found in 9(13.0%), 7(10.1%), 4(5.8%), and 3(4.3%) of 69 patients, respectively. Overall mortality was 15.9%. Pneumonia (81.8%) and acute MI (18.2%) were the major causes of death. Conclusions Most adult hospitalized patients with RSV infection were of advanced age and had comorbidities. Cardiopulmonary complications were the major causes of death. Management and prevention of RSV infection in these vulnerable groups are necessary.

As both fever and pneumonia can be associated with tachypnea, we investigated the relationship between body temperature and respiratory rate (RR) in young children and whether temperature-adjusted RR enhances the prediction of pneumonia.In this retrospective cross-sectional analysis of 91,429 children5 years of age presenting to an urban pediatric emergency department, the relationship between triage RR and temperature was analyzed using regression analysis. We assessed the predictive value of temperature-adjusted RR for the diagnosis of pneumonia; diagnostic performance was evaluated for continuous RR as well as World Health Organization (WHO) age-based RR thresholds.The mean RR increased 2.6 breaths/minute for each 1°C increase in temperature. Interpatient variability was comparatively large; at any temperature, the interquartile range (75th percentile minus 25th percentile) varied from 4 to 16 breaths/minute. For predicting pneumonia, temperature- and age-adjusted RR was superior to age-adjusted RR: area under the curve (AUC) = 0.76 (95% confidence interval [CI], 0.75-0.78) versus AUC = 0.73 (95% CI, 0.72-0.75), respectively. Using WHO RR criteria, temperature-adjusted RR improved diagnostic discrimination, as the AUC increased from 0.58 (95% CI, 0.57-0.59) to 0.72 (95% CI, 0.70-0.73).The effects of temperature on respiratory rate are modest, with a mean increase of 2.6 breaths/minute for each 1°C rise in temperature. Despite considerable interpatient variability in respiratory rates by temperature, temperature adjustment improves the diagnostic value of respiratory rate for pneumonia.

This case series of five patients with Duchenne muscular dystrophy demonstrates the nutritional advantages of instituting noninvasive intermittent positive pressure ventilatory support via 15 mm angled mouthpieces to relieve tachypnea and provide more time to swallow food safely. In each case weight loss was reversed. Keywords: Noninvasive ventilatory support, Noninvasive ventilation, Neuromuscular disease, Duchenne muscular dystrophy, Dysphagia, Malnutrition

Enterovirus D68 (EV-D68) is a causative agent of recent outbreaks of severe respiratory illness, pneumonia and acute flaccid myelitis (AFM) worldwide. The study of the pathogenesis, vaccines and anti-viral drugs for EV-D68 infection has been reported. Given the previously described mouse model of EV-D68, we sought to establish a neonatal mice model inducing both pneumonia and AFM. The neonatal BALB/c mice were inoculated intraperitoneally with the EV-D68 strain (named15296-virus) which was produced by the reverse genetics method. The infected mice displayed limb paralysis, tachypnea and even death, which were similar to the clinical symptoms of human infections. Moreover, the results of histopathologic examination and immunohistochemical staining showed acidophilic necrosis in the muscle, the spinal cord and alveolar wall thickening in the lung, indicating that EV-D68 exhibited strong tropism to the muscles, spinal cord and lung. Furthermore, the results of real-time PCR also suggested that the viral loads in the blood, spinal cord, muscles and lung were higher than those in other tissues at different time points post-infection. Additionally, the neonatal mouse model was used for evaluating the EV-D68 infection. The results of the anti-serum passive and maternal antibody protection indicated that the neonatal mice could be protected against the EV-D68 challenge, and displayed that both the serum of 15296-virus and prototype-virus (Fermon) were performing a certain cross-protective activity against the 15296-virus challenge. In summary, the above results proved that our neonatal mouse model possessed not only the interstitial pneumonia and AFM simultaneously but also a potentiality to evaluate the protective effects of EV-D68 vaccines and anti-viral drugs in the future.

Background Patients commonly present to primary care services with upper and lower respiratory tract infections, and guidelines to help physicians investigate and treat acute cough due to suspected pneumonia and influenza are needed. Methods A systematic search was carried out with eight patient, intervention, comparison, outcome questions related to acute cough due to suspected pneumonia or influenza. Results There was a lack of randomized controlled trials in the setting of outpatients presenting with acute cough due to suspected pneumonia or influenza who were not hospitalized. Both clinical suggestions and research recommendations were made on the evidence available and CHEST Expert Cough Panel advice. Conclusions For outpatient adults with acute cough due to suspected pneumonia, we suggest the following clinical symptoms and signs are suggestive of pneumonia: cough; dyspnea; pleural pain; sweating, fevers, or shivers; aches and pains; temperature ≥ 38°C; tachypnea; and new and localizing chest examination signs. Those suspected of having pneumonia should undergo chest radiography to improve diagnostic accuracy. Although the measurement of C-reactive protein levels strengthens both the diagnosis and exclusion of pneumonia, there was no added benefit of measuring procalcitonin levels in this setting. We suggest that there is no need for routine microbiological testing. We suggest the use of empiric antibiotics according to local and national guidelines when pneumonia is suspected in settings in which imaging cannot be performed. Where there is no clinical or radiographic evidence of pneumonia, we do not suggest the routine use of antibiotics. There is insufficient evidence to make recommendations for or against specific nonantibiotic, symptomatic therapies. Finally, for outpatient adults with acute cough and suspected influenza, we suggest that initiating antiviral treatment (according to Centers for Disease Control and Prevention advice) within 48 hours of symptoms could be associated with decreased antibiotic use and hospitalization and improved outcomes.

A 52 year old previously healthy woman from Mumbai presented with fever and jaundice of 10 days duration. At admission, she was jaundiced with tachycardia, tachypnea, hypoxia, hypotension, conjunctival congestion and mild erythematous flush over the skin. She had very high WBC counts and CRP's with direct hyperbilirubinemia and azotemia. Investigations for infectious causes of fever were negative. RT-PCR for SARS-CoV-2 in the nasopharynx was negative. However her SARS-CoV-2 antibodies were reactive. She also had echocardiographic and biochemical evidence of cardiac dysfunction. The diagnosis of Multisystem inflammatory syndrome–Adult (MIS-A) was thus established. She rapidly improved with intravenous immunoglobulin (2 gm/kg) and high dose steroids.

Introduction A diagnosis of ductal infective endocarditis (DIE) usually relies on the clinical histories of infectious syndrome, results of blood cultures and echocardiography. It remains a therapeutic challenge. The prognosis is still poor. Is the prevention of infective endarteritis a valid reason to always close the isolated silent PDA in childhood? The question is not yet eluded [1] , [2] , [3] , [4] . We present the case of six years old girl with DIE developed after dental procedure. The patient was managed by combined medical and early surgery with favorable evolution. Case report A six year old girl was admitted to our service with tachypnea, fatigue and fever lasting for seven days. The patient had dental procedures few days earlier. The physical examination revealed a temperature at 40 °C and a left subclavian murmur. The acute phase marker levels were significantly elevated and β-hemolytic group A streptococcus was grown in his blood culture. Echocardiography revealed vegetations with the diameter of 10 mm on the left side of the PDA ( Fig. 1 ) with turbulent flow in the left pulmonary artery. Treatment with ceftriaxone 200 mg/kg/day and gentamycin 5 mg/kg/day was started then readapted according to antibiogram. The operation was performed on day 15 of antibiotherapy ( Fig. 2 a and b), whom was continued for 4 weeks. The fever did not return and the clinical course of the patient was stable; the final echocardiogram revealed the absence of left ventricular dilatation with a correct systolic function, normal pulmonary pressure. She was discharged four weeks after the surgical cardiac procedure. Conclusions Infective endarteritis (IE) complicating PDA is very rare nowadays and the risk is very low especially in the industrialized world. Indeed, standardized management by a skilled multidisciplinary team with expertise in imaging, surgery and intensive care has proven to decrease mortality [3] , [4] , [5] , [6] , [7] . Primary prevention is vital. Even though it was not clear if the closure of a small PDA was beneficial, routine closure of any PDA in children and young adults appeared reasonable. The reasons for this recommendation included the risk of infective endocarditis and low-or-zero morbidity from closure, especially when using a transcatheter device [8] , [9] .

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: COVID-19 is responsible for a large pandemic worldwide Multiple cases have been reported of a hyperinflammatory immune response, similar to cytokine storm syndrome (CSS) usually seen in cancer patients receiving CAR T-cell therapy This can lead to a rapid multi-organ failure in patients Anti-inflammatory medications such as tocilizumab have been used for this condition CASE PRESENTATION: A 22-year-old female with a history of mixed connective tissue disease on hydroxychloroquine (HCQ) and methotrexate presented with 3 weeks of dyspnea, sore throat, cough and fevers She had tested positive for SARS-CoV-2 and her symptoms rapidly worsened despite initial conservative management She was febrile and tachycardic upon presentation Her blood pressure remained normal and she was saturating >98% on ambient air CBC showed lymphopenia of 0 52 10*3/uL Her lactate dehydrogenase was 249 U/L, ferritin was 145 ng/ml, d-dimer was 0 49 ug/ml and CRP was 56 8 mg/L A chest x-ray (CXR) showed bilateral consolidations She continued to deteriorate, with worsening fevers, tachypnea and hypoxia necessitating intubation The following day, a CXR showed worsening bilateral infiltrates and an arterial blood gas revealed a PaO2/FiO2 (PF) ratio of 62 on 100% FiO2, consistent with severe ARDS Paralysis and proning were initiated She failed to improve and repeat lab work showed that ferritin, D-dimer, and CRP values had increased to 843 ng/ml, 3 24 ug/ml and 233 5 mg/L, respectively Her IL-6 level was elevated at 106 8 pg/ml She was given one dose of tocilizumab (8 mg/kg) It resulted in rapid improvement in her clinical status over the next two days Repeat inflammatory markers were decreasing Her PF ratio improved to 254 on an FiO2 of 100% and rapidly weaned on the following day She was later extubated and discharged home with close follow-up DISCUSSION: COVID-19 has been shown to exhibit a wide range of presentations In most cases, the physiologic immune response is appropriately regulated and self-limited In certain patients, an uncontrolled immune activation, also known as CSS has been reported This is associated with pro-inflammatory cytokines such as IL-1 and IL-6 A similar phenomenon was observed in SARS-CoV-1 and MERS-CoV infection Tocilizumab is a monoclonal antibody which targets IL-6 receptors and has shown to have favorable results in COVID-19 patients by suppressing the severe immune response Our patient had rapid improvement, both clinically and in her inflammatory markers after being given the medication CONCLUSIONS: Patients can develop cytokine storm syndrome when suffering from COVID-19 Tocilizumab therapy has been shown to have favorable outcomes as it targets IL-6, a pro-inflammatory marker This case highlights a young patient with a severe presentation that responded remarkably well to tocilizumab Her chronic use of HCQ did not appear to limit the severity of the disease Reference #1: Mehta P, et al COVID-19: consider cytokine storm syndromes and immunosuppression Lancet 2020;395(10229):1033–1034 Reference #2: D McGonagle, K Sharif, A O’Regan, C Bridgewood The role of cytokines including Interleukin-6 in COVID-19 induced pneumonia and macrophage activation syndrome-like disease Autoimmun Rev, 102537 (2020) Reference #3: Qin C, et al Dysregulation of immune response in patients with COVID-19 in Wuhan, China [published online March 12, 2020] Clin Infect Dis https://doi org/10 1093/cid/ciaa248 DISCLOSURES: No relevant relationships by Japjot Chahal, source=Web Response No relevant relationships by Gaston Habib, source=Web Response No relevant relationships by Dragos Manta, source=Web Response No relevant relationships by Pardeep Masuta, source=Web Response No relevant relationships by Kartik Ramakrishna, source=Web Response

Objective: We investigated the incidence, risk factors, clinical characteristics and outcome of spontaneous pneumothorax (SP) in COVID-19 patients attended in emergency departments (ED) before hospitalization. Methods: We retrospectively reviewed all COVID patients diagnosed with SP (case group) in 61 Spanish EDs (20% of Spanish EDs), during the first two months of the COVID outbreak and compared them with two control groups: COVID patients without SP (control group A) and non-COVID patients with SP (control group B). Relative frequencies of SP were estimated in cases and control group B. Unadjusted comparisons between cases and controls included 52 clinical, analytical and radiological characteristics and 4 outcomes. Results: We identified 40 SP in 71,904 patients with COVID-19 attending EDs (0.56‰, 95%CI=0.40-0.76‰). This incidence was higher than that observed in non-COVID patients (387/1,358,134, 0.28‰, 95%CI=0.26-0.32; OR=1.93, 95%CI=1.41-2.71). In COVID patients the characteristics associated with a higher risk of SP were: male sex, shorter symptom length, less fever, greater dyspnea, tachycardia, tachypnea and hypoxia, higher hemoglobin, leukocyte count, D-dimer and LDH, and lower lymphocyte count. Compared to control group B, case group patients were older, more frequently had obesity, asthma, dyspnea, tachycardia, tachypnea, hypoxia and analytical disturbances, and less frequently diabetes mellitus, hypertension, smoker habit, and chest pain. All the outcomes measured, including in-hospital death, were worse in cases than in control groups A and B. Conclusions: SP as a form of COVID presentation is unusual (

Introduction Asphyxiating thoracic dystrophy (ATD), also known as Jeune syndrome, is an autosomal recessive disease which causes thoracic insufficiency. Complications and life expectancy vary based on specific mutations. Infants with this condition may require operative feeding access in addition to surgery for other associated anomalies. No prior cases of laparoscopic surgery in ATD have been recorded in the literature. This case demonstrates that with proper technique, laparoscopic surgery can be accomplished safely. Case presentation Newborn diagnosed with ATD prenatally with anatomical 20-week ultrasound who required long term enteral feeding access due to inability to tolerate oral feeds secondary to tachypnea. Management and outcome Patient underwent laparoscopic gastrostomy tube placement at 2 weeks of age. This was well tolerated, and no complications arose from insufflation pressure despite small thoracic volumes. Pressure control ventilation was used along with frequent desufflation breaks. Patient tolerated tube feeds at goal until expiration at 8 weeks of age. Discussion Laparoscopic surgery can be safely performed in patients with ATD with appropriate monitoring and ventilatory support. Although ATD is commonly fatal, this type of palliative surgery can improve patients’ quality of life and allow them to discharge home safely so they can spend more time with family.

A 35-year-old diabetic woman was referred to the emergency department with fever, left flank pain, pneumaturia, and impaired vision of the left eye from 4 days ago. Fever, tachycardia, tachypnea, low blood pressure, metabolic acidosis, and azotemia were the first findings. The diagnosis was a coincidence of emphysematous pyelonephritis and emphysematous endophthalmitis due to computerized tomography of the patient. Immediate fluid and electrolytes resuscitation, intravenous antibiotic administration, and nephrectomy save the patient. Urine, blood, and vitreous cultures revealed mixed germ infection.

A 16-month-old Thoroughbred filly was evaluated for lethargy, tachycardia, tachypnea, and signs suggestive of colic. Rapid ventricular tachycardia with a heart rate of 210 beats/min was identified on initial physical examination. Multiple doses of lidocaine transiently restored sinus rhythm. Echocardiography revealed several foci of variably increased echogenicity within the left ventricular myocardium, including an area of marked transmural hyperechogenicity and endocardial depression suspected to be chronic scar tissue of the left ventricular free wall. Serum cardiac troponin I concentration was markedly elevated. Because of the recurrent ventricular tachyarrhythmia and echocardiographic findings, the filly was euthanized. Postmortem examination demonstrated multifocal, acute myocardial necrosis and an area of chronic myocardial fibrosis in the left ventricular free wall. The exact cause of the myocardial lesions remains undetermined; however, the chronic fibrosis is suspected to have resulted from myocardial injury or infarction associated with cardiopulmonary cerebral resuscitation when the filly was 5 days old.

Background Human Rhinovirus (HRV) has been identified as the most common cause of acute respiratory infections and hospitalizations in premature children. It is unclear if premature children are more susceptible to HRV due to their decreased pulmonary reserve or because they have enhanced lower airway reactivity to HRV. Methods We conducted a retrospective analysis of the clinical respiratory presentation of all PCR-confirmed HRV infections in full-term and premature children aged ≤3 years in our institution. Standardized respiratory distress scores were developed to examine lower airway obstruction (i.e., wheezing, hyperinflation, and sub-costal retractions) along with markers of decreased pulmonary reserve (hypoxemia and tachypnea) in young children with HRV infections. Demographic and clinical variables were obtained from reviewing electronic medical records (EMR). Results This study included a total of 205 children; 71% of these children were born full-term (>37 weeks gestation), 10% preterm (32–37 weeks) and 19% severely premature (

Background: A/H1N1 influenza is a viral disease that affects a significant part of the population mainly in winter, leading to increased number of medical consultations, hospitalizations and consequently care spending in emergency. Methods: This is a case-series retrospective study, involving patients admitted to a tertiary hospital in southern Brazil in 2016 with a clinical diagnosis of acute respiratory infection of the influenza type and laboratory confirmation of influenza A/H1N1. Results: 64 patients were included, mostly male, median age of 48.3 months. Chronic underlying diseases were found in 73% of the patients, and these patients evolved to the most unfavorable outcome. About vaccination, of the 57 patients with an age range for vaccination, only 28% had complete vaccination coverage. The main clinical manifestations found in the included patients were fever, cough, intercostal indrawing, wheezing, tachypnea and pulmonary crackles. These patients were mainly followed-up with laboratory tests and chest X-ray. Consolidation was evident in 43% of patients followed by interstitial infiltrate in 33%. A five-day course of neuraminidase inhibitor was prescribed for all patients, as recommended by the WHO, but due to the complications, 73% of the patients required antibiotic therapy, and 61% oxygen therapy. The majority of patients had a favorable outcome, but 11 required intensive care and one died. Conclusions: A/H1N1 influenza persists as an important public health problem, mainly due to high morbidity and hospitalization rates. It is important to identify patients with A/H1N1 influenza and clinical situations with higher risk of complications. Through this study, it is possible to analyze the characteristics of pediatric patients with A/H1N1 influenza and mainly to emphasize assistance of populations with comorbidities, since they present higher rates of complications and death. Keywords: H1N1 influenza, Emergency, Critical care, Children

Background At three weeks of age, a previous 34 weeks' gestation male infant (twin A) was transferred to our regional perinatal center (RPC) with complaints of poor oral feeding and intermittent tachypnea. Twin B was discharged at 37 weeks with an uneventful course. Case Twin A briefly required respiratory support but continued to have difficulty transitioning from gavage to oral feeding. Initially, his inability to feed orally was thought to be secondary to nasal congestion and prematurity, but with worsening respiratory distress he was transferred for further evaluation and management. Diagnosis & Conclusion On admission to RPC, the examination prompted a cardiac assessment which revealed a large aortic-pulmonary window type II. After surgery, the infant quickly improved and went home on-demand oral feeds. Cardiac lesions are more common in monochorionic twins but should be suspected in dichorionic twins especially if one twin has a normal course.

Recent observations from our group seem to indicate that repeated stress-evoked dorsomedian hypothalamic nucleus (DMH) activation in rats can lead to persistent bradypnea. One possibility was that respiratory responses to peripheral chemoreceptor activation were reduced by DMH stimulation. In the present study, we therefore investigated the effect of minimal supra-threshold DMH stimulation on respiratory carotid chemoreflex responses. For this purpose, the chemoreflex was activated by potassium cyanide (KCN, 40μg/rat, i.v.) during electrical and chemical stimulation of the DMH. In both situations, changes in breathing frequency but not tidal volume responses to KCN administration were reduced. These findings suggest that low DMH neurotransmission negatively affects respiratory chemoreflex responses and may be involved in stress-induced bradypnea.

A 6-day-old female presented to a pediatric cardiologist with tachypnea. A computed tomography angiogram of the chest showed partial anomalous pulmonary venous return, a pulmonary sequestration, and a horseshoe lung. Depicted here are radiographic findings which display this rare combination. This case demonstrates the need for the radiologist to consider additional abnormalities in the setting of anomalous pulmonary venous return. Keywords: Congenital venolobar syndrome, Horseshoe lung, Pulmonary sequestration

Theileria equi is a tickborne hemoparasite that can cause severe illness in equids. In this report, we are describing a condition of acute bilateral hyphema in a 4-month-old Kathiawari filly infected with T. equi. The horse showed clinical signs such as fever, lethargy, icterus, tachycardia, tachypnea, and bilateral hyphema. Laboratory diagnosis revealed anemia and thrombocytopenia. Atypical clinical manifestation of bilateral hyphema, to our knowledge, has never been reported so far in equids infected with T. equi. The diagnosis was confirmed by microscopic examination of Geimsa-stained blood smear. Specific and supportive therapy for T. equi allowed remission of clinical signs and laboratory profile abnormalities.

TOPIC: Tobacco Cessation and Prevention TYPE: Medical Student/Resident Case Reports INTRODUCTION: The United States is in an epidemic of electronic cigarette or vaping product use-associated lung injury (EVALI) which is characterized by a combination of respiratory, constitutional and gastrointestinal symptoms1. The most common presenting signs and symptoms include dyspnea, cough, fever, tachypnea, tachycardia, hypoxia, malaise, and emesis2. Two predominant patterns of acute lung injury have been recognized in EVALI: Diffuse Alveolar Damage and Organizing Pneumonia. Radiographic findings in the literature for patients diagnosed with EVALI include a pattern of bilateral and symmetric ground glass opacities with subpleural and areas of lobular sparing3. We present a unique case of severe EVALI isolated to a single lung that has not been documented in the literature and was managed conservatively. CASE PRESENTATION: A 36-year-old male with a history of vaping nicotine products presented with acute onset of dyspnea, hypoxia and tachycardia. Prior to switching to vaping, he admitted to a 7 pack-year smoking history of cigarettes. He endorsed using a Juul© vaping device for two years before switching to another product, Fume©, for 2 months prior to presentation. On physical exam, the patient was tachypneic and in severe respiratory distress with crackles in the right lung. Vital signs were significant for a heart rate of 129 and oxygen saturation of 90% on ambient air. COVID PCR and viral respiratory panel testing were negative. CT of the chest showed diffuse right sided nonspecific reticulonodular pattern with some bronchiectatic changes. Our patient requested conservative management due to financial concerns. Thus we elected to treat without antibiotics and systemic steroids. Supportive treatment included bronchodilators and supplemental oxygen. He improved clinically over the next five days despite our unusual conservative approach. A repeat CT of the chest at that time showed marked interval resolution of radiographic findings. DISCUSSION: Our case highlights that clinicians must be able to recognize that unilateral organizing pneumonia in the setting of recent vaping can be a manifestation of EVALI. Anecdotal literature supports the use of systemic glucocorticoids but an exact treatment of EVALI is not yet known1. The approach in our patient with significant hypoxia and radiographic lung involvement reinforces that supportive treatment of EVALI, as opposed to aggressive measures with empiric antibiotics and systemic glucocorticoids, can lead to similar outcomes without the risk of adverse effects of those medications. CONCLUSIONS: A conservative approach can likely decrease financial burdens for patients and medical institutions and still yield positive medical results. Further longitudinal research is required to determine the benefit of empiric treatment of EVALI and radiographic studies to database future unilateral presentations of EVALI. REFERENCE #1: Werner AK, Koumans EH, Chatham-Stephens K, et al. Hospitalizations and Deaths Associated with EVALI. The New England Journal of Medicine 2020;382;1589-98. REFERENCE #2: Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin - preliminary report. N Engl J Med 2019;382:903-916. REFERENCE #3: Kligerman S, Raptis C, Larsen B, et al. Radiologic, Pathologic, Clinical and Physiologic Findings of Electronic Cigarette or Vaping Product Use-associated Lung Injury (EVALI): Evolving Knowledge and Remaining Questions. Radiology 2020;294: 491-505 DISCLOSURES: No relevant relationships by MARIA CANIZARES-OTERO, source=Web Response No relevant relationships by Benjamin Carmel, source=Web Response No relevant relationships by Vijay Srinivasan, source=Web Response No relevant relationships by Hector Vazquez Saad, source=Web Response

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Sepsis is common in critically ill COVID-19 patients and is associated with high mortality. However, the diagnosis of sepsis and the prediction of mortality are challenging in COVID-19 patients, especially in the early stage of sepsis. Research about the performance of SIRS criteria and qSOFA score in patients with COVID sepsis is limited. Therefore, this study aimed to compare the performance of SIRS, qSOFA, and a combination of both in hospitalized COVID-19 adult patients regarding the diagnosis of sepsis and the prediction of in-hospital mortality. METHODS: Retrospective data analysis included 341 patients who were hospitalized with laboratory-confirmed COVID-19 infection during April 2020 and January 2021 (the peaks of the first and second waves in New York state) at a 242-bed university-affiliated community-based hospital. Data from the initial patient encounter at the emergency room was collected by reviewing the electronic health records. SIRS criteria, qSOFA score, and a combination of both (SIRS+qSOFA) were analyzed by the MATLAB software. SIRS+qSOFA includes 5 parameters: tachypnea (respiratory rate ≥ 22), tachycardia (heart rate >90/min), fever or hypothermia (temperature >38°C (100.4°F) or 12000/mm³, 10% bands), altered mentation, and hypotension (systolic blood pressure ≤100 mmHg). The area under the receiver operating characteristic curves (AUC) was calculated to evaluate the performance of SIRS, qSOFA, and SIRS+qSOFA. RESULTS: In 341 COVID-19 patients, 128 patients were diagnosed with sepsis (37.5%), which included 77 expired patients (60.2%);213 patients were not diagnosed with sepsis (62.5%), which included 50 expired patients (23.5%). The AUCs for the diagnosis of sepsis with SIRS, qSOFA, and SIRS+qSOFA were 0.739, 0.731, and 0.793, respectively. The AUCs for the prediction of mortality with SIRS, qSOFA, and SIRS+qSOFA were 0.593, 0.665, and 0.646, respectively. For diagnosing sepsis, the sensitivity of SIRS (≥ 2), qSOFA (≥ 2), and SIRS+qSOFA (≥ 3) were 82.0%, 48.4%, and 68.8%, respectively;the specificity of SIRS (≥ 2), qSOFA (≥ 2), and SIRS+qSOFA (≥ 3) were 54.9%, 85.4%, and 76.5%, respectively. For predicting mortality, the sensitivity of SIRS (≥ 2), qSOFA (≥ 2), and SIRS+qSOFA (≥ 3) were 68.5%, 42.5%, and 55.9%, respectively;the specificity of SIRS (≥ 2), qSOFA (≥ 2), and SIRS+qSOFA (≥ 3) were 46.7%, 81.8%, and 68.7%, respectively. CONCLUSIONS: For diagnosing sepsis in COVID-19 patients, the performance of SIRS+qSOFA with 5 parameters (AUC=0.793) is better than either SIRS (AUC=0.739) or qSOFA (AUC=0.731). For predicting mortality, the performance of qSOFA (AUC=0.665) is superior to either SIRS (AUC=0.593) or SIRS+qSOFA (AUC=0.646). CLINICAL IMPLICATIONS: This study will facilitate the diagnosis of sepsis and the prediction of mortality in the hospitalized COVID-19 adult patients. DISCLOSURES: No relevant relationships by Shraddha Acharya, source=Web Response No relevant relationships by Inigo Atienza, source=Web Response No relevant relationships by Stephen Jesmajian, source=Web Response No relevant relationships by Jeffrey Lederman, source=Web Response No relevant relationships by Liyun Liu, source=Web Response No relevant relationships by Junfeng Xue, source=Web Response

Children with obstructive sleep apnea are considered high risk for postoperative respiratory complications, but opinions differ regarding the polysomnography (PSG) criteria that suggest the need for postoperative admission. Our objective was to determine if otherwise healthy children age ≥3 years with an apnea-hypopnea index (AHI) 24 on overnight PSG can be safely discharged on the same day of surgery.Case series with chart review of children age18 years with positive PSG (AHI 2) who underwent adenotonsillectomy (TA) between January 2013 and August 2019. Data collected included patient demographics, medical history, comorbidities, PSG results, operative details, length of stay, intraoperative and postoperative respiratory complications and management. Potential predictors of respiratory complications were evaluated using chi-square/Fisher's exact test and 2-tailed unpaired t tests with the Bonferroni adjustment for multiple comparison artifact. The percentages of healthy children age ≥3 years who were discharged on the day of surgery at various PSG cutoffs were calculated.Of the 560 children, mean (SD) age was 6.4 (3.7) years, 318 (56.8%) were male, 438 (78.2%) were African American, 243 (43.4%) were obese, 16 (2.9%) had Down Syndrome and 12 (2.1%) had sickle cell disease. Median (range) AHI was 12.3 (2-145). Fifteen children (2.7% [95% CI 1.3, 4.0]) had an intraoperative or postoperative respiratory complication. Minor complications including mild desaturation, stridor, croupy cough, and laryngospasm occurred in 9 patients and did not prolong the planned ambulatory or hospital stay. Of the 6 children with more severe complications including prolonged desaturation, tachypnea, atelectasis, intercostal retraction and obstructive apnea requiring continuous positive airway pressure, all were planned admissions based on age, severe sleep study indices (AHI ≥ 24 or oxygen saturation nadir 80%) or underlying medical condition. Of the 165 children age ≥3 without medical comorbidities known to be predictive of postoperative complications with an AHI ≥10 but24, 113 (68.5%) were discharged home on the same day of surgery without additional respiratory sequelae.This study demonstrates a low risk of respiratory complications after TA. Otherwise healthy children age ≥3 years with AHI24 may be considered for ambulatory discharge.

Introduction. Respiratory muscle stretching is useful in reducing chest wall rigidity, consequently increasing chest wall expansion and improving ventilatory patterns. There are few reports that have examined the effects of these techniques in relation to both minute ventilation and inspiratory muscle activities. The purpose of this study was to evaluate the acute effects of respiratory muscle stretching on ventilatory patterns and respiratory muscle activities in healthy persons. Methods. Ten healthy young men participated in the experiment. Subjects were placed in the Fowler’s position. The stretching of both bilateral neck and pectoralis major muscles by a physical therapist was performed throughout the expiratory phase, allowing inspiratory muscles to reach their maximum length during the relaxation time. Two sets of 10 consecutive stretches were performed for each muscle, with a 30 s interval between the series. The ventilatory pattern and inspiratory muscle activities (both sternocleidomastoid and external intercostal muscles) were evaluated through spirometry and electromyography before and immediately after each intervention. Both measurements were taken while the subject breathed at a rate of 30 times per minute. Muscle discharges were quantified using the root mean square to analyze the changes in the contraction levels. The study was performed according to the guidelines set by the Ethics Committee of Aomori University of Health and Welfare. All participants signed an informed consent form. Results. Respiratory muscle stretching promoted a significant acute increase in maximum voluntary ventilation, mean inspiratory flow, and inspiratory muscle activities during tachypnea compared with the control group. Conclusion. Acute effects of respiratory muscle stretching suggested increased respiratory muscle activities and/or improved expansion of ventilatory functions.

Introduction. Myasthenia gravis (MG) occurs in 10-20 persons per 1 million people per year and in women twice as much as men. Pitfalls in MG therapy include numerous drugs and conditions that could worsen muscle weakness, leading to myasthenic crisis. One of the most common exacerbating conditions is infection, especially pneumonia. This case report will discuss the management of exacerbated MG with pneumonia in a pregnant woman. Results. Mrs. I, 35 years old and 12 weeks pregnant, visited Emergency Room of Dr. Iskak General Hospital with the chief complaint of shortness of breath for two days. There were fever, productive cough, and nausea. A week prior, she forgot to take her pyridostigmine. There was history of dyspnea in her first pregnancy. Her vital signs showed tachypnea and fever, peripheral saturation was normal, and patient was fully alert. There was neither weakness in extremities nor difficulty in swallowing. Remarkable laboratory results were leucocytosis and neutrophilia. She was diagnosed as pneumonia and exacerbated MG. Treatments during hospitalization included cefadroxil 2x500 mg, pyridostigmine 6x60 mg, paracetamol 3x500 mg, O2 nasal cannule 3 L/m, Ventolin nebulization, and ambroxol 3x30 mg. Conclusion. Mrs. I’s clinical features pointed towards pneumonia, but MG exacerbation cannot be fully excluded since pneumonia can worsen the muscle weakness. Therefore, the main purposes of treatment should be to eradicate the bacteria and prevent MG from worsening to myasthenic crisis. Cefadroxil was chosen since it is not teratogenic and does not induce myasthenic crisis. Pyridostigmine was given twice the normal dose, which was in the safe range for not causing microcephaly. In short, dyspnea in a MG patient should be assessed like any other dyspnea case with several differential diagnoses instead of focusing to the MG itself. Treatment of this patient should consider the teratogenic effect to the pregnancy and the exacerbating effect to the MG.

Objectives: To summarize the current literature describing high-flow nasal cannula use in children, the components and mechanisms of action of a high-flow nasal cannula system, the appropriate clinical applications, and its role in the pediatric emergency department. Sources: A computer-based search of PubMed/MEDLINE and Google Scholar for literature on high-flow nasal cannula use in children was performed. Data summary: High-flow nasal cannula, a non-invasive respiratory support modality, provides heated and fully humidified gas mixtures to patients via a nasal cannula interface. High-flow nasal cannula likely supports respiration though reduced inspiratory resistance, washout of the nasopharyngeal dead space, reduced metabolic work related to gas conditioning, improved airway conductance and mucociliary clearance, and provision of low levels of positive airway pressure. Most data describing high-flow nasal cannula use in children focuses on those with bronchiolitis, although high-flow nasal cannula has been used in children with other respiratory diseases. Introduction of high-flow nasal cannula into clinical practice, including in the emergency department, has been associated with decreased rates of endotracheal intubation. Limited prospective interventional data suggest that high-flow nasal cannula may be similarly efficacious as continuous positive airway pressure and more efficacious than standard oxygen therapy for some patients. Patient characteristics, such as improved tachycardia and tachypnea, have been associated with a lack of progression to endotracheal intubation. Reported adverse effects are rare. Conclusions: High-flow nasal cannula should be considered for pediatric emergency department patients with respiratory distress not requiring immediate endotracheal intubation; prospective, pediatric emergency department-specific trials are needed to better determine responsive patient populations, ideal high-flow nasal cannula settings, and comparative efficacy vs. other respiratory support modalities. Resumo: Objetivos: Resumir a literatura atual que descreve o uso da cânula nasal de alto fluxo em crianças, os componentes e mecanismos de ação do sistema de cânula nasal de alto fluxo, as aplicações clínicas adequadas e o papel desse sistema no departamento de emergência pediátrico. Fontes: Realizamos uma pesquisa informatizada na PubMed/MEDLINE e utilizamos o Google Acadêmico para encontrar literatura sobre o uso da cânula nasal de alto fluxo em crianças. Resumo dos dados: A cânula nasal de alto fluxo, modalidade de suporte respiratório não invasiva, fornece misturas de gases aquecidas e totalmente umidificadas para pacientes por meio de uma cânula nasal. A cânula nasal de alto fluxo provavelmente auxilia a respiração por meio da redução da resistência inspiratória, eliminação do espaço morto anatômico nasofaríngeo, redução do trabalho metabólico relacionado ao condicionamento de gás, melhora da condutância das vias aéreas e transporte mucociliar e fornecimento de baixos níveis de pressão positiva nas vias aéreas. A maior parte dos dados que descrevem o uso da cânula nasal de alto fluxo em crianças é focada em crianças com bronquiolite, embora a cânula nasal de alto fluxo tenha sido usada em crianças com outras causas de doenças respiratórias. A introdução da cânula nasal de alto fluxo na prática clínica, incluindo o departamento de emergência, foi associada à redução dos índices de intubação endotraqueal. Dados intervencionistas prospectivos limitados sugerem que a cânula nasal de alto fluxo pode ser tão eficaz quanto a pressão positiva contínua nas vias aéreas e mais eficaz do que a oxigenoterapia padrão em alguns pacientes. As características dos pacientes, como melhora da taquicardia e taquipneia, foram associadas a uma ausência de progressão para intubação endotraqueal. Foram raros os efeitos adversos relatados. Conclusões: A cânula nasal de alto fluxo deve ser considerada para pacientes do departamento de emergência pediátrico com insuficiência respiratória que não precisam de intubação endotraqueal imediata, contudo, são necessários ensaios clínicos prospectivos específicos para o departamento de emergência pediátrico para determinar melhor as populações de pacientes que respondem ao tratamento, as configurações ideais da cânula nasal de alto fluxo e a eficácia comparada a outras modalidades de suporte respiratório. Keywords: High-flow nasal cannula, Children, Emergency department, Bronchiolitis, Palavras-chave: Cânula nasal de alto fluxo, Crianças, Departamento de emergência, Bronquiolite

Sheehan syndrome is a potentially serious complication in the postpartum period corresponding to ischemic necrosis of the anterior pituitary related to postpartum haemorrhage. We report three original observations showing an unusual mode of revelation of this syndrome. The first observation is that of a 46-year-old patient admitted initially to resuscitation for a recovered cardiorespiratory arrest, severe hypoglycemia and profound hyponatremia. The second is that of a 45-year-old patient, admitted for recurrent cardiac tamponade after pericardial and pleural puncture and pericardial drainage; clinical survey found signs of slight panhypopituitarism. The latest case is that of a patient of 44 years, admitted to pericardial effusion average abundance revealed by dyspnea and tachypnea with hypotension. The interrogation of all patients revealed the concept of an old hemorrhagic syndrome, absence of lactation and secondary amenorrhea thereafter. Laboratory tests showed insufficient thyroid-stimulating, low cortisol, a hypogonadism hypogonadism. The pituitary magnetic resonance imaging showed an empty sella in the three cases. Patients were placed under replacement therapy with L-thyroxine and hydrocortisone with good clinical, biological and echocardiographic evolution. The three cases illustrate a rare heart atypical presentation for Sheehan's syndrome and underline the importance of early diagnosis and suitable replacement therapy of this syndrome to avoid this complication that can be life threatening.