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Introduction: More than 15 million adults in the USA have chronic obstructive pulmonary disease. Chronic obstructive pulmonary disease (COPD) places a high burden on the healthcare system. Many hospital admissions are due to an exacerbation, which is suspected to be from a viral cause. The purpose of this analysis was to compare the outcomes of patients with a positive and negative respiratory virus panel who were admitted to the hospital with COPD exacerbations. Methods: This retrospective cohort study was conducted in the Geisinger Healthcare System. The dataset included 2729 patient encounters between 1 January 2006 and 30 November 2017. Hospital length of stay was calculated as the discrete number of calendar days a patient was in the hospital. Patient encounters with a positive and negative respiratory virus panel were compared using Pearson&rsquo, s chi-square or Fisher&rsquo, s exact test for categorical variables and Student&rsquo, s t-test or Wilcoxon rank-sum tests for continuous variables. Results: There were 1626 patients with a total of 2729 chronic obstructive pulmonary disease exacerbation encounters. Nineteen percent of those encounters (n = 524) had a respiratory virus panel performed during their admission. Among these encounters, 161 (30.7%) had positive results, and 363 (69.3%) had negative results. For encounters with the respiratory virus panel, the mean age was 64.5, 59.5% were female, 98.9% were white, and the mean body mass index was 26.6. Those with a negative respiratory virus panel had a higher median white blood cell count (11.1 vs. 9.9, p = 0.0076). There were no other statistically significant differences in characteristics between the two groups. Respiratory virus panel positive patients had a statistically significant longer hospital length of stay. There were no significant differences with respect to being on mechanical ventilation or ventilation-free days. Conclusion: This study shows that a positive respiratory virus panel is associated with increased length of hospital stay. Early diagnosis of chronic obstructive pulmonary disease exacerbation patients with positive viral panel would help identify patients with a longer length of stay.

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: COVID-19 infection is now well known to cause venous thrombotic complications. More recently, arterial thrombotic complications of COVID-19 have been reported. Incidence of Acute limb ischemia (ALI) ranges from 3 to 15%. CASE PRESENTATION: A 50-year-old male with a history of hypertension presented to the ED with left foot numbness, discoloration, and pain for 2 days. Two weeks before the presentation, he tested positive for SARS-CoV2 after an outpatient evaluation for acute cough. He did not have any other respiratory complaints and was quarantined at home. His cough persisted, but he denied any fever, shortness of breath, chest pain, or hemoptysis. On physical exam, he was afebrile, heart rate of 71 beats per minute, blood pressure 141/90 mm of Hg, respiratory rate of 19 breaths per minute, and oxygen saturation of 98% while breathing ambient air. His respiratory exam was unremarkable. There were no palpable femoral, popliteal, dorsalis pedis, and posterior tibial pulses on the left side. He had sensory loss in the left foot. Laboratory evaluation showed mild transaminitis. His CK was 767 U/L, and D-dimer was 4.92 mg/L. CTA abdominal aorta with iliofemoral runoff was performed, which showed partial occlusion of the distal abdominal aorta, near-complete occlusion of the left common iliac artery, and complete occlusion of the proximal popliteal artery at the level of the distal femur with no flow distal to this point.Anticoagulation with unfractionated heparin was initiated. The patient was emergently taken to the OR and underwent extensive embolectomy involving the aortoiliac, femoral, popliteal, and tibial artery of the left leg. Antiphospholipid antibodies were normal. He had no family or personal history of blood clots. His presentation was believed to be due to thrombotic complications of the COVID-19 infection. His postoperative course was unremarkable, and he was discharged home on postoperative day 5. DISCUSSION: ALI is a vascular emergency. The exact pathophysiology causing thrombosis is unknown, but endothelial dysfunction, cytokine production, acquired antiphospholipid syndrome, and hypoxia may contribute to thrombosis (1). The current prevalence of ALI is noted to be 4 to 21 per 100,000 COVID-19 hospitalizations. In one observational review and in most case series, the median age was over 60. Male sex, Hispanic ethnicity, history of myocardial infarction, CAD, and elevated D-dimer increase the risk of developing ALI (2). The patient usually presents with pain, pallor, numbness, and loss of pulses. CONCLUSIONS: We present a young patient with no significant risk factors and otherwise mild COVID-19 infection presenting with acute lower limb ischemia. A high index of suspicion and prompt recognition of ALI in patients with COVID-19 infection is critical. Surgical revascularization, either open or catheter-directed, and systemic anticoagulation is the mainstay of treatment. REFERENCE #1: Rahi MS, Jindal V, Reyes S-P, Gunasekaran K, Gupta R, Jaiyesimi I. Hematologic disorders associated with COVID-19: a review. Annals of Hematology. 2021. REFERENCE #2: Bilaloglu S, Aphinyanaphongs Y, Jones S, Iturrate E, Hochman J, Berger JS. Thrombosis in Hospitalized Patients With COVID-19 in a New York City Health System. Jama. 2020. DISCLOSURES: No relevant relationships by Kwesi Amoah, source=Web Response No relevant relationships by Kavitha Gopalratnam, source=Web Response No relevant relationships by Kulothungan Gunasekaran, source=Web Response No relevant relationships by Lakshmi Polisetty, source=Web Response No relevant relationships by Mandeep Singh Rahi, source=Web Response

The intensive care unit (ICU) was initially developed in the 1950s to treat patients who required invasive respiratory support and hemodynamic resuscitation. Since the beginning, ICU medicine has focused on maintaining sufficient arterial blood flow and oxygenation to provide adequate tissue oxygen delivery to forestall or reverse organ failure. Over time, ICU medicine became more intensive, with the administration of many diagnostic tests and monitors, invasive procedures, and treatments, often with scant evidence of benefit associated with them. An alternative perspective holds that ICU patients may represent a group of patients that is especially vulnerable to iatrogenic harm. We outline a case that presents common ICU dilemmas and discusses current data that propose that "less is more" when making key diagnostic or therapeutic choices in the ICU. Further, we assert that providers should skeptically consider common ICU interventions, trying to account for the potential unintended consequences of interventions. Finally, we suggest that the guiding principle of ICU medicine should be primum non nocere: in delicate situations, it may be better not to do something, or even to do nothing, rather than risk causing harm.

Adult onset Still’s disease (AOSD) is a systemic auto-inflammatory condition of unknown etiology, characterized by high fever, an evanescent, salmon-pink maculopapular skin rash, arthralgia or arthritis and leukocytosis. AOSD can also present with atypical cutaneous manifestations, such as persistent pruritic coalescent papules or plaques and linear lesions that have highly distinctive pathological features and are usually associated with severe disease. Herein, we present a 31-year-old Brazilian man with both typical Still’s rash and atypical persistent polymorphic cutaneous manifestations associated with severe systemic inflammatory response syndrome. Eosinophils that are consistently lacking in the AOSD-associated skin lesions were evident in the skin biopsy of the persistent atypical cutaneous manifestations and were either drug-related or AOSD-associated.

Ischemic strokes occur when there is a sudden obstruction of an artery supplying blood flow to an area of the brain, leading to a focal neurological deficit. Strokes can be thrombotic or embolic in etiology and are associated with underlying conditions such as hypertension and atherosclerosis. Possible etiologies of strokes include cardioembolic disease, hematologic disorders, connective tissue disorders, and substance abuse or can be cryptogenic. Most stroke cases are seen in patients over 65 years of age. However, about one-fourth of strokes occur in young adults. Iron deficiency anemia (IDA) has been described as a known cause for strokes in children, but very few case reports describe this association in adults. We describe a 20-year-old female who presented with sudden onset left side weakness. Magnetic Resonance Imaging (MRI) of the brain demonstrated ischemic infarctions. Patient was also found to be severely anemic. Patient had a thorough work-up including Magnetic Resonance Angiography (MRA) of the brain, echocardiogram, and an extensive screen for thrombophilia disorders. This, however, did not demonstrate a clear etiology. As it has been suggested that IDA is a potential cause for stroke, it is possible the stroke in this young patient was attributable to severe IDA.

Autoimmune haemolytic anaemia (AIHA) is a disease characterised by the production of pathological antibodies that attach to the surface of a patient9s own red blood cells, resulting in haemolysis. It can present in either an acute or a chronic manner. In addition to the obvious consequence of anaemia, there are other potentially deadly complications that can arise from AIHA, such as venous thromboembolism (VTE) and pulmonary hypertension. We report a case of a 52-year-old woman who developed a pulmonary embolism (PE) soon after being diagnosed with AIHA. Despite having a very small pulmonary venous clot burden, she developed profound haemodynamic compromise with severe right ventricular dysfunction, which quickly reversed with inhaled nitric oxide treatment. This case makes an interesting observation of cell-free haemoglobin-associated nitric oxide scavenging as a mechanism of pulmonary hypertension and highlights the possible benefit of nitric oxide in treatment.

with RDW, and 0.764 with RIFLE classification. AU-ROC for NEWS improved from 0.748 to 0.771 when combined with both RDW and RIFLE classification. Based on NEWS alone, there were 128 patients with moderate and high risk scores, while this number increased to 170 when RDW and RIFLE were added to the tool. Conclusions