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Rene Laennec came up with the idea of a stethoscope in 1816 to avoid the embarrassment of performing immediate auscultation on women. Soon many doctors around the world started using this tool because of its increased accuracy and ease of use. Stethoscopes hold great significance in the medical community. However, is the importance placed on stethoscopes justified today? We now have devices like portable ultrasound machines that make it much easier to visualize the body. These devices offset their higher initial cost by reducing downstream costs due to their greater accuracy and their capability of detecting diseases at an earlier stage. Also, because of the COVID-19 pandemic, new ways are being investigated to reduce the transmission of diseases. Stethoscopes being a possible vector for infectious agents coupled with the advent of newer devices that can visualize the body with greater accuracy put into question the continued use of stethoscopes today. With that said, the use of stethoscopes to diagnose diseases is still crucial in places where buying these new devices is not yet possible. The stethoscope is a great symbol of medicine, but its use needs to be in line with what is best for the patient.

The emergence of SARS-CoV-2 in late December 2019 has taken the world by storm. In March 2020, the World Health Organization (WHO) named this virus COVID-19. To date, it has infected approximately 186 million people worldwide and is attributed as the cause of death of more than 5 million people (and this number is only increasing.) The global effort to develop vaccines and therapeutics occurred at the fastest pace yet, with several vaccines' approval under emergency authorization use. There are also several post-marketing side effects, including myocarditis, cerebral venous embolism, and Guillain Barre Syndrome. Global vaccine disparity complicates the control of pandemic challenges. Several highly infectious variants have emerged, and more variants are feared to emerge if global vaccination plans are not developed soon.

Obstructive sleep apnea (OSA) remains a prominent disease state characterized as the recurrent collapse of the upper airway while sleeping and is estimated to plague 936 million adults globally. Although the initial clinical presentation of OSA appears harmless, it increases the risk of cardiovascular diseases such as heart failure, stroke, and hypertension; metabolic disorders; and an overall decrease in quality of life, in addition to increasing mortality. Current treatment of OSA includes lifestyle changes, behavioral modification, mandibular advancement devices, surgical treatment, and continuous positive airway pressure, which remains the gold standard. It is crucial to identify OSA early on and initiate treatment to mitigate the adverse health risks it imposes. This review will discuss the pathophysiology, epidemiology, management strategies, and medical treatment of OSA.

We have witnessed rapid advancement in technology over the last few decades. With the advent of artificial intelligence (AI), newer avenues have opened for researchers. AI has added an entirely new dimension to this technological boom. Researchers in medical science have been excited about the tantalizing prospect of utilizing AI for the benefit of patient care. Lately, we have come across studies trying to test and validate various models based on AI to improve patient care strategies in critical care medicine as well. Thus, in this review, we will attempt to succinctly review current literature discussing AI in critical care medicine and analyze its future utility based on prevailing evidence.

Tracheobronchial injuries are either traumatic or iatrogenic but can be lethal in a high dependency setting if not managed promptly. There are few reported cases of cocaine-induced airway damage and barotrauma due to thermal or ischemic injury and increased intra-alveolar pressure. We present a sui generis case of cocaine-induced bronchial laceration with pneumomediastinum which was challenging to diagnose based on the patient's recent history of hospitalization, as well as the patient's reluctance to share the history of cocaine use. The patient was successfully managed conservatively. Here, we discuss the mechanism involved and the various treatment options available, along with the role of early involvement of the multidisciplinary team to deliver the best possible outcome.

Pneumoperitoneum is pneumatosis in the potential space of the abdominal cavity. It is generally considered a surgical emergency and is mostly due to perforated hollow viscus. Rarely, pneumoperitoneum might occur even in the absence of bowel perforation. We hereby present a case of pneumoperitoneum in a patient with COVID-19 pneumonia and pneumomediastinum, which was managed non-surgically.

Image in medicine An 85-year-old Caucasian female with past medical history of hypertension, hyperlipidemia, polymyalgia rheumatica, coronary artery disease, Osler-Weber-Rendu syndrome (diagnosed 18 years ago), intermittent epistaxis and pulmonary arteriovenous malformation (AVM) was referred to the clinic for abnormal chest imaging. She underwent multiple bilateral AVM embolization 17 years ago. She had minimal shortness of breath without epistaxis, hemoptysis, hematemesis or hematochezia. One month ago, her chest X-ray revealed multiple embolization coils bilaterally (A). Computed tomography (CT) chest scan without contrast showed multiple embolization coils, multiple tortuous vascular malformations in both lungs with enlargement of left lower lobe AVM (B). Magnetic resonance imaging (MRI) brain 17 years ago did not show brain vascular malformation. The diagnosis of progressive Osler-Weber-Rendu or hereditary hemorrhagic telangiectasia (HHT) was made. She was referred to HHT center and underwent coiling. After that, she has been clinically stable and a repeat CT chest on the follow-up visit showed smaller left lower lobe AVM (B), so conservative management was planned. Figure 1 A) chest X-ray showing multiple embolization coils bilaterally; B) CT chest without contrast showing large AVM at left lower lobe (arrow); C) a repeat CT chest without contrast one year later showing smaller AVM at left lower lobe after coiling (arrow)

Paravalvular leaks (PVL) are an uncommon sequelae of valve replacement but can be seen as a complication of both mechanic and prosthetic valves. Patients with PVL may remain asymptomatic or have detrimental complications, which include heart failure, hemodynamically significant hemolysis, and endocarditis. Management depends on the clinical presentation and the degree of the valvular leak. We hereby present a case report of a patient with a complicated clinical course secondary to a PVL of the mitral valve. The patient had a recent mitral valve replacement and presented with symptoms of heart failure that was refractory to standard medical therapy. Valvular abnormality was not seen with initial trans-thoracic echocardiogram (TTE), but with high clinical suspicion, a trans-esophageal echocardiogram (TEE) was done confirming a PVL. The patient’s condition continued to deteriorate; he became hemodynamically unstable with end-organ damage. Cardiothoracic surgery was consulted for surgical repair of the PVL. The patient, however, remained too unstable for surgery and the family opted for comfort measures per the patient’s wishes.

After kidney transplantation, fibroblast growth factor-23 (FGF-23) normally returns to baseline within 1 year whereas hyperparathyroidism persists in most kidney transplant (KT) recipients. As a result, serum phosphate remains relatively low in association with increased serum calcium and urinary phosphate excretion when compared to chronic kidney disease patients. The relationship between mineral metabolism and outcomes in long-term KT recipients has not been extensively studied. This study investigated whether the alteration in mineral metabolism influenced graft survival in long-term KT recipients.This study included 273 KT recipients after 1 year of transplantation. Mineral parameters were obtained at the time of enrolment and patients were followed prospectively for an average of 71 months.Graft loss (death-censored) occurred in 41 (15%) patients. In univariate analysis, deceased donor transplantation, decreased serum albumin and estimated glomerular filtration rate, increased serum phosphate, parathyroid hormone (PTH), FGF-23 and fractional excretion of phosphate (FePi) predicted future allograft loss. After adjustments for cardiovascular disease risk factors, donor type, dialysis vintage, serum albumin and allograft function, only increased PTH and FePi remained associated with the outcome. Relationships between increased serum phosphate and FGF-23 with graft survival were lost after adjustments. Adjusted survival curves revealed the association between PTH90 pg/mL and FePi20% with worse graft survival.Hyperparathyroidism and increased FePi predicted allograft loss in long-term KT recipients.

After successful kidney transplantation, accumulated waste products and electrolytes are excreted and regulatory hormones return to normal levels. Despite the improvement in mineral metabolites and mineral regulating hormones after kidney transplantation, abnormal bone and mineral metabolism continues to present in most patients. During the first 3 mo, fibroblast growth factor-23 (FGF-23) and parathyroid hormone levels decrease rapidly in association with an increase in 1,25-dihydroxyvitamin D production. Renal phosphate excretion resumes and serum calcium, if elevated before, returns toward normal levels. FGF-23 excess during the first 3-12 mo results in exaggerated renal phosphate loss and hypophosphatemia occurs in some patients. After 1 year, FGF-23 and serum phosphate return to normal levels but persistent hyperparathyroidism remains in some patients. The progression of vascular calcification also attenuates. High dose corticosteroid and persistent hyperparathyroidism are the most important factors influencing abnormal bone and mineral metabolism in long-term kidney transplant (KT) recipients. Bone loss occurs at a highest rate during the first 6-12 mo after transplantation. Measurement of bone mineral density is recommended in patients with estimated glomerular filtration rate > 30 mL/min. The use of active vitamin D with or without bisphosphonate is effective in preventing early post-transplant bone loss. Steroid withdrawal regimen is also beneficial in preservation of bone mass in long-term. Calcimimetic is an alternative therapy to parathyroidectomy in KT recipients with persistent hyperparathyroidism. If parathyroidectomy is required, subtotal to near total parathyroidectomy is recommended. Performing parathyroidectomy during the waiting period prior to transplantation is also preferred in patients with severe hyperparathyroidism associated with hypercalcemia.