The Efficacy of Bamlanivimab in Reducing Emergency Department Visits and Hospitalizations in a Real-world Setting

Bamlanivimab, a monoclonal antibody targeting the spike protein of severe acute respiratory syndrome coronavirus 2, is available for ambulatory treatment of coronavirus disease 2019 (COVID-19). This real-world study confirms the efficacy of bamlanivimab in reducing hospital admissions and emergency department visits among high-risk outpatients with mild to moderate COVID-19 illness and reveals a trend toward improved mortality.

Falling Through the Cracks: The Need to Include Acute Pancreatitis in Risk Assessment Models for Acute Deep Venous Thrombosis

Acute pancreatitis is an inflammatory condition caused by an insult to the pancreas. Pancreatitis is associated with local and systemic complications such as splenic vein thrombosis and systemic inflammatory response syndromes (SIRS), respectively. Pancreatitis increases the risk of deep vein thrombosis (DVT) through a combination of increased production of pro-inflammatory cytokines and systemic vascular injury. However, DVT and pulmonary embolism remain under-recognized and underappreciated complications of acute pancreatitis as they fall through the cracks in the commonly used venous thromboembolism (VTE) risk assessment model. We therefore propose that VTE prophylaxis needs to be considered by all clinicians when admitting and evaluating patients with acute pancreatitis and that acute pancreatitis needs to be included on the various VTE risk assessment calculators as it is a significant risk factor for the development of VTE.

Bradycardia in Patients With COVID-19: A Calm Before the Storm?

Cardiac manifestations of coronavirus disease 19 (COVID-19), including arrhythmia, have been described in the literature. However, to our knowledge, association of COVID-19 with bradycardia has not been reported. This case study describes sinus bradycardia as a potential manifestation of COVID-19.

This is a retrospective case series of four patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, admitted to St. Luke’s University Health Network ICU between 24 March 2020 and 5 April 2020. Medical records of these patients were reviewed using the EPIC electronic health record system. Demographic, clinical, laboratory, and treatment data were reviewed against periods of bradycardia in each patient.

The patient group comprised two males and two females. Two patients had pre-existing cardiovascular (CV) comorbidities but no history of arrythmias. Heart rates ranged between 66 and 88 beats/min on admission. The lowest rates during bradycardia were between 42 and 49 beats/min. The onset of sinus bradycardia in patients 1, 2, and 3 were day nine, 15, and five of illness, respectively. Patient 4 had three episodes of bradycardia, starting on day 10 of illness. Patients’ bradycardia episodes lasted one to 14 days. During bradycardia, maximum body temperatures ranged between 99.9 and 100.2 degree Fahrenheit. Patients 2, 3, and 4 required vasopressors to maintain mean arterial pressure > 65 mmHg during episodes. All four patients were on propofol at some point during bradycardia with patients 1, 2, and 3 also receiving dexmedetomidine. There was no consistent correlation of these medications with bradycardia. Electrocardiogram (ECG) findings included sinus bradycardia. Prolonged QTc interval observed in patient 2 on admission improved during bradycardia.

Transient sinus bradycardia is a possible manifestation of COVID-19 and is important for close CV surveillance. Etiology can be multifactorial, but severe hypoxia, inflammatory damage of cardiac pacemaker cells, and exaggerated response to medications are possible triggers. High levels of pro-inflammatory cytokines may act directly on the sinoatrial (SA) node contributing to the development of bradycardia. This may be a warning sign of the onset of a serious cytokine storm. An increased awareness of possible exaggerated bradycardia response is important to consider with the use of empiric medications which have arrhythmogenic effects.

Lymphoproliferative disorder in a lung transplant recipient

Post-transplantation lymphoproliferative disorder (PTLD) is uncommon following solid organ transplantation. We present a case of PTLD presenting as hematochezia and abdominal pain in a 66-year-old man, who had undergone bilateral lung transplantation with alemtuzumab induction 7 months prior to presentation. The transplant serologic status was "high-risk" for the presence of both Epstein-Barr virus (EBV) serologies in the donor and negative serologies in the recipient. Biopsies taken during colonoscopy stained strongly positive for EBV-encoded RNA. Mediastinal lymph node biopsies also showed atypical, EBV-positive lymphohistiocytic infiltration with focal necrosis. The patient's hospital course was complicated by treatment side effects, most notably bowel perforation following rituximab. In this case report the topic of PTLD is reviewed and consideration is given to whether alemtuzumab induction may have contributed to the patient's development of PTLD.

Learned helplessness among families and surrogate decision-makers of patients admitted to medical, surgical, and trauma ICUs

BACKGROUND

We sought to determine the prevalence of and clinical variables associated with learned helplessness, a psychologic state characterized by reduced motivation, difficulty in determining causality, and depression, in family members of patients admitted to ICUs.

METHODS

We conducted an observational survey study of a prospectively defined cohort of family members, spouses, and partners of patients admitted to surgical, medical, and trauma ICUs at a large academic medical center. Two validated instruments, the Learned Helplessness Scale and the Perceived Stress Scale, were used, and self-report of patient clinical characteristics and subject demographics were collected.

RESULTS

Four hundred ninety-nine family members were assessed. Of these, 238 of 460 (51.7%) had responses consistent with a significant degree of learned helplessness. Among surrogate decision-makers, this proportion was 50% (92 of 184). Characteristics associated with significant learned helplessness included grade or high school education (OR, 3.27; 95% CI, 1.29-8.27; P = .01) and Perceived Stress Scale score > 18 (OR, 4.15; 95% CI, 2.65-6.50; P < .001). The presence of a patient advance directive or do not resuscitate (DNR) order was associated with reduced odds of significant learned helplessness (OR, 0.56; 95% CI, 0.32-0.98; P = .05).

CONCLUSIONS

The majority of family members of patients in the ICU experience significant learned helplessness. Risk factors for learned helplessness include lower educational levels, absence of an advance directive or DNR order, and higher stress levels among family members. Significant learned helplessness in family members may have negative implications in the collaborative decision-making process.

Weight and length increases in children after gastrostomy placement

OBJECTIVE

To document catch-up growth in children in the first 18 months after gastrostomy surgery and characterize how weight and length growth differ according to medical and nutritional risks.

DESIGN

Repeated measures study to evaluate weight and linear growth in gastrostomy-fed children.

SUBJECTS/SETTING

Seventy-five subject met the selection criteria; gastrostomy placement anytime from birth to age 6.5 years, diagnosis of failure to thrive before gastrostomy. surgery, absence of nonmedical barriers to adequate nutrition. Children were seen in specialty outpatient clinics.

OUTCOME MEASURES

Three measurements of weight and length: at the time of surgery and 12 and 18 months after surgery.

STATISTICAL ANALYSES

Paired t tests of z scores were used to determine catch-up growth. Analysis of variance used variables (age of placement, ambulatory status, prematurity, mode of feeding) to determine statistically significant predictors of growth.

RESULTS

After gastrostomy surgery, catch-up growth was observed in height and weight for children regardless of prematurity or age at the time of gastrostomy placement. Ambulatory children did not achieve catch-up growth, but nonambulatory children did. At 18 months after surgery, catch-up growth occurred in children whose sole source of nutrition was through occurred in children whose sole source of nutrition was through the gastrostomy, as well as in those who were able to receive nutrition by mouth. Children with a diagnosis of cerebral palsy experienced better growth than children with other diagnoses. CONCLUSION/APPLICATION: Failure to thrive in children up to age 6.6 years can be corrected when adequate nutrition is provided. Benefits of gastrostomy surgery observed in catch-up growth reinforce the importance of medical nutrition therapy.