Helmet Non-invasive Ventilation Therapy: Measurement of Comfort Behaviour

Comfort is integral towards tolerance in helmet non-invasive ventilation (NIV) therapy among acute respiratory failure (ARF) patients. This study aims to measure the patients’ comfort behaviour level after completion of helmet NIV therapy. It is a quantitative, descriptive, observational study involving 67 ARF patients. Kolcaba's Comfort Behavioural Checklist (CBC) was used, with the highest score of 120. The mean CBC score was 88.54, SD 7.35, indicating moderate comfort level; for Acute Pulmonary Oedema (APO) and non- APO, patients were 89.88, SD 7.25, and 87.08, SD 7.80 respectively. This reflects genuine patients' response towards therapy which is significant for future improvement. Keywords: Helmet Continuous Positive Airway Pressure; CPAP; Kolcaba’s Behavioural Checklist; Acute Respiratory Failure eISSN: 2398-4287© 2021. The Authors. Published for AMER ABRA cE-Bs by e-International Publishing House, Ltd., UK. This is an open access article under the CC BYNC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer–review under responsibility of AMER (Association of Malaysian Environment-Behaviour Researchers), ABRA (Association of Behavioural Researchers on Asians/Africans/Arabians) and cE-Bs (Centre for Environment-Behaviour Studies), Faculty of Architecture, Planning & Surveying, Universiti Teknologi MARA, Malaysia. DOI: https://doi.org/10.21834/ebpj.v6i18.3082

682 Cardioncology: is it time to spread the need for dedicated management?

Case report A 56-year-old man affected by micromolecular multiple myeloma was treated by several cycles of different chemotherapy drugs from September 2015 to December 2020. The chemotherapy regimen included 4-cycle first-line therapy with Bortezomib, Thalidomide, and Dexamethasone; 19-cycle second-line therapy with Carfilzomib, Revlimid, and Dexamethasone; 8-cycle third-line therapy with Daratumumab, Revlimid, and Dexamethasone; finally, he was started on therapy with Pomalidomide and Endoxan. During the various treatments, the patient did not follow a dedicated cardiological follow-up programme. In November 2020, he was hospitalized in the Intensive Care Unit for acute pulmonary oedema and subsequently discharged with a diagnosis of mild left ventricular systolic dysfunction (LVEF 50%). One month later, due to the worsening of dyspnoea, the patient was finally referred to our Cardioncology Unit for the medical assessment. The echocardiographic examination revealed a global and severe left ventricular dysfunction (FE 40%) with significant reduction in left ventricular global longitudinal strain (GLS −10%). For these reasons, we referred the patient to coronary angiography. Conclusions This case report wants to underline how important a dedicated cardiological follow-up is in patients undergoing chemotherapy drugs, especially if used at high doses and for many cycles.

37 Prognostic role of the lung ultrasound in the acute coronary syndrome

Aim Acute coronary syndromes (ACS) represent one of the major causes of mortality in our country. Lung ultrasound is an important diagnostic tool in the assessment of lung and pleural diseases; it is easy to perform and provides low-cost analysis and it is also easily learned with a few hours of training. To evaluate the usefulness of lung ultrasound in the early diagnosis of pulmonary congestion in patients admitted to ICU for ACS and to evaluate its possible prognostic role in the short and long term. Methods Forty-three patients with ACS admitted in the ICU of Foggia were enrolled in the study between April 2020 and July 2020 (mean age 64.7 ± 12.7 years, male: 67.4%). Medical history, physical examination, ECG, blood analysis, chest X-ray, lung ultrasound and echocardiography were collected at the admission in ICU, after 24 h and at the dismission. All patients were re-evaluated, through a telephone follow-up 3 months after discharge. The primary endpoints were re-hospitalization at 30 days and the following MACEs: development of acute pulmonary oedema during hospitalization, cardiogenic shock, death and the need for oxygen therapy or the use of non-invasive ventilation. The secondary endpoints were out-of-hospital death from cardiac causes and re-hospitalization after 3 months. Results The analysis of the ROC curves showed that pulmonary ultrasound performed on admission in the ICU predicted more than the thoracic physical examination [AUC 0.536 (0.367–0.699); P = 0.111], chest radiograph (AUC 0.561 (0.391–0.721); P = 0.109] and LVEF [AUC 0.525 (0.357–0.689); P = 0.119], the risk of adverse cardiovascular events hospital, although not reaching the cut-off for statistical significance [AUC 0.661 (0.489–0.806); P = 0.0895]. Among all in-hospital events, pulmonary ultrasound predicted higher sensitivity and specificity [AUC 0.665 (0.493–0.809); P = 0.0927] than chest radiography [AUC 0.588 (0.417–0.745); P = 0.113], clinical examination [AUC 0.550 (0.380–0.711); P = 0.116] and LVEF [AUC 0.515 (0.348–0.680); P = 0.125], the use of oxygen therapy and NIV during hospitalization stay. Conclusions In patients with ACS, on admission lung ultrasound predicts the risk of in-hospital events, particularly the use of oxygen therapy or non-invasive mechanical ventilation more than physical examination, chest X-ray and LVEF estimated by echocardiography. It can be considered a complementary method to echocardiography in the evaluation of cardiac function, allowing to estimate the amount of extra-vascular lung water.

Bee sting leading to stroke: a case report and review of the literature

In India, bee stings are very common, seen mainly in farmers and honey collectors. Usually, it presents with local reactions and anaphylaxis. It rarely requires urgent hospitalisation. Other major complications seen are acute renal failure, intravascular coagulation, rhabdomyolysis and acute pulmonary oedema. Stroke as a presentation is uncommon. We report a case of a 45-year-old man presenting with right-sided hemiplegia and aphasia due to multiple bee stings. Diffusion MRI showed left middle cerebral artery territory hyperacute infarct.

Safety and efficacy of a prehospital initiated protocol of nitrates plus non-invasive ventilation on prehospital and Emergency Department outcomes for acute cardiogenic pulmonary oedema

Background Acute heart failure is a common presentation to Emergency Departments (ED) the world over. Amongst the most common presenting signs and symptoms is dyspnoea due to acute pulmonary oedema, a life threatening emergency that if left untreated or poorly managed. There is increasing evidence demonstrating improved outcomes following the use of vasodilators or non invasive ventilation for these patients in the emergency setting. Consequently, the potential exists that initiating these therapies in the prehospital setting will similarly improve outcomes. Methods A historical cohort study was conducted to assess the effect of a prehospital initiated treatment protocol of nitrates plus non invasive ventilation (NIV) versus regular therapy for severe cardiogenic APO on all-cause in-hospital mortality at 7 days, 30 days, and in total. Secondary outcomes included changes in EMS respiratory and haemodynamic parameters; admission status; length of stay; and emergency endotracheal intubation. Results The intervention led to an approximate 85% reduction in adjusted odds of mortality at 7 days compared to the regular therapy (AOR 0.15, 95% CI: 0.05 to 0.46, p = 0.001); approximate 80% reduction in odds of mortality at 30 days (AOR 0.19, 95% CI: 0.07 to 48, p < 0.0001); and Approximate 60% reduction in odds of total mortality (AOR 0.25, 95% CI: 0.12 to 0.56, p = 0.001). Conclusion The results of this analysis provide strong evidence of the potential synergistic benefits that can be achieved with the early implementation of a simple treatment protocol of prehospital administered nitrates and initiation of NIV for cardiogenic APO.

Francisella philomiragia bacteremia in an immunocompromised patient: a rare case report

Background Francisella philomiragia is a very rare opportunistic pathogen of humans which causes protean diseases such as pneumonia and other systemic infections. Subsequent failure of prompt treatment may result in poor prognosis with mortality among infected patients. Case presentation The present report describes a case of F. philomiragia bacteraemia first reported in Malaysia and Asian in a 60-year-old patient with underlying end-stage renal disease (ESRF) and diabetes mellitus. He presented with Acute Pulmonary Oedema with Non-ST-Elevation Myocardial Infarction (NSTEMI) in our hospital. He was intubated in view of persistent type I respiratory failure and persistent desaturation despite post haemodialysis. Blood investigation indicated the presence of ongoing infection and inflammation. The aerobic blood culture growth of F. philomiragia was identified using the matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) mass spectrometry (Score value: 2.16) and confirmed by 16S Ribosomal DNA (16S rDNA) sequencing. He was discharged well on day 26 of admission, after completing one week of piperacillin/tazobactam and two weeks of doxycycline. Conclusion Clinical suspicion should be raised if patients with known risk factors are presenting with pneumonia or pulmonary nodules especially as these are the most common manifestations of F. philomiragia infection. Early diagnosis via accurate laboratory identification of the organism through MALDI-TOF mass spectrometry and molecular technique such as 16S rDNA sequencing are vital for prompt treatment that results in better outcomes for the afflicted patients.

Factors Associated with Prolonged Hospital Length of Stay in Adults with Imported Falciparum Malaria—An Observational Study from a Tertiary Care University Hospital in Berlin, Germany

Outcome of falciparum malaria is largely influenced by the standard of care provided, which in turn depends on the available medical resources. Worldwide, the COVID-19 pandemic has had a major impact on the availability of these resources, even in resource-rich healthcare systems such as Germany’s. The present study aimed to determine the under-explored factors associated with hospital length of stay (LOS) in imported falciparum malaria to identify potential targets for improving management. This retrospective observational study used multivariate Cox proportional hazard regression with time to discharge as an endpoint for adults hospitalized between 2001 and 2015 with imported falciparum malaria in the Charité University Hospital, Berlin. The median LOS of the 535 cases enrolled was 3 days (inter-quartile range, IQR, 3–4 days). The likelihood of being discharged by day 3 strongly decreased with severe malaria (hazard ratio, HR, 0.274; 95% Confidence interval, 95%CI: 0.190–0.396) and by 40% with each additional presenting complication (HR, 0.595; 95%CI: 0.510–0.694). The 55 (10.3%) severe cases required a median LOS of 7 days (IQR, 5–12 days). In multivariate analysis, occurrence of shock (adjusted HR, aHR, 0.438; 95%CI 0.220–0.873), acute pulmonary oedema or acute respiratory distress syndrome (aHR, 0.450; 95%CI: 0.223–0.874), and the need for renal replacement therapy (aHR, 0.170; 95%CI: 0.063–0.461) were independently associated with LOS. All patients survived to discharge. This study illustrates that favourable outcomes can be achieved with high-standard care in imported falciparum malaria. Early recognition of disease severity together with targeted supportive care can lead to avoidance of manifest organ failure, thereby potentially decreasing LOS and alleviating pressure on bed capacities.

1313 Unusual Supraannular Aortic Root Intimal Tear in a Patient with Severe Aortic Regurgitation

We present an extremely rare case of occult supraannular aortic root intimal tear in a patient presenting with acute severe aortic regurgitation (AR) and a previously undiagnosed bicuspid aortic valve. A 41-year-old Africo-Carribean female presented to the emergency department with acute pulmonary oedema and increasing dyspnea on exertion. She had been treated empirically with antibiotics for a chest infection. Initial concerns were either aortic dissection or infective endocarditis. Transthoracic echocardiography (TTE) demonstrated a normal size left ventricle with hyperdynamic systolic function and severe AR. The patient was transferred to a tertiary cardiothoracic surgical centre for urgent surgical treatment in view of haemodynamic instability and acute AR. A gated computed tomography aortogram identified pulmonary oedema with an asymmetrically dilated aortic root (maximal diameter 45 mm). Despite advanced multimodality preoperative imaging, diagnosis was made intraoperatively and prompted Bentall procedure with mechanical aortic valve. After median sternotomy and initiation of cardiopulmonary bypass, a supraannular aortic intimal tear starting from the right coronary cusp/noncoronary cusp commissure was found with no extension into the aorta. The aortic valve was bicuspid and severe AR not amenable to repair was found. Bentall procedure was performed using the 23/26mm Carbomedics Carbo Seal Valsalva composite graft (Sulzer Carbomedics Inc, Austin, TX, USA). The patient was discharged on the 7th postoperative day in sinus rhythm. At 30-day clinical follow-up she was symptom free with a satisfactory TTE.

A life-threatening case of pseudo-aldosteronism secondary to excessive liquorice ingestion

Background Liquorice is found in many food products, soft drinks, and herbal medicines. Liquorice ingestion is an uncommon cause of apparent mineralocorticoid excess or pseudo-aldosteronism. The mechanism involves the inhibition of 11-beta-hydroxysteroid dehydrogenase type-2 by the active ingredient called glycyrrhizin. This leads to the uninhibited activation of mineralocorticoid receptors by cortisol. Confectionary products that contain liquorice are readily available in many countries around the world. Case presentation We report a case of severe refractory hypokalaemia with hypertensive crisis and acute pulmonary oedema due to excessive liquorice consumption. A 79-year-old female presented to the emergency department following a road traffic accident. She described feeling weak and dizzy while driving before the collision. She attended her general practitioner (GP) several weeks earlier for fatigue and was being managed for hypokalaemia on oral potassium supplements. Investigations revealed hypertension (BP 180/69 mmHg), severe hypokalaemia (K 2.2 mmol/l), normal renal function, normal serum magnesium with metabolic alkalosis. Spot urinary potassium was 22 mmol/l. The patient denied taking medications including over-the-counter or herbal medication that can cause hypokalaemia. Hypokalaemia persisted despite aggressive intravenous (i.v.) and oral potassium replacement. She later developed a hypertensive crisis (BP 239/114 mmHg) with pulmonary oedema. She required admission to the intensive care unit and was managed with intravenous furosemide infusion and isosorbide dinitrate infusion. On further discussion, our patient admitted to struggling with nicotine cravings since quitting smoking two months earlier. She began eating an excessive amount of liquorice sweets to manage her cravings. Suppression of plasma renin and aldosterone supported the diagnosis of apparent mineralocorticoid excess secondary to excessive liquorice consumption. Her symptoms and hypokalaemia resolved after stopping liquorice intake. Conclusions This case highlights the life-threatening and refractory nature of hypokalaemia secondary to excessive liquorice consumption. This case also emphasizes the importance of comprehensive history taking including dietary habits. Increased awareness among the public is required regarding the potential health hazards of excessive liquorice consumption.