Bacterial Pericarditis Caused by Penetration of a Migrated Biliary Stent from the Lateral Segment of the Liver: A Case Report

Endoscopic biliary stent insertion is a well-established procedure that is indispensable in the management of various benign and malignant biliary disorders, and one that helps prevent mortality related to invasive surgical procedures. We report a rare case of the distal migration of a biliary stent outside the abdomen to the pericardium, inducing constrictive pericarditis and septic shock. This case alerts clinicians to be aware of potential adverse events that can lead to unfavorable patient outcomes. Such adverse events can be effectively avoided through early detection and intervention.

Noninvasive respiratory support for COVID-19 patients: when, for whom, and how?

The significant mortality rate and prolonged ventilator days associated with invasive mechanical ventilation (IMV) in patients with severe COVID-19 have incited a debate surrounding the use of noninvasive respiratory support (NIRS) (i.e., HFNC, CPAP, NIV) as a potential treatment strategy. Central to this debate is the role of NIRS in preventing intubation in patients with mild respiratory disease and the potential beneficial effects on both patient outcome and resource utilization. However, there remains valid concern that use of NIRS may prolong time to intubation and lung protective ventilation in patients with more advanced disease, thereby worsening respiratory mechanics via self-inflicted lung injury. In addition, the risk of aerosolization with the use of NIRS has the potential to increase healthcare worker (HCW) exposure to the virus. We review the existing literature with a focus on rationale, patient selection and outcomes associated with the use of NIRS in COVID-19 and prior pandemics, as well as in patients with acute respiratory failure due to different etiologies (i.e., COPD, cardiogenic pulmonary edema, etc.) to understand the potential role of NIRS in COVID-19 patients. Based on this analysis we suggest an algorithm for NIRS in COVID-19 patients which includes indications and contraindications for use, monitoring recommendations, systems-based practices to reduce HCW exposure, and predictors of NIRS failure. We also discuss future research priorities for addressing unanswered questions regarding NIRS use in COVID-19 with the goal of improving patient outcomes.

What underlies the observed hospital volume-outcome relationship?

Background Studies of the hospital volume-outcome relationship have highlighted that a greater volume activity improves patient outcomes. While this finding has been known for years, most studies to date have failed to delve into what underlies this relationship. Objective This study aimed to shed light on the basis of the hospital volume effect on patient outcomes by comparing treatment modalities for epithelial ovarian carcinoma patients. Data An exhaustive dataset of 355 patients in first-line treatment for Epithelial Ovarian Carcinoma (EOC) in 2012 in three regions of France was used. These regions account for 15% of the metropolitan French population. Methods In the presence of endogeneity induced by a reverse causality between hospital volume and patient outcomes, we used an instrumental variable approach. Hospital volume of activity was instrumented by the distance from patients’ homes to their hospital, the population density, and the median net income of patient municipalities. Results Based on our parameter estimates, we found that the rate of complete tumor resection would increase by 15.5 percentage points with centralized care, and by 8.3 percentage points if treatment decisions were coordinated by high-volume centers compared to decentralized care. Conclusion As volume alone is an imperfect correlate of quality, policy-makers need to know what volume is a proxy for in order to devise volume-based policies.

Expert Opinions on the Debate of Pericardial Reconstruction in Cardiovascular Surgery: To Close or Not to Close?

Background: As of 2019, pericardial closure was performed in only a small portion of the over 320,000 cardiac surgeries performed annually. However, evidence regarding the benefits of pericardial closure or reconstruction has been accruing, particularly with the publication of the RECON study in 2019. Methods: This group of authors convened to try to arrive at consensus expert opinion regarding pericardial reconstruction. Structured topic questions initially were used to stimulate discussion. Subsequently, a survey of proposed expert opinion statements was conducted among the authors. Based on that survey, consensus expert opinion statements and recommendations were compiled. Results: The expert opinions encompass various topics relating to pericardial reconstruction, including definitions, benefits/risks, and technique. Observed benefits include reductions in: (1) adhesions; (2) postoperative pericardial effusion, atrial fibrillation, and bleeding; and (3) readmissions and length of hospital stay. Expert opinion recommendations regarding surgical technique are compiled into a single chart. Complete pericardial reconstruction should be performed, using native pericardial tissue if available and viable; if not feasible, a patch may be used. Patches that stimulate the formation of site-specific tissue in situ (such as natural extracellular matrix) may have additional benefits (including bioregenerative properties and lack of inflammatory response). Closure should be taut, but tension-free. Adequate drainage of the closed pericardium must be ensured. Conclusions: Based on available data and collective surgical experience, we endorse pericardial reconstruction as standard approach in appropriately selected patients. We also endorse adoption of standardized pericardial reconstruction techniques to optimize patient outcomes and improve evidence quality in future studies.

Chest Radiographic Findings in High-risk Covid-19 Pneumonia Patients

Background/ objectivesThe severity of Covid-19 pneumonia has shown a positive association with co-existing risk factors. However, the exact nature of lung involvement in high-risk Covid-19 patients is yet to be resolved. Therefore, we evaluated the CXR features, temporal progression, and the factors associated with CXR severity in high-risk patients.MethodsChest X-rays (n=289) of Covid-19 infected high-risk adults (n=228) treated at the Base Hospital Homagama were evaluated to record CXR features, their temporal progression, CXR severity score and the patient outcomes. ResultsThe studies patients (48.2% men) were in mean age(SD) of 59(15) years. The most frequent CXR features were patchy ground-glass opacities (49%; GG) and patchy consolidations (42%; CON). They showed bilateral (100%) involvement, superoinferior gradient (100%) and diffuse (27%), peripheral (18%) or perihilar (10%) distribution. CON was the predominant opacity among the non-survivors and GG among the survivors (χ2=14.73; p=0.001). Right lung predominant (28%) asymmetrical lung involvement was more frequent than bilateral symmetrical (16%) or left lung predominance (7%). Progression into fatal disease was significantly higher when the lung involvement is asymmetrical: right predominance: ODDs:0.502; p=0.023; left predominance: ODDs:0.268; p=0.002. The CXRs were frequently normal in early (66%) and progressive (56%; χ2=36.64; p<0.001) stages than in peak or resolving stages. The predictors of CXR severity included age (β:0.140; 95% CI:0.041–0.233; p=0.004), male gender (β:4.140; 95% CI:1.452–6.481; p=0.003), and disease day (β:0.622; 95% CI:0.301–0.942; p<0.001). ConclusionThis study decoded the CXR features of Covid-19 pneumonia in a high-risk cohort while describing their associations.