BACKGROUND In this study, we examined the association between 25-hydroxyvitamin D (25(OH)D) concentration and successful weaning from mechanical ventilation in a cohort of ICU survivors requiring prolonged mechanical ventilation. METHODS This was a retrospective cohort study of ICU survivors admitted to a long-term acute care hospital. Demographic data were extracted from medical records, including 25(OH)D concentrations drawn on admission. Subjects were divided into 2 groups based on their 25(OH)D concentrations (deficient, < 20 ng/mL; not deficient, ≥ 20 ng/mL), and associations between 25(OH)D concentration and successful weaning were calculated. RESULTS A total of 183 subjects were studied. A high prevalence of 25(OH)D deficiency was found (61%, 111/183). No association was found between 25(OH)D concentration and weaning from mechanical ventilation. Increased comorbidity burden (Charlson comorbidity index) was associated with decreased odds of weaning (odds ratio of 0.50, 95% CI 0.25– 0.99, P = .05). CONCLUSIONS Vitamin D deficiency is common in ICU survivors requiring prolonged mechanical ventilation. Surprisingly, there was no significant relationship between 25(OH)D concentration and successful weaning. This finding may be due to the low 25(OH)D concentrations seen in our subjects. Given what is known about vitamin D and lung function and given the low vitamin D concentrations seen in patients requiring long-term ventilatory support, interventional studies assessing the effects of 25(OH)D supplementation in these patients are needed.

Constrictive Bronchiolitis (CB) has been reported in US Operation Iraqi Freedom/Enduring Freedom (OIF/OEF) deployers but not in those from prior US conflicts. A 62-year old presented with progressive dyspnea 13 years after deployment to the Persian Gulf in 1991-1992, where he was exposed to burning oil well fire emissions, dust storms, and other potential airborne hazards. In 2014, after a chest computed tomography (CT) scan demonstrated diffuse mosaic attenuation, he underwent surgical lung biopsy, which revealed CB. Deployers from both GWI and OIF/OEF share many exposures. As respiratory symptoms are a feature associated with Gulf War medically unexplained illness, there may be a role for renewed interest in evaluating GWI Veterans with unexplained respiratory symptoms for conditions such as CB, which may result from exposures relevant to deployers from both conflicts.

A 25-year-old woman with a history of systemic lupus erythematosus who was taking steroids came to the hospital because of vague signs and symptoms of weight loss, constipation, and oral ulcers. Multiorgan dysfunction developed, and catastrophic antiphospholipid syndrome was suspected. She was treated with an intravenous infusion of heparin, but she experienced a subdural hemorrhage and died on day 10 of the hospitalization. An autopsy revealed disseminated invasive aspergillosis. This case illustrates that invasive aspergillosis is a frequently missed diagnosis and should be part of the differential diagnosis for any patient who is immunosuppressed, including patients with autoimmune diseases such as systemic lupus erythematosus. (American Journal of Critical Care. 2013;22:448-451)

SUMMARYNovel anticoagulants are increasingly utilised in lieu of warfarin to treat non-valvular atrial fibrillation. Their clinical use in other non-FDA approved settings is also increasing. We present a case in which a patient abruptly stopped taking dabigatran due to a small bowel obstruction and shortly thereafter suffered a myocardial infarction complicated by left ventricular thrombosis with fatal embolisation to the superior mesenteric artery. In this context, we discuss the possibility of a rebound phenomenon of hypercoagulability with abrupt cessation of novel anticoagulants. BACKGROUND

A 62-year-old woman treated with several courses of corticosteroids for an undifferentiated rash came to the emergency department with progressively worsening cutaneous signs and symptoms and generalized weakness. She had scabies, and despite treatment continued to decompensate. Repeat skin biopsies revealed disseminated herpes simplex virus infection, and results of blood cultures were consistent with infection by methicillin-resistant Staphylococcus aureus. Despite antiviral and antimicrobial therapy, sepsis and multiorgan failure developed, and the patient died. This case illustrates the complications of the rare entity eczema herpeticum, which occurs most often in immunocompromised patients and is associated with a high mortality. Maintaining a high index of suspicion for this disease in decompensating patients with an unidentified rash is essential to avoid catastrophic outcomes. (American Journal of Critical Care. 2016;25:379-382 M any life-threatening diseases initially have seemingly innocuous dermatological findings, and subtle abnormalities may only be evident to an astute clinician considering a broad range of potential diagnoses. Although chronic skin conditions, such as atopic dermatitis, are common and are relatively benign, severe complications can occur. For example, eczema herpeticum is a cutaneous dissemination of herpes simplex virus (HSV) in patients with a chronic skin condition, most commonly atopic dermatitis. Because of the rare occurrence and difficult diagnosis, the true incidence and prevalence of eczema herpeticum are unknown, although the condition is thought to affect 3% to 6% of patients with atopic dermatitis.1 Even though eczema herpeticum is exceedingly rare, 6% to 10% of immunocompetent hosts and up to 50% of immunocompromised patients can die of the viremia, multiorgan involvement, and bacterial superinfection potentially associated with it. highlights an important condition to consider in both critical care and primary care assessment of a patient with an undiagnosed rash.A 62-year-old woman with a history of mild mental retardation, diabetes, hypertension, and hypothyroidism who was living in a group home came to the emergency department with a rash and generalized weakness. She had intermittently experienced a pruritic, generalized rash for approximately 1 year before she came to the hospital. Her caregivers at the group home had taken her to the primary care doctor for the workup of this rash throughout the year. The results of an outpatient skin biopsy were consistent with a drug eruption, thus prompting her primary care physician to have her stop taking hydrochlorothiazide and sitagliptin. Despite this step, the rash did not resolve.The patient had an empiric trial of prednisone, which resulted in temporary resolution of the rash.However, whenever prednisone was discontinued, the rash would promptly reappear. The patient received repeated short courses of steroids (< 7 days each) throughout the year. Despite the prednisone therapy, during the week before she ca...