Background The clinical features and outcomes of mechanically ventilated patients with COVID-19 infection who develop a pneumothorax has not been rigorously described or compared to those who do not develop a pneumothorax. Purpose To determine the incidence, clinical characteristics, and outcomes of critically ill patients with COVID-19 infection who developed pneumothorax. In addition, we compared the clinical characteristics and outcomes of mechanically ventilated patients who developed a pneumothorax with those who did not develop a pneumothorax. Methods This study was a multicenter retrospective analysis of all adult critically ill patients with COVID-19 infection who were admitted to intensive care units in 4 tertiary care centers in the United States. Results A total of 842 critically ill patients with COVID-19 infection were analyzed, out of which 594 (71%) were mechanically ventilated. The overall incidence of pneumothorax was 83/842 (10%), and 80/594 (13%) in those who were mechanically ventilated. As compared to mechanically ventilated patients in the non-pneumothorax group, mechanically ventilated patients in the pneumothorax group had worse respiratory parameters at the time of intubation (mean PaO 2 :FiO 2 ratio 105 vs 150, P<0.001 and static respiratory system compliance: 30ml/cmH 2 O vs 39ml/cmH 2 O, P=0.01) and significantly higher in-hospital mortality (63% vs 49%, P=0.04). Conclusion The overall incidence of pneumothorax mechanically ventilated patients with COVID-19 infection was 13%. Mechanically ventilated patients with COVID-19 infection who developed pneumothorax had worse gas exchange and respiratory mechanics at the time of intubation and had a higher mortality compared to those who did not develop pneumothorax.

Background Secondary pulmonary infections (SPI) have not been well described in COVID-19 patients. Our study aims to examine the incidence and risk factors of SPI in hospitalized COVID-19 patients with pneumonia. Methods This was a retrospective, single-center study of adult COVID-19 patients with radiographic evidence of pneumonia admitted to a regional tertiary care hospital. SPI was defined as microorganisms identified on the respiratory tract with or without concurrent positive blood culture results for the same microorganism obtained at least 48 hours after admission. Results Thirteen out of 244 (5%) had developed SPI during hospitalization. The median of the nadir lymphocyte count during hospitalization was significantly lower in patients with SPI as compared to those without SPI [0.4 K/uL (IQR 0.3-0.5) versus 0.6 K/uL (IQR 0.3-0.9)]. Patients with lower nadir lymphocyte had an increased risk of developing SPI with odds ratio (OR) of 1.21 (95% CI: 1.00 to 1.47, p=0.04) per 0.1 K/uL decrement in nadir lymphocyte. The baseline median inflammatory markers of CRP [166.4 mg/L vs. 100.0 mg/L, p=0.01] and D-dimer (18.5 mg/L vs. 1.4 mg/L, p<0.01), and peak procalcitonin (1.4 ng/mL vs. 0.3 ng/mL, p<0.01) and CRP (273.5 mg/L vs. 153.7 mg/L, p<0.01) during hospitalization were significantly higher in SPI group. Conclusions The incidence of SPI in hospitalized COVID-19 patients was 5%. Lower nadir median lymphocyte count during hospitalization was associated with an increased OR of developing SPI. The CRP and D-dimer levels on admission, and peak procalcitonin and CRP levels during hospitalization were higher in patients with SPI.

Fat embolism syndrome (FES) is a rare complication of long bone fractures with an incidence of 0.3%–1.3%. FES most commonly presents within 72 hours of injury but may develop as late as 10 days following a fracture. FES is rarely associated with elective orthopaedic procedures. In this case report, we describe a patient who developed FES 9 days after an elective left total hip arthroplasty. Presentation far outside of the typical 72-hour window for FES, the diagnosis was initially missed. The patient initially presented to our emergency room on postoperative day 14 with 5 days of dyspnoea and was diagnosed with pneumonia and sent home on antibiotics. Sixteen days following this ED admission and on postoperative day 30, she remained dyspneic and was found to be hypoxic to 74% on room air. CT angiography at this time found bilateral diffuse ground glass opacities. Bronchoalveolar lavage was notable for lipid-laden macrophages, and FES was subsequently diagnosed.

Introduction: Patients with decreased LV ejection fraction (LVEF) presenting with elevated troponin incur high in-patient and follow-up mortality. Despite guidelines, testing for CAD and guideline-directed therapy in such patients has not been consistently utilized. To better understand this issue, we investigated hospital practice patterns in this vulnerable population. Methods: We conducted a tertiary single-center study of consecutive in-patients with abnormal troponin results on testing performed for clinical indications as requested by the treating physician. The study cohort included 432 patients, 67 +/- 14 years old with HTN in 75%, DM in 38%, smoking in 51%, dyslipidemia in 64%, family history of CAD in 28% and personal history of CAD or equivalent in 46%. Among them, 412 patients underwent echocardiographic LVEF assessment. Patients were then stratified according to the LVEF. The use of both ischemic evaluation and evidence-based medical therapy were compared. Hospital and long-term outcomes were analyzed. Results: Hospital mortality was 51/432 (11.8%) and during 28.1+/-13.8 months of follow-up additional 82/432 (18.9%) patients expired. Ischemia evaluation (both cardiac catheterization and non-invasive) was underutilized across all subgroups, including patients with decreased LVEF. Regarding guideline-directed medical therapy, only beta-blocker therapy was consistently utilized. Afterload reduction therapies such as angiotensin convertase enzyme inhibitors, angiotensin II receptor blockers, neprilysin inhibitors, hydralazine and nitrates were significantly underutilized. Statins and mineralocorticoid receptor blockers were also significantly underused (Table). Conclusions: Despite increased mortality, there continues to be room for improvement in the utilization of diagnostic evaluation and application of evidence-based therapy and in patients admitted with elevated cardiac biomarkers.

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