Empagliflozin, a sodium-glucose transporter 2 inhibitor, has been shown to bind to late sodium channels in mice cardiomyocytes. We sought to investigate the electrocardiographic (ECG) features associated with empagliflozin use in patients with diabetes mellitus. We compared ECG features of 101 patients before and after initiation of empagliflozin and found that empagliflozin was associated with a significant increase in QRS duration among diabetes patients with heart failure.

Background Sepsis is marked by elevated histamine, which is a vasodilator that increases vascular permeability. Although human studies are lacking, murine models of sepsis have indicated potential protective effects of histamine 2 receptor antagonist administration (H2RAs). Objective To assess any association between H2RA use in sepsis-3 patients admitted to the ICU and mortality, mechanical ventilation, length of stay, and markers of renal, liver, and lung dysfunction. Design Retrospective cohort study. Setting Intensive care units of the Beth Israel Deaconess Medical Center (BIDMC) accessed via the MIMIC-IV database spanning an 11-year period from 2008 to 2019. Patients (or participants) A total of 30,591 patients met the inclusion criteria for sepsis-3 on admission (mean age 66.49, standard deviation 15.92). Main measures We collected patient age, gender, ethnicity, comorbidities (contained within the Charlson comorbidity index), SOFA score, OASIS score, APS III score, SAPS II score, H2RA use, creatinine, BUN, ALT, AST, and P/F ratios. Primary outcomes were mortality, mechanical ventilation, and ICU length of stay. Key results A total of 30,591 patients met inclusion criteria over the 11-year sample period. The 28-day in hospital mortality rate was significantly lower among patients who received an H2RA (12.6% vs 15.1%, p < 0.001) as compared to those who did not receive an H2RA. Patients receiving an H2RA had significantly lower adjusted odds of mortality (0.802, 95% CI 0.741–0.869, p < 0.001), but significantly higher adjusted odds of invasive mechanical ventilation (4.426, 95% CI 4.132–4.741, p < 0.001) and significantly higher ICU LOS (3.2 days vs. 2.4 days, p < 0.001) as compared to the non-H2RA group. H2RA use was also associated with decreased severity of acute respiratory distress syndrome (ARDS) and lower serum creatinine. Conclusion Among patients hospitalized in the ICU for sepsis, the use of an H2RA was associated with significantly lower odds of mortality, decreased severity of ARDS, and a lower incidence of renal insufficiency.

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Acute encephalopathy with an unclear etiology is a common presentation to the hospital. We describe the case of a 50-year-old male who presented with a one-day history of slurred speech, nausea, insomnia, and altered mental status. His surgical history was notable for a strabismus surgery two days ago. He presented with elevated ammonia levels that continued to increase. Metabolic studies were suggestive of hyperammonemia secondary to ornithine transcarbamylase (OTC) deficiency triggered due to fasting prior to the strabismus surgery. OTC gene sequencing confirmed the diagnosis of OTC deficiency. We summarize the current case reports in the literature and review the treatment options for OTC deficiency. Our case occurred after a low-risk outpatient strabismus surgery and is a good example of maintaining a broad differential and revising the suspected diagnosis constantly.

Acute respiratory distress syndrome (ARDS) is a severe complication of coronavirus disease 2019 (COVID-19) infection marked by increased fluid diffusely in alveolar spaces. The management of ARDS can be complicated by mechanical hyperinflation, and thus a mainstay of treatment has included low tidal volume mechanical ventilation. This, however, can lead to ventilation-associated hypercapnia, which may result in respiratory acidosis. COVID-19-associated ARDS (CARDs) has been described in the literature, and guidelines tend to mimic ARDS management. However, the heterogeneous nature of COVID-19 pulmonary disease with respect to dead space, compliance, and shunting could alter guidelines. As low tidal volume remains a cornerstone in CARDS management, hypercapnic acidosis remains a risk. An emerging technology, extracorporeal CO2 removal devices (ECCO2R), has been granted emergency use authorization by the FDA for the management of CARDS. We present a 44-year-old male patient presenting positive for COVID-19. Following admission, the patient's oxygen status continually deteriorated and the patient went into acute respiratory distress, eventually requiring invasive mechanical ventilation. The patient became hypercapnic and acidotic due to low tidal volume ventilation. ECCO2R was used to manage the patient's hypercapnia, resulting in significant amelioration of his partial pressure of carbon dioxide (PCO2) and pH. The patient was eventually transferred to extracorporeal membrane oxygenation (ECMO) certified facility and survived after a prolonged hospital and rehabilitation course. In the management of CARDS patients who require mechanical respiration, there are many unanswered questions as to the appropriate ventilation strategy. Current practice recommends low tidal volume ventilation, carrying, and increased risk of hypercapnic respiratory acidosis as occurred in our patient. We believe that ECCO2R may be an appropriate bridge between low tidal volume ventilation and ECMO to stabilize acid-base disturbances in ventilated patients.