Haddad, Toufik Mahfood

Introduction: Intracranial hemorrhage (ICH) is associated with high mortality rate of 30-52% despite current advances in management. New cardiovascular abnormalities (CA), such as EKG or cardiac biomarker abnormalities ensue in ICH and are postulated to be due to hypothalamic injury and catecholamine surge. These CA are thought to portend a poor prognosis. Methods: We evaluated clinical studies reporting CA in ICH and assessing their effect on mortality. Studies without a control group, pediatric, and non-English literature were excluded. We extracted data on demographics, comorbidities and mortality [in-hospital (IHM), 30 day (30M) and 90 day (90M)]. CA data included EKG changes (bradycardia, atrial fibrillation, bundle branch blocks, QTc prolongation, ST-segment depression, and ST-segment elevation), biomarker elevation (troponin-T (TnT), CK-MB and BNP), and wall motion abnormalities (WMA). Unadjusted and adjusted rates for CA and pooled risk ratio (RR) with 95% CI were calculated using Mantel-Haenszel random effects model for mortality. Results: We reviewed 453 studies, of which 26 met our inclusion criteria. Heterogeneity varied from moderate to severe depending on the outcome chosen. Of a total 5580 patients, 2796 (50.1%) had sub-arachnoid hemorrhage (SAH), 1633 ICH (29.3%) and 1151 (20.6%) both. The incidence of CA is presented in Table 1. Of these 26 studies, 19 evaluated the influence of new CA on mortality. IHM was noted in 175/566 (30.9%) and 491/2496 (19.7%) patients with and without CA, respectively. In addition, 30M and 90M were noted in 18/38 (47.4%) vs. 14/136 (10.3%) and 90/175 (51.4%) vs. 247/1139 (21.7%) patients with and without CA, respectively. CA was associated with worse IHM (RR 2.03, 95% CI 1.58-2.62, p<0.001), 30M (RR 3.18, 95% CI 1.86-5.42, p<0.001) and 90M (RR 2.11, 95% CI 1.44-3.08, p<0.001) in patients with ICH compared to those who did not have CA. Conclusion: CA are common in patients with ICH and are associated with worse IHM, 30M and 90M.

Background: The role of B-type natriuretic peptide (BNP) is less understood in the risk stratification of patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), especially in patients with normal left ventricular ejection fraction (LVEF). Methods: This retrospective study from 2008 to 2012 evaluated all adult patients with AECOPD having BNP levels and available echocardiographic data demonstrating LVEF ≥40%. The patients were divided into groups 1, 2, and 3 with BNP ≤ 100, 101 to 500, and ≥501 pg/mL, respectively. A subgroup analysis was performed for patients without renal dysfunction. Outcomes included need for and duration of noninvasive ventilation (NIV) and mechanical ventilation (MV), NIV failure, reintubation at 48 hours, intensive care unit (ICU) and total length of stay (LOS), and in-hospital mortality. Two-tailed P < .05 was considered statistically significant. Results: Of the total 1145 patients, 550 (48.0%) met our inclusion criteria (age 65.1 ± 12.2 years; 271 [49.3%] males). Groups 1, 2, and 3 had 214, 216, and 120 patients each, respectively, with higher comorbidities and worse biventricular function in higher categories. Higher BNP values were associated with higher MV use, NIV failure, MV duration, and ICU and total LOS. On multivariate analysis, BNP was an independent predictor of higher NIV and MV use, NIV failure, NIV and MV duration, and total LOS in groups 2 and 3 compared to group 1. B-type natriuretic peptide continued to demonstrate positive correlation with NIV and MV duration and ICU and total LOS independent of renal function in a subgroup analysis. Conclusion: Elevated admission BNP in patients with AECOPD and normal LVEF is associated with worse in-hospital outcomes and can be used to risk-stratify these patients.

Pneumocystis jirovecii is responsible for P. jirovecii pneumonia (PJP) in immunocompromised individuals, with a recent rise of cases noted in non-HIV patients. A middle-aged man presented with new-onset cough, fever, hypoxia and tachypnoea. He was on a tapering course of dexamethasone for amiodarone-induced thyrotoxicosis. He developed worsening airspace disease necessitating mechanical ventilation. Bronchoalveolar lavage (BAL) fluid was positive for P. jirovecii and he was managed with trimethoprim/sulfamethoxazole and pentamidine, but succumbed to cardiorespiratory arrest. One-third of PJP cases occur in non-HIV patients, and have a higher morbidity and mortality. Most immunocompromised patients typically exhibit PJP during a corticosteroid taper. The accurate dose, duration or frequency of steroid use in not well established. Diagnosis of PJP in this population is more challenging due to lower BAL yield with alternate modalities such as serum/BAL β-d-glucan and PCR enhancing the yield. Further studies are needed to highlight PJP prophylaxis in patients with steroid use.