Shah, Sadia Z.

The Omicron variant of SARS-CoV-2 is associated with milder symptoms and lower hospitalization and mortality rates than Delta variants, although the impact of Omicron on immunocompromised patients, especially solid organ transplant (SOT) recipients, is still unclear. This study compares the hospitalization rate and outcomes between immunocompromised, immunocompetent, and SOT patients during the Delta and Omicron periods. We included adult patients who tested positive for SARS-CoV-2 on PCR or nasopharyngeal antigen test between 26 June 2021 to 8 September 2022, at our institution. A total of 12,401 COVID-19 patients were included, of which 11,055 were immunocompetent, and 1346 were immunocompromised (375 SOT recipients). Throughout the Delta and Omicron outbreaks, immunocompromised patients exhibited higher comorbidities and 30-day hospitalizations, but rates of mechanical ventilation and ICU-level care were like immunocompetent patients. During the Omicron wave, immunocompromised patients had higher unadjusted relative risk estimates (RR = 2.37, 95% CI 1.96–2.87, p < 0.05) than Delta (RR = 1.58, 95% CI 1.24–2.01, p < 0.05), with higher adjusted relative risk for hospitalization in Omicron (RR = 1.50, 95% CI 1.10–2.03, p = 0.01). Analyses show increased hospitalization risk in immunocompromised during the Omicron wave compared to the Delta wave, with no significant difference in hospitalization outcomes. The relative risk of hospitalization for SOT patients was higher in both waves.

Background Ketamine has demonstrated efficacy in treatment-resistant depression, primarily in psychiatric or outpatient populations. Its use in ICU patients remains underexplored, with limited data beyond case reports and small series. This study evaluated the association between subanesthetic ketamine infusions and improvement in depressive symptoms and hemodynamic changes in ICU patients. Methods We conducted a retrospective study of adults admitted to the ICU who received IV ketamine (0.3-0.75 mg/kg over 40 min on three consecutive days) for depressive symptoms. Changes in depressive symptoms were assessed using routine clinical documentation by physicians, nurses, and occupational and physical therapists. Hemodynamic parameters (blood pressure and heart rate) were recorded before and up to 120 min after infusion. The primary outcome was to evaluate depressive symptoms while the secondary outcome was to assess hemodynamic changes post transfusion. Results Thirty-four patients met criteria, including 18 solid organ transplant recipients. Median age was 59 years; 61.8% were male. Ketamine was associated with improvement in apparent sadness (90.0% vs 52.2%, P < .05) and reported sadness (95.0% vs 59.1%, P < .05). In transplant recipients, improvement in apparent sadness remained significant (80.0% vs 41.7%, P < .05). Hemodynamic parameters remained stable; heart rate increased transiently at 15-30 min post-infusion, returning to baseline by 60-90 min. Adverse effects observed were anxiety (12.5%), restlessness and/or agitation (10.4%), and dissociation (8.16%). Conclusion Subanesthetic ketamine improved specific depressive symptoms in critically ill ICU patients without significant hemodynamic instability. These findings support its potential as a rapid-acting antidepressant in the ICU, warranting further prospective trials.

ABSTRACT Background Treating Mycobacterium avium complex (MAC) infection pre‐lung transplant (LT) can be challenging to treat, given prolonged therapy and side effects. The impact of pre‐transplant MAC treatment on recurrence and outcomes post‐LT remains unclear, especially in patients with interstitial lung disease (ILD) who have a median survival of less than 2 years. Methods We performed a retrospective cohort study of adult LT patients at the Mayo Clinic who had positive MAC sputum cultures pre‐LT. The cohort was stratified and compared based on the type of treatment (complete, partial, or no treatment) for MAC pulmonary infection. The primary outcome was MAC recurrence post‐LT, and secondary outcomes were mortality, FEV‐1, and FVC at 1‐year post‐LT. Results Among the cohort of 47 patients, 9 (19.1%) were partially treated and 11 (23.4%) were completely treated for MAC infection pre‐LT. Post‐transplant MAC pulmonary infection recurrence occurred in eight (17%) of the total cohort, with four (14.8%) in the non‐treated, four (44.4%) in the partially‐treated, and none (0%) in the completely treated patients ( p = 0.026). There was no difference in mortality in patients who had MAC recurrence post‐transplantation (13% vs. 9.7%, p > 0.9) and those who were completely or partially treated, compared to non‐treated (0% vs. 13% vs. 13%, p > 0.9). The FEV1 and FVC at 1‐year post‐LT did not differ by the pre‐transplant treatment or post‐transplant MAC recurrence status. Conclusion The role of treatment for MAC infection pre‐transplant is questionable, especially in patients with diseases like ILD who may not have enough wait time to complete therapy.

INTRODUCTION Gastroesophageal reflux is common in respiratory disease, but the interplay between gastrointestinal mechanisms that expose individuals to reflux and potentially aspiration, and lung mechanics and function remain incompletely understood. Our aim was to investigate this in patients with chronic obstructive pulmonary disease (COPD) and non-idiopathic pulmonary fibrosis (IPF) interstitial lung disease (non-IPF ILD), and compare with our published findings in IPF. METHODS Fifty-seven patients with COPD (aged: 34–75 years) and 64 with non-IPF ILD (22–75 years) who underwent high-resolution impedance manometry and 24-hour pH impedance together with pulmonary function assessment were compared with 35 IPF patients (51–84 years). RESULTS COPD patients were less likely to exhibit ineffective esophageal motility (IEM) and/or absent contractility ( P = 0.009; P = 0.028), and tended to exhibit esophagogastric junction outflow obstruction (EGJOO) and/or hypercontractility ( P = 0.09, P = 0.14) than IPF and non-IPF ILD patients. Notably, integrated relaxation pressure correlated with esophageal length index (ELI) ( P = 0.048) and inspiratory LESP ( P = 0.003), with latter 2 correlating with each other ( P < 0.001). EGJOO patients tended to have fewer proximal reflux events and reduced pulmonary function, with the latter inversely correlating with ELI ( P < 0.05). Non-IPF ILD patients were less likely to exhibit EGJOO than COPD patients ( P = 0.27), and less likely to exhibit IEM ( P = 0.07) than IPF patients. However, those with IEM or EGJOO exhibited greater proportions of reflux events reaching the proximal esophagus than those with normal motility ( P < 0.03), which in contrast to IPF, seemed not to associate with worse pulmonary function. DISCUSSION Associations between esophageal motility, and lung mechanics and function, and consequently reflux, are very disease-specific.

AbstractBackgroundFor many patients with lung disease the only proven intervention to improve survival and quality of life is lung transplantation (LTx). Esophageal dysmotility and gastroesophageal reflux (GER) are common in patients with respiratory disease, and often associate with worse prognosis following LTx. Which, if any patients, should be excluded from LTx based on esophageal concerns remains unclear. Our aim was to understand the effect of LTx on esophageal motility diagnosis and examine how this and the other physiological and mechanical factors relate to GER and clearance of boluses swallowed.MethodsWe prospectively recruited 62 patients with restrictive (RLD) and obstructive (OLD) lung disease (aged 33–75 years; 42 men) who underwent high resolution impedance manometry and 24‐h pH‐impedance before and after LTx.Key ResultsRLD patients with normal motility were more likely to remain normal (p = 0.02), or if having abnormal motility to change to normal (p = 0.07) post‐LTx than OLD patients. Esophageal length (EL) was greater in OLD than RLD patients' pre‐LTx (p < 0.001), reducing only in OLD patients' post‐LTx (p = 0.02). Reduced EL post‐LTx associated with greater contractile reserve (r = 0.735; p = 0.01) and increased likelihood of motility normalization (p = 0.10). Clearance of reflux improved (p = 0.01) and associated with increased mean nocturnal baseline impedance (p < 0.001) in RLD but not OLD. Peristaltic breaks and thoraco‐abdominal pressure gradient impact both esophageal clearance of reflux and boluses swallowed (p < 0.05).Conclusions and InferencesRLD patients are more likely to show improvement in esophageal motility than OLD patients post‐LTx. However, the effect on GER is more difficult to predict and requires other GI, anatomical and pulmonary factors to be taken into consideration.