Background Preliminary data from SARS-CoV-2 pneumonia patients indicate that a cytokine storm may increase morbidity and mortality. Tocilizumab (anti-IL-6R) is FDA-approved for treatment of cytokine storm associated with chimeric antigen receptor T-cell therapy. Here we examined compassionate use of tocilizumab in patients with SARS-CoV-2 pneumonia. Methods We report on a single-center study of tocilizumab in hospitalized patients with SARS-CoV-2 pneumonia. All patients had confirmed SARS-CoV-2 pneumonia and oxygen saturations <90% on oxygen support with most intubated. We examined clinical and laboratory parameters including oxygen and vasopressor requirements, cytokine profiles, and C-reactive protein (CRP) levels pre- and post-tocilizumab treatment. Results Twenty seven SARS-CoV-2 pneumonia patients received one 400 mg dose of tocilizumab. IL-6 was the predominant cytokine detected at tocilizumab treatment. Significant reductions in temperature and CRP were seen post-tocilizumab. However, four patients did not show rapid CRP declines, of whom three had poorer outcomes. Oxygen and vasopressor requirements diminished over the first week post-tocilizumab. Twenty-two patients required mechanical ventilation; at last follow-up, 16 were extubated. Adverse events and serious adverse events were minimal, but two deaths (7.4%) occurred that were felt unrelated to tocilizumab. Conclusions Compared to published reports on the morbidity and mortality associated with SARS-CoV-2, tocilizumab appears to offer benefits in reducing inflammation, oxygen requirements, vasopressor support, and mortality. The rationale for tocilizumab treatment is supported by detection of IL-6 in pathogenic levels in all patients. Additional doses of tocilizumab may be needed for those showing slow declines in CRP. Proof of efficacy awaits randomized, placebo-controlled clinical trials.
Introduction. Thorough quality control (QC) study with systemic monitoring and evaluation is crucial to optimizing the effectiveness of EUS-FNA. Methods. Retrospective analysis was composed of investigating consecutive patient files that underwent EUS-FNA. QC specifically focused on diagnostic accuracy, impacts on preexisting diagnoses, and case management. Results. 268 patient files were evaluated. EUS-FNA cytology helped establish accurate diagnoses in 92.54% (248/268) of patients. Sensitivity, specificity, PPV, NPV, and accuracy were 83%, 100%, 100%, 91.6%, and 94%, respectively. The most common biopsy site was the pancreas (68%). The most accurate location for EUS-FNA was the esophagus, 13/13 (100%), followed by the pancreas (89.6%). EUS-FNA was least informative for abdominal lymph nodes (70.5%). After FNA and followup, eight false negatives for tumors were found (3%), while 7.5% of samples still lacked a definitive diagnosis. Discussion. QC suggests that the diagnostic accuracy of EUS-FNA might be improved further by (1) taking more FNA passes from suspected lesions, (2) optimizing needle selection (3) having an experienced echo-endoscopist available during the learning curve, and (4) having a cytologist present during the procedure. QC also identified remediable reporting errors. In conclusion, QC study is valuable in identifying weaknesses and thereby augmenting the effectiveness of EUS-FNA.
AIM:To perform a quality control (QC) review of endoscopic ultrasound (EUS) with emphasis on current consensus established quality indicators. METHODS:A national quality control study of EUS was performed with expanded international comparison. Ten different healthcare institutions in Israel participated in coordination with University of Chicago Medical Center. Each Israeli center provided ten patient reports, compared with twenty reports from University of Chicago Medical Center. Quality indicator forms were prepared with sections to be completed before, during, and after EUS. Physician compliance to all listed indicators was evaluated. Quality indicators were evaluated prior to, during, and after performing EUS. RESULTS:One hundred different EUS procedural reports were analyzed. The mean patient age was 59 years old. Indications for referral were mostly for pancreatic or biliary reasons. QC showed several strongly reported areas, including indications for EUS (97%), anesthesia given (94%), periprocedural pancreatic evaluation (87%), and an overall summary of the EUS examination (82%). Intermediately reported areas included patients' pertinent past medical history (71.7%), evaluation of the biliary tree (63%), and providing medical guidance about potential procedural adverse events, including pancreatitis and bleeding (52%). Half of the reports (50%) did not include a systemic organ evaluation. Other areas, including systematic reporting of screened organs (36%), description of fine needle aspiration (15%), tumor description via tumor-nodemetastasis (5%), and listing of adverse events (0%) were largely lacking from procedural documentation. CONCLUSION:Documenting specific EUS quality indicators including listing post-procedural recommendations may improve the quality and efficiency of future EUS examinations and subsequent patient follow-up.© 2013 Baishideng Publishing Group Co., Limited. All rights reserved.Key words: Endoscopic ultrasound; Quality indicators; Quality control; Fine needle aspiration; Malignancy Core tip: Certain key points of quality control have been delineated as quality indicators by American and European Gastrointestinal Societies, which serve to establish and maintain high-quality gastrointestinal minimally invasive procedures and reports, minimize potential adverse events, and to optimize costs, resulting in savings for both hospitals and patients while optimizing patient care in the process. This national quality control study of endoscopic ultrasound (EUS) with expanded international comparison emphasized developing a
Introduction: Patients undergoing esophagogastroduodenoscopy (EGD) have variable stress and anxiety and therefore commonly receive medications as sedative-anxiolytics. These medications have small but significant risks. To possibly make procedures safer and to increase patient satisfaction, this study aimed to measure the effects of allowing an accompanying person (AP) to be present in the endoscopy suite during EGD. Patients and Methods: Forty-two patients were randomly divided into two groups who would either be or not be offered to have an AP during endoscopy. Spielberger’s well-validated state and trait anxiety evaluations were administered to patients before and after EGD. APs also completed questionnaires as to their reactions after EGD. Results: 84.2% of the patients after EGD recommended accompaniment. Patients who underwent EGD with an AP tended (p < 0.06) to have decreased measurable anxiety compared to patients who were not offered an AP. The benefit was significant for persons with higher levels of anxiety prior to EGD (p < 0.04). Patients undergoing EGD for the first time had significantly more anxiety than those with previous EGD experience (p < 0.034). There was no significant reduction in sedative dosage when APs were present. Conclusions: Offering to permit the presence of an accompanying person during EGD was often shown to improve patient satisfaction and reduce anxiety.
Pasteurella multocida is a gram-negative coccobacillus that causes a spectrum of illnesses. P multocida lives as commensal bacteria in the upper respiratory tracts of fowl and mammals. Infections most commonly result from cat or dog bites; however, direct inoculation via saliva has been reported. Although the majority of P. multocida infections manifest in skin and soft tissue, it may cause bacteremia with disseminated infection in an immunocompromised host. Dissemination is responsive to treatment but carries a significant mortality risk of about 30%. We present a case of a 46 year old male with type 2 diabetes mellitus, coronary artery disease and chronic kidney disease with stage 4 neuropathic heel ulcer who presented with hypothermia and chills. One day into admission, 4/4 blood culture bottles were positive for Pasteurella multocida. MRI of the foot was concerning for osteomyelitis which was confirmed via I&D. The patient did report having a dog and a cat at home, but adamantly denied any bites from either animal. Examination of his boot used for support with his foot containing the ulcer revealed extensive animal hair stuck to the boot. It was deemed likely that the route of inoculation occurred from contamination of his neuropathic ulcer from his dog's saliva, likely from a lick, for which his diabetic neuropathy may have impaired initial sensation of the contamination. The patient was treated with ampicillin-sulbactam while admitted and discharged with oral levofloxacin 6 week course for residual osteomyelitis.
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