Background Recent trials with dexamethasone and hydrocortisone have demonstrated benefit in patients with coronavirus disease 2019 (COVID‐19). Data on methylprednisolone are limited. Methods Retrospective cohort of consecutive adults with severe COVID‐19 pneumonia on high‐flow oxygen (FiO2 ≥ 50%) admitted to an academic centre in New York, from 1 March to 15 April 2020. We used inverse probability of treatment weights to estimate the effect of methylprednisolone on clinical outcomes and intensive care resource utilization. Results Of 447 patients, 153 (34.2%) received methylprednisolone and 294 (65.8%) received no corticosteroids. At 28 days, 102 patients (22.8%) had died and 115 (25.7%) received mechanical ventilation. In weighted analyses, risk for death or mechanical ventilation was 37% lower with methylprednisolone (hazard ratio 0.63; 95% CI 0.47‐0.86; P = .003), driven by less frequent mechanical ventilation (subhazard ratio 0.56; 95% CI 0.40‐0.79; P = .001); mortality did not differ between groups. The methylprednisolone group had 2.8 more ventilator‐free days (95% CI 0.5‐5.1; P = .017) and 2.6 more intensive care‐free days (95% CI 0.2‐4.9; P = .033) during the first 28 days. Complication rates were not higher with methylprednisolone. Conclusions In nonintubated patients with severe COVID‐19 pneumonia, methylprednisolone was associated with reduced need for mechanical ventilation and less‐intensive care resource utilization without excess complications.

No abstract

ObjectiveThis study is the first in a series investigating the relationship between autonomic nervous system dysfunction and chronic cerebrospinal venous insufficiency in multiple sclerosis patients. We screened patients for the combined presence of the narrowing of the internal jugular veins and symptoms of autonomic nervous system dysfunction (fatigue, cognitive dysfunction, sleeping disorders, headache, thermal intolerance, bowel/bladder dysfunction) and determined systolic and diastolic blood pressure responses to balloon angioplasty.MethodsThe criteria for eligibility for balloon angioplasty intervention included ≥50% narrowing in one or both internal jugular veins, as determined by the magnetic resonance venography, and ≥3 clinical symptoms of autonomic nervous system dysfunction. Blood pressure was measured at baseline and post-balloon angioplasty.ResultsAmong patients who were screened, 91% were identified as having internal jugular veins narrowing (with obstructing lesions) combined with the presence of three or more symptoms of autonomic nervous system dysfunction. Balloon angioplasty reduced the average systolic and diastolic blood pressure. However, blood pressure categorization showed a biphasic response to balloon angioplasty. The procedure increased blood pressure in multiple sclerosis patients who presented with baseline blood pressure within lower limits of normal ranges (systolic ≤105 mmHg, diastolic ≤70 mmHg) but decreased blood pressure in patients with baseline blood pressure above normal ranges (systolic ≥130 mmHg, diastolic ≥ 80 mmHg). In addition, gender differences in baseline blood pressure subcategories were observed.DiscussionThe coexistence of internal jugular veins narrowing and symptoms of autonomic nervous system dysfunction suggests that the two phenomena may be related. Balloon angioplasty corrects blood pressure deviation in multiple sclerosis patients undergoing internal jugular vein dilation. Further studies should investigate the association between blood pressure deviation and internal jugular veins narrowing, and whether blood pressure normalization affects Patient's clinical outcomes.

Aims We examined the value of N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) in patients admitted for coronavirus disease 2019 (COVID‐19) without prior history of heart failure (HF) or cardiomyopathy. Methods and results Retrospective cohort of consecutive adults ( N = 679; median age 59 years; 38.7% women; 87.5% White; 7.1% Black; 5.4% Asian; 34.3% Hispanic) admitted with documented COVID‐19 in an academic centre in Long Island, NY. Admission NT‐proBNP was categorized using the European Society of Cardiology Heart Failure Association age‐specific criteria for acute presentations. We examined (i) mortality and the composite of death or mechanical ventilation and (ii) out‐of‐hospital, intensive care unit (ICU)‐free, and ventilator‐free days at 28 days. Estimates were adjusted for confounders using a lasso selection process. Using age‐specific criteria, 417 patients (61.4%) had low, 141 (20.8%) borderline, and 121 (17.8%) high NT‐proBNP. Mortality was 5.8%, 20.6%, and 36.4% for patients with low, borderline, and high NT‐proBNP, respectively. In lasso‐adjusted models, high NT‐proBNP was associated with higher mortality [hazard ratio (HR) 2.15; 95% confidence interval (CI) 1.06–4.39; P = 0.034] and composite endpoint rates (HR 1.66; 95%CI 1.04–2.66; P = 0.035). Patients with high NT‐proBNP had 32%, 33%, and 33% fewer out‐of‐hospital, ICU‐free, and ventilator‐free days compared with low NT‐proBNP counterparts. Results were consistent across age, sex, and race, and regardless of coronary artery disease or hypertension, except for stronger mortality signal with high NT‐proBNP in women. Conclusions In patients with COVID‐19 and no HF history, high admission NT‐proBNP is associated with higher mortality and healthcare resources utilization. Preventive strategies may be required for these patients.

IMPORTANCE Serum ferritin, an acute phase marker of inflammation, has several physiologic functions, including limiting intracellular oxidative stress. Whether the effectiveness of corticosteroids differs according to serum ferritin level in COVID-19 has not been reported. OBJECTIVE To examine the association between admission serum ferritin level and methylprednisolone treatment outcomes in nonintubated patients with severe COVID-19.

No abstract

Patient: Male, 63-year-old Final Diagnosis: Electrical storm Symptoms: Hypotension • syncope Medication: — Clinical Procedure: — Specialty: Cardiology Objective: Rare disease Background: Pheochromocytomas are catecholamine-secreting tumors that develop within the chromaffin cells of the adrenal glands. They most commonly present with hypertension, and the classic triad of symptoms is headaches, palpitations, and diaphoresis. Electrical storm (ES) is defined as at least 3 sustained episodes of ventricular tachycardia (VT), ventricular fibrillation (VF), or appropriate shocks from an implanted cardioverter-defibrillator (ICD) within 24 h. We discuss the case of a 63-year-old man with known bilateral pheochromocytomas who presented with ES prompting multiple ICD shocks, possibly exacerbated by catecholamine surge from his adrenal tumors. Case Report: The patient was a 63-year-old man with an extensive medical history including ischemic cardiomyopathy and congestive heart failure with reduced ejection fraction presented with multiple syncopal episodes secondary to persistent monomorphic ventricular tachycardia (MMVT), polymorphic ventricular tachycardia (PMVT), and VF requiring ICD shocks. He had known bilateral pheochromocytomas. ES was attributed to catecholamine excess in the setting of these tumors, so VT ablation was deferred pending tumor removal. Alpha blockade was initiated preoperatively, and the patient subsequently underwent bilateral adrenalectomy; however, he continued to sustain tachyarrhythmias and eventually died despite resuscitative efforts. Conclusions: Bilateral pheochromocytomas are rare adrenal tumors. In even more infrequent situations, they can cause ES secondary to adrenergic stimulation from catecholamine surges. It is worth considering pheochromocytoma in patients with refractory ES, as treating these tumors could potentially reduce the frequency of this dangerous arrhythmia.

No abstract