To the Editor: Prone position ventilation has been shown to improve oxygenation and survival in patients with severe acute respiratory distress syndrome (ARDS) [1]. Facing the coronavirus disease 2019 (COVID-19) pandemic, prone positioning (PP) is of crucial importance to treat severe ARDS patients [2]. Nevertheless, the high number of ICU admissions quickly overwhelmed the ability of the daily ICU team to place patients in PP, a complex and time-consuming maneuver. Thus, we created a dedicated medical team with reassigned volunteers to cope with the large number of patients requiring PP. PP Team consisted of five volunteers: a senior medical non-intensivist physician placed at the patient's head to secure the endotracheal tube and four medical fellows or medical students placed at each side of the bed. For patients treated with VV-ECMO, a supplementary physician was added to secure the lines. Since PP is a complex procedure and has many potential adverse events requiring adequate and well-trained staff, volunteers received previously a theoretical training and a hands-on ad hoc training session. PP teams followed the guidelines for PP placement [1]. This retrospective observational study was performed in our extended ICU (from 22 to 46 beds), from the first day of deployment of PPT (March 23 to April 23, 2020). The main characteristics and outcomes of prone positioned patients (n = 63) are presented in Table 1.
The landscape of HIV medicine dramatically changed with the advent of contemporary antiretroviral therapies (ART) which has allowed persons with HIV (PWH) to achieve good virologic control, essentially eliminating HIV-related complications and increasing life expectancy. As PWH are living longer, non-communicable diseases, such as cardiovascular disease (CVD), have become a leading cause of morbidity and mortality in PWH with rates that are 50-100% higher than in well-matched persons without HIV. In this review, we focus on disease of the coronary microvasculature and myocardium in HIV. We highlight a key hormonal system important to cardiovascular endocrinology, the renin-angiotensin-aldosterone system (RAAS), as a potential mediator of inflammatory driven-vascular and myocardial injury and consider RAAS blockade as a physiologically-targeted strategy to reduce CVD in HIV.
Background Arterial inflammation remains increased among persons with HIV (PWH) compared with persons without HIV (PWOH) even when controlling for traditional risk factors. We sought to understand whether increased renin–angiotensin–aldosterone system (RAAS) activation may be related to arterial inflammation in PWH and when compared with PWOH. Design Twenty PWH and 9 PWOH followed a controlled, standardized low and liberal sodium diet to simulate a RAAS‐activated and RAAS‐suppressed state, respectively. We measured serum lipoprotein‐associated phospholipase A2 (LpPLA2) concentrations following both conditions to assess the physiologic dynamics of aldosterone in relation to arterial inflammation. Results LpPLA2 levels were significantly higher among PWH versus PWOH during both the RAAS‐activated state[5.3(4.2, 6.1) versus 4.0(3.0, 4.8)nmol/L, median(interquartile range),p = .01]) and RAAS‐suppressed state[4.4(3.9, 5.3) versus 3.8(3.4, 4.1)nmol/L,p = .01]. Among PWH, but not PWOH, LpPLA2 increased significantly with RAAS activation(p = .03). LpPLA2 levels measured during the RAAS‐suppressed state among PWH remained relatively higher than LpPLA2 levels under both conditions among PWOH. Log LpPLA2 was related to log aldosterone during the RAAS‐activated state(r = .39,p = .04) among all participants. Log LpPLA2 was correlated with visceral fat(r = .46,p = .04) and log systolic blood pressure(r = .57,p = .009) during a RAAS‐activated state when an increase in aldosterone was stimulated in HIV. Conclusion LpPLA2 is increased during a RAAS‐activated state among PWH, but not among PWOH. Further, LpPLA2 was increased in both RAAS‐activated and suppressed states in PWH compared with PWOH. These data suggest a biological link between increased aldosterone and arterial inflammation in this population. Future studies should test RAAS blockade on arterial inflammation as a targeted treatment approach in HIV.
Black widow spider bites are uncommon in South Africa, but it is important for clinicians to be aware of the clinical presentation in order to initiate appropriate treatment. This case highlights the presentation and management of a middle-aged gentleman who presented to the Chris Hani Baragwanath hospital following a spider bite. The bite was later confirmed to be that of a black widow spider. The patient presented with the typical symptoms of latrodectism -autonomic dysfunction, muscle rigidity and cramps -and was managed symptomatically with a favourable outcome.
Subclinical myocardial dysfunction is prevalent among well-treated persons with HIV (PWH). We have previously demonstrated unique renin-angiotensin-aldosterone system physiology among PWH with metabolic dysregulation. Mineralocorticoid receptor blockade may be a targeted treatment strategy for subclinical heart disease in PWH. Forty-six PWH were randomized to receive either eplerenone 50 mg daily or placebo in a 6-month randomized, double-blinded, placebo-controlled trial. We assessed changes in N-terminal pro-B-type natriuretic peptide (NT-proBNP), a biomarker of cardiac stretch, under controlled posture and dietary conditions. The eplerenone- and placebo-treated groups demonstrated a long duration of HIV with good immunological control. NT-proBNP levels were similar between the groups at baseline (41.1 [20.2, 97.9] vs 48.9 [29.2, 65.4] ng/L, P = .80) and decreased significantly more in the eplerenone- vs placebo-treated groups after 6 months (change NT-proBNP -9.6 [-46.8, 0.3] vs -3.0 [-17.0, 39.9] ng/L, P = .02 for comparison of change between groups). Decreases in NT-proBNP were independent of changes in systolic and diastolic blood pressure, and related to decreases in high-sensitivity C-reactive protein (ρ = 0.32, P = .05) and inversely to increases in serum aldosterone (ρ = -0.33, P = .04) among all participants. Treatment with eplerenone for 6 months vs placebo significantly decreases NT-proBNP levels among PWH, independent of eplerenone’s known blood pressure-lowering effects. Further studies should elucidate whether lowering NT-proBNP in this at-risk metabolic population with subclinical heart disease will offer cardioprotection. Clinical Trial Registration NCT01405456
Black widow spider bites are uncommon in South Africa, but it is important for clinicians to be aware of the clinical presentation in order to initiate appropriate treatment. This case highlights the presentation and management of a middle-aged gentleman who presented to the Chris Hani Baragwanath hospital following a spider bite. The bite was later confirmed to be that of a black widow spider. The patient presented with the typical symptoms of latrodectism – autonomic dysfunction, muscle rigidity and cramps – and was managed symptomatically with a favourable outcome.
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