Prior work showed that neurons in the lateral, dorsal, and perifornical regions of the tuberal and mammillary levels of the hypothalamus participate in the control of breathing. The same areas also contain large numbers of neurons that produce either orexins (hypocretins) or melanin concentrating hormone (MCH). These peptides have been implicated in regulating energy balance and physiological changes that occur in transitions between sleep and wakefulness, amongst other functions. The goal of this study was to determine if hypothalamic neurons involved in respiratory control, which were identified in cats by the retrograde transneuronal transport of rabies virus from the diaphragm, were immunopositive for either orexin-A or MCH. In animals with limited rabies infection of the hypothalamus (< 10 infected cells/section), where the neurons with the most direct influences on diaphragm motoneurons were presumably labeled, a large fraction (28–75%) of the infected hypothalamic neurons contained orexin-A. In the same cases, 6–33% of rabies-infected hypothalamic cells contained MCH. However, in animals with more extensive infection, where rabies had presumably passed transneuronally through more synapses, the fraction of infected cells that contained orexin-A was lower. The findings from these experiments thus support the notion that hypothalamic influences on breathing are substantially mediated through orexins or MCH.
Patient: Female, 80Final Diagnosis: Aortoesophageal fistulaSymptoms: HematemesisMedication: —Clinical Procedure: Thoracic endovascular aortic repairSpecialty: General and Internal MedicineObjective:Rare diseaseBackground:Hemetemesis is rarely caused by an aorta-esophageal fistula with thoracic aorta aneurysm in patients. This uncommon etiology, AEF/TAA, can potentially rupture and cause death if left untreated. Thoracic endovascular aorta repair places a stent-graft to seal the aneurysm and cover the fistulous track. Open surgical repair is associated with high risk of morbidity and mortality; therefore, TEVAR is a much safer alternative to it. However, recurrent or persistent infection remains a major concern with TEVAR for AEF.Case Report:We present a rare case of an 80-year-old woman who presented with complaints of hemetemesis and epigastric pain. The patient underwent a computerized tomography scan, highlighting a TAA and AEF. A stent was placed in the descending thoracic aorta via endovascular approach and a subsequent EGD was negative for any residual bleeding. Methicillin-resistant Staphylococcus aureus was isolated from the patient’s sputum cultures and she was treated with a prolonged course of antibiotics. She presented to the hospital a few weeks later with new-onset hematemesis. Workup identified an AEF. The patient was high risk for open surgical repair due to her comorbid conditions; therefore, an esophageal stent was placed. She was diagnosed with AEF secondary to an infected endovascular thoracic aorta stent.Conclusions:Patients who are high risk for open surgical repair from immediate rupture of TAA with AEF can benefit from use of the TEVAR approach. The stent itself is a foreign body; therefore, the risk of infection persists. AEF is a rare but potentially fatal complication of the infected thoracic aortic stent itself.
OBJECTIVES: To assess 30-day mortality in coronavirus disease 2019 acute respiratory distress syndrome patients transferred from rural Appalachian hospitals. DESIGN: Retrospective case controlled, based on consecutive patients transferred and admitted from rural hospitals to a tertiary-care ICU. The primary outcome was all-cause 30-day mortality. Kaplan-Meier method and log-rank test were used in the survival data analysis. SETTING: Medical ICU, West Virginia University Hospital, Morgantown, WV. PATIENTS: All adult patients admitted to the ICU for coronavirus disease 2019 disease between September 30, 2020, and December 2, 2020. INTERVENTION: Not applicable. MEASUREMENTS AND MAIN RESULTS: Seventy-nine consecutive coronavirus disease 2019 patients were admitted to the ICU during the defined period. Overall mortality of the cohort was 54%. Of the 79 patients, 50 were transferred from critical access hospitals/rural facilities with coronavirus disease 2019–induced acute respiratory distress syndrome. A control group consisted of 39 patients admitted to the ICU with noncoronavirus disease 2019 acute respiratory distress syndrome who were intubated and mechanically ventilated. Thirty-day mortality in patients with coronavirus disease 2019 admitted to the ICU was significantly higher than the control group (68% vs 42%) ( p = 0.034). Mean Sequential Organ Failure Assessment scores were similar in both coronavirus disease 2019 acute respiratory distress syndrome group and controls. Intubation in patients 70 years or older and mechanical ventilation for over 5 days was associated with significantly higher mortality. CONCLUSIONS: Our data on critically ill and mechanically ventilated coronavirus disease 2019 acute respiratory distress syndrome patients transferred from critical access hospitals/rural facilities have increased mortality compared with noncoronavirus disease 2019 acute respiratory distress syndrome controls. These data suggest that lack or delay in access to tertiary care may impact coronavirus disease 2019 outcome in rural areas. Intubated patients 70 years old or more and mechanical ventilation for over 5 days may be a risk factor for increased mortality. These data may help physicians and hospital administrators in rural areas for optimal utilization of limited resources.
Purpose This study aimed to evaluate the relationship between sleep, burnout, and psychomotor vigilance in residents working in the medical intensive care unit (ICU). Methods A prospective cohort study of residents was implemented during a consecutive 4-week. Residents were recruited to wear a sleep tracker for 2 weeks before and 2 weeks during their medical ICU rotation. Data collected included wearable-tracked sleep minutes, Oldenburg burnout inventory (OBI) score, Epworth sleepiness scale (ESS), psychomotor vigilance testing, and American Academy of Sleep Medicine sleep diary. The primary outcome was sleep duration tracked by the wearable. The secondary outcomes were burnout, psychomotor vigilance (PVT), and perceived sleepiness. Results A total of 40 residents completed the study. The age range was 26–34 years with 19 males. Total sleep minutes measured by the wearable decreased from 402 min (95% CI: 377–427) before ICU to 389 (95% CI: 360–418) during ICU ( p < 0.05). Residents overestimated sleep, logging 464 min (95% CI: 452–476) before and 442 (95% CI: 430–454) during ICU. ESS scores increased from 5.93 (95% CI: 4.89, 7.07) to 8.33 (95% CI: 7.09,9.58) during ICU ( p < 0.001). OBI scores increased from 34.5 (95% CI: 32.9–36.2) to 42.8 (95% CI: 40.7–45.0) ( p < 0.001). PVT scores worsened with increased reaction time while on ICU rotation (348.5 ms pre-ICU, 370.9 ms post-ICU, p < 0.001). Conclusions Resident ICU rotations are associated with decreased objective sleep and self-reported sleep. Residents overestimate sleep duration. Burnout and sleepiness increase and associated PVT scores worsen while working in the ICU. Institutions should ensure resident sleep and wellness checks during ICU rotation.
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