Kratom induced severe cholestatic liver injury histologically mimicking primary biliary cholangitis: A case report

BACKGROUND Kratom is a psychoactive substance that is isolated from the plant Mitragyna speciosa.The leaves can be chewed fresh or dried,smoked,or infused similar to herbal teas.The plant leaves have been used by natives of Southeast Asia for centuries.The substance has been used for its stimulant activity at low doses,and as an opium substitute at higher doses due to a morphine like effect.CASE SUMMARY A 37-year-old female with a history of depression and obesity(body mass index:32)presented to emergency room with a week-long history of nausea,decreased appetite,fatigue,and two days of jaundice.On admission bilirubin was markedly elevated.Her condition was thought to be due to consumption of Kratom 2 wk before onset of symptoms.Liver biopsy showed changes mimicking primary biliary cholangitis.Patient’s symptoms and jaundice improved quickly.CONCLUSION The use of Kratom has been on the rise in recent years across the United States and Europe.Several case reports have associated adverse health impact of Kratom-containing products including death due to its ability to alter levels of consciousness.Only a few case reports have highlighted the hepatotoxic effects of Kratom.Even fewer reports exist describing the detailed histopathological changes.

Review of X-ray and computed tomography scan findings with a promising role of point of care ultrasound in COVID-19 pandemic

As healthcare professionals continue to combat the coronavirus disease 2019(COVID-19)infection worldwide,there is an increasing interest in the role of imaging and the relevance of various modalities.Since imaging not only helps assess the disease at the time of diagnosis but also aids evaluation of response to management,it is critical to examine the role of different modalities currently in use,such as baseline X-rays and computed tomography scans carefully.In this article,we will draw attention to the critical findings for the radiologist.Further,we will look at point of care ultrasound,an increasingly a popular tool in diagnostic medicine,as a component of COVID-19 management.

Challenges in hyperglycemia management in critically ill patients with COVID-19

Hyperglycemia is commonly associated with adverse outcomes especially in patients requiring intensive care unit stay.Data from the corona virus disease 2019(COVID-19)pandemic indicates that individuals with diabetes appear to be at similar risk for COVID-19 infection to those without diabetes but are more likely to experience increased morbidity and mortality.The proposed hypothesis for hyperglycemia in COVID-19 include insulin resistance,critical illness hyperglycemia(stress-induced hyperglycemia)secondary to high levels of hormones like cortisol and catecholamines that counteract insulin action,acute cytokine storm and pancreatic cell dysfunction.Diabetic patients are more likely to have severe hyperglycemic complications including diabetic ketoacidosis and hyperosmolar hyperglycemic state.Management of hyperglycemia in COVID-19 is often complicated by use of steroids,prolonged total parenteral or enteral nutrition,frequent acute hyperglycemic events,and restrictions with fluid management due to acute respiratory distress syndrome.While managing hyperglycemia special attention should be paid to mode of insulin delivery,frequency of glucose monitoring based on patient and caregiver safety thereby minimizing exposure and conserving personal protective equipment.In this article we describe the pathophysiology of hyperglycemia,challenges encountered in managing hyperglycemia,and review some potential solutions to address them.

COVID-19 and venous thromboembolism: Known and unknown for imaging decisions

As we continue to fight against the current coronavirus disease-2019(COVID-19)pandemic,healthcare professionals across the globe are trying to answer questions surrounding how to best help patients with the up-to-date available science while awaiting the development of new therapies and mass vaccination.Since early in the pandemic,studies indicated a heightened risk of venous thromboembolism(VTE)in COVID-19 infected patients.There have been differing expert opinions about how to assess pretest probability of VTE in this patient population.This has been partly due to the high prevalence of respiratory failure in this patient population and the use of D-dimer as a prognostic test which is also frequently elevated in patients with COVID-19 in absence of VTE.Some experts have argued for an approach similar to usual care with testing if clinical suspicion is high enough.Some have argued for more routine screening at different points of care.Others have even suggested empiric therapeutic anticoagulation in moderate to severely ill COVID-19 patients.In the following article,we review and summarize the most current literature in hopes of assisting clinicians in decision making and guidance for when to be concerned for VTE in COVID-19 patients.We also discuss research gaps and share pathways currently being used within our institution.

Association of latitude and altitude with adverse outcomes in patients with COVID-19: The VIRUS registry

BACKGROUND The coronavirus disease 2019(COVID-19)course may be affected by environmental factors.Ecological studies previously suggested a link between climatological factors and COVID-19 fatality rates.However,individual-level impact of these factors has not been thoroughly evaluated yet.AIM To study the association of climatological factors related to patient location with unfavorable outcomes in patients.METHODS In this observational analysis of the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study:COVID-19 Registry cohort,the latitudes and altitudes of hospitals were examined as a covariate for mortality within 28 d of admission and the length of hospital stay.Adjusting for baseline parameters and admission date,multivariable regression modeling was utilized.Generalized estimating equations were used to fit the models.RESULTS Twenty-two thousand one hundred eight patients from over 20 countries were evaluated.The median age was 62(interquartile range:49-74)years,and 54%of the included patients were males.The median age increased with increasing latitude as well as the frequency of comorbidities.Contrarily,the percentage of comorbidities was lower in elevated altitudes.Mortality within 28 d of hospital admission was found to be 25%.The median hospital-free days among all included patients was 20 d.Despite the significant linear relationship between mortality and hospital-free days(adjusted odds ratio(aOR)=1.39(1.04,1.86),P=0.025 for mortality within 28 d of admission;aOR=-1.47(-2.60,-0.33),P=0.011 for hospital-free days),suggesting that adverse patient outcomes were more common in locations further away from the Equator;the results were no longer significant when adjusted for baseline differences(aOR=1.32(1.00,1.74),P=0.051 for 28-day mortality;aOR=-1.07(-2.13,-0.01),P=0.050 for hospital-free days).When we looked at the altitude’s effect,we discovered that it demonstrated a non-linear association with mortality within 28 d of hospital admission(aOR=0.96(0.62,1.47),1.04(0.92,1.19),0.49(0.22,0.90),and 0.51(0.27,0.98),for the altitude points of 75 MASL,125 MASL,400 MASL,and 600 MASL,in comparison to the reference altitude of 148 m.a.s.l,respectively.P=0.001).We detected an association between latitude and 28-day mortality as well as hospital-free days in this worldwide study.When the baseline features were taken into account,however,this did not stay significant.CONCLUSION Our findings suggest that differences observed in previous epidemiological studies may be due to ecological fallacy rather than implying a causal relationship at the patient level.