Background: Pulmonary artery bleeding secondary to iatrogenic injury is a troublesome intraoperative complication. The likelihood of encountering this complication is significantly higher in redo surgery for a number of reasons, including distortion of anatomical structures, adhesions and loss of tissue planes. Significant blood loss, although rare, remains a concern, and can occasionally be life-threatening. When significant bleeding from the pulmonary artery occurs, it can be a challenging situation to manage. Case Report: A 65 year old female was undergoing redo thoracic surgery in the setting of a completion lobectomy for biopsy-proven primary adenocarcinoma of the lung. Iatrogenic injury to the pulmonary artery resulted in significant bleeding that could not be managed by gaining proximal control due to dense adhesions. The novel decision to utilize a Foley catheter for balloon tamponade was taken, in order to provide sufficient haemostasis for definitive surgical repair of the defect to be undertaken Conclusion: The increased technical difficulties of redo thoracic surgery are well recognised. We describe the first case of Foley catheter balloon tamponade being utilized in the context of iatrogenic pulmonary artery bleeding during thoracic surgery.

We report the radio-clinical observation of a 21-year-old patient, referred for anterior chest parietal discomfort evolving for 3 months ago, with the notion of trauma. The chest CT (computed tomography) scan detected a costal cartilage fracture without associated traumatic pulmonary or mediastinal changes. This case illustrates the usefulness of imaging in the diagnosis and management of costal cartilage fractures, and for screening out differential diagnoses. The aim of this study is to determine the interest of imaging in the study of fractures of the chrondro-costal cartilage. Is to determine the CT value in chrondro-costal cartilage fracture.

COVID-19 virus structural components: The 2019-nCoV, also called SARS-CoV-2, was first reported in Wuhan, China in December 2019. The disease was named Coronavirus Disease 2019 (COVID-19) and the virus responsible for it as the COVID-19 virus, respectively, by WHO. The 2019-nCoV has a round, elliptic or pleomorphic form with a diameter of 60–140 nm. It has single-stranded RNA genome containing 29891 nucleotides, a lipid shell, and spike, envelope, membrane and hemagglutinin-esterase (HE) proteins. Steps in progression of COVID-19 illness: Once inside the airways, the S protein on the viral surface recognizes and mediates the attachment to host ACE-2 receptors and gains access to endoplasmic reticulum. The HE protein facilitates the S protein-mediated cell entry and virus spread through the mucosa, helping the virus to attack the ACE2-bearing cells lining the airways and infecting upper as well as lower respiratory tracts. With the dying cells sloughing down and filling the airways, the virus is carried deeper into the lungs. In addition, the virus is able to infect ACE2-bearing cells in other organs, including the blood vessels, gut and kidneys. With the viral infestation, the activated immune system leads to inflammation, pyrexia and pulmonary edema. The hyperactivated immune response, called cytokine storm in extreme cases, can damage various organs apart from lungs and increases susceptibility to infectious bacteria especially in those suffering from chronic diseases. The current therapeutics for COVID-19: At present, there is no specific antiviral treatment available for the disease. The milder cases may need no treatment. In moderate to severe cases, the clinical management includes infection prevention and control measures, and symptomatic and supportive care, including supplementary oxygen therapy. In the critically ill patients, mechanical ventilation is required for respiratory failure and hemodynamic support is imperative for managing circulatory failure and septic shock. Conclusion: Confusion, despair and hopes: There is no vaccine for preexposure prophylaxis or postexposure management. There are no specific approved drugs for the treatment for the disease. A number of drugs approved for other conditions as well as several investigational drugs are being canned and studied in several clinical trials for their likely role in COVID-19 prophylaxis or treatment. The future seems afflicted with dormant therapeutic options as well as faux Espoir or false hopes. As obvious, not all clinical trials will be successful, but having so many efforts in progress, some may succeed and provide a positive solution. Right now, though, confusion and despair prevail.

Introduction - the perennial pandemic: It is being increasingly realised that the COVID-19 may have become the new reality associated with human existence world over and the mankind may have to live with it for years or even decades. Further, the grievous nature of the disease is evolving further with the genomic changes in the virus in form of mutations and evolution of variants, with enhanced infectivity and probably virulence. There are serious challenges posed by the SARS-CoV-2 virus and COVID-19 as the disease. COVID-19 as acute and chronic disease: On exposure to the SARS-CoV-2 virus, not all patients develop a disease. Further, for those who develop the disease, there is a large variation in disease severity. The known factors including the constituent factors and several still unknown factors influence the disease manifestations, its course, and later the convalescent phase as well. In fact, substantial continuing morbidity after resolution of the infection indicates persisting multisystem effects of COVID-19. The ‘long COVID-19’ or ‘long haulers’: The patients who continue to suffer with persisting symptoms have been described as long haulers and the clinical condition has been called post-COVID-19 or ‘long COVID-19’. The diagnosis should be entertained if various symptoms and signs linger well beyond the period of convalescence in COVID-19. With the chronicity, there occur inflammatory changes and damage in various organs, and the extent of organ damage determines the long-term effects. Management of ‘long COVID’ syndrome: The ‘long COVID’ syndrome has multi-system involvement, variable presentation, and unpredictable course. Following clinical and investigational assessment, the patients should be managed as per clinical manifestations, extent of organ damage and associated complications. The findings from various studies indicate that preventing further organ damage in ‘long COVID’ is crucial. The long COVID’s prognostic challenges: As apparent, the ‘long COVID’ afflictions are more common than realized earlier. The symptoms can escalate in patients with co-morbid conditions. The persistent symptoms among COVID-19 survivors pose new challenges to the healthcare providers and may be suitably managed with a combination of pharmacological and non-pharmacological treatments, and holistic healthcare. 

Background: Azithromycin (AZM) is a macrolide antibiotic with distinct pharmacokinetic properties and is increasingly used as maintenance treatment in patients with bronchiectasis in order to reduce infectious exacerbations and improve pulmonary symptoms. The exact mechanism of action is not known and the relation between azithromycin dose level, local and systemic drug levels and clinical effect however, has not been extensively studied yet. Objectives: To explore the relation between AZM serum and sputum concentrations, clinical effect parameters and side effects. Methods: Azithromycin concentrations were measured in serum and sputum samples of bronchiectasis patients receiving one year of AZM treatment (250mg OD) enrolled in the Bronchiectasis and Azithromycin Treatment (BAT) trial, a double blind, randomised placebo-controlled trial. Results were correlated with data on AZM dose level, exacerbation frequency, lung function (forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC), quality of life and symptoms collected within the same year. Results: 83 sputum samples from 31 patients and 151 serum samples from 43 patients were available for analysis. Mean AZM dose-level ranged from 18.8 to 39.8 mg/kg body weight/ week, generating mean AZM concentrations of 7.57 mg/L (SD 9.49) in sputum and 0.11 mg/L (SD 0.085) in serum. No correlation was found between side effects and AZM dose level, sputum- or serum concentrations. Significant correlation was found between AZM sputum concentration and CRP-level (r= -0.6). Conclusion: High and stable AZM sputum levels were reached during long term treatment, as opposed to low AZM levels in serum. Apart from CRP-levels to AZM sputum concentration, no other outcome parameter showed significant correlation to AZM serum- or sputum levels. AZM dose- or exposure levels were not predictive for the occurrence of side effects.

As per report of WHO [1] (World Health Organization), air pollution (ambient/outdoor and household/indoor air pollution) kills an estimated seven million people worldwide every year largely as a result of increased mortality from stroke, heart disease, chronic obstructive pulmonary disease, lung cancer and acute respiratory infections. Data of WHO shows that 9 out of 10 people breathe air containing high levels of pollutants. World Health Organization is working with countries to monitor air pollution and improve air quality. From smog hanging over cities to smoke inside the home, air pollution poses a major threat to health and climate. More than 80% of people living in urban areas and around 91% of the world’s population live in places where air quality levels exceed WHO limits, with developing and under-developed countries suffering from the highest exposures, both indoors and outdoors [1]. While outdoor air pollution comes from the motor vehicles, burning of fossil fuels and other industrialization activities, indoor air pollution is the result of tobacco smoke and burning fuel for cooking & heating. Furniture and construction materials also emit such pollutants. Both outdoor and indoor air pollution are harmful to the human health.

Introduction: In Madagascar, plague is a highly contagious acute endemic infectious disease. The diagnosis of the most severe form of pneumonic plague remains difficult in children, hence the objectives of the present study; which is to identify the clinical signs of this clinical form in children and to describe its epidemiological and evolutionary profile. Methods: A retrospective case-control study was conducted in four pediatric wards in Antananarivo during the urban pneumonic plague outbreak from September 2017 to January 2018. Those cases were defined as children aged 0-15 years old suspected of having plague with positive RDT and PCR, and they were defined as children aged 0-15 years old with negative RDT and PCR. Results: Fifty-two cases of pneumonic plague were identified, half of which (50%) were under 24 months of age. A male predominance was noted with a sex ratio of 1.23 and 86.54% of the patients were from urban areas. Several clinical signs were found but none was specific for pneumonic plague: cough (59.62% p: 0.5), dyspnea (3.85% p: 0.16), chest pain (3.85% p: 0.26%), hemoptysis (7.69% p: 0.17), vomiting (9.62% p: 0.14), diarrhea (11.54% p: 0.45), altered general condition (38.46% p: 0.24%). Two deaths were noted (3.8%). Conclusion: No specific clinical warning signs have been identified in childhood pneumonic plague. In the event of an epidemic of urban pneumonic plague, any bacterial pneumonia should at least initially include active treatment against Yersinia pestis.

The European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) jointly developed a series of hypertension guidelines in the years 2003, 207 and 2013. The most recent guidelines were issued by the two societies in August this year (2018) and were published in the European Heart Journal. The new guidelines are printed in more than 90 pages and cover almost all aspects of hypertension based on extensive review of literature giving highest priority to data from randomized controlled trials and well conducted meta-analysis. In important areas where there is inadequate or no evidence, guidelines authors resort to expert opinion. The text was developed over approximately 24 months and was reviewed by representatives of ESC and ESH national hypertension societies. Although it is less than five years since the last hypertension European guidelines in 2013, the recent 2018 guidelines show important differences in diagnosis and treatment strategies with the addition of new sections and recommendations on management of hypertensive emergencies, hypertension in women and pregnancy, different ethnic groups, chronic obstructive pulmonary disease, cancer therapies, peri-operative management, sexual dysfunction and perioperative management.

Background: Respiratory muscle strength can be reduced in patients diagnosed with stroke, which reasonably justifies the use of respiratory muscle training in this population. This study determines the comparative efficacy of inspiratory, expiratory, and combined respiratory muscle training on the pulmonary functions and chest expansion in acute stroke survivors. Method: Forty-five acute stroke survivors (15 in each group) completed all protocols of the study. Participants were randomly assigned to any one of three groups. In addition to the conventional exercise therapy, participants received any one of the three respiratory muscle training protocols (inspiratory muscle training, expiratory muscle training or combined respiratory muscle training). Chest expansion was assessed using tape measure and pulmonary function parameters were assessed using a spirometer. Results: Paired t-test analysis showed significant improvements in the chest expansion and the pulmonary function parameters following training in each group. One-way ANOVA showed significant improvements in the pulmonary function parameters across the three groups but not in the chest expansion with p - value = 0.405. Least significant difference (LSD), post-hoc analysis shows that the significant difference for FEV1, FVC and FEV1/FVC lies between inspiratory muscle training group and expiratory muscle training group. Conclusion: When the three training methods were compared, it was found that expiratory muscle training was the most beneficial in improving the pulmonary functions and chest expansion in acute stroke survivors.

The NIH has published treatment guidelines for treating COVID-19 patients in the hospital. However, as of this writing, there are no established protocols for treating COVID-19 positive patients in primary care. Accordingly, this investigator has taken on the task of reviewing the medical literature to be able to propose evidence-based protocols for treating COVID-19 positive patients in primary care. The CDC is advising people to do nothing when they find out they are positive for COVID-19 unless they have symptoms. The evidence from the literature irrefutably shows COVID-19 infection evokes a massive and deadly hyperinflammatory response called the “Cytokine storm” and that Cytokine levels in the blood have a predictive value in identifying an impending Cytokine storm. With such data primary care providers can effectively lower Cytokine levels and prevent critical illness and death. Accordingly, this paper presents identification of the problem of not having standard practices in primary care for people who are positive for COVID-19 and not knowing who is at risk. Moreover, the evidence shows that knowing vitamin D levels and correcting deficiencies can go a long way in reducing Cytokine levels. Additionally, the literature review presents evidence that undeniably shows the stark possibility that many of the COVID-19 related deaths can be prevented by identifying who is at risk for the Cytokine storm and other complications and providing early treatment even before symptoms appear.

Zinc induced pediatric preventing respiratory 2019-nCoV is required that supplementation with zinc gluconate 20 mg in Zn deficient children resulted in a nearly twofold reduction of acute lower respiratory infections as well as the time to recovery. Zinc supplementation in children is associated with a reduction in the incidence and prevalence of pneumonia. Preventing 2019-nCoV pneumonia is required that zinc supplementation alone (10 to 20 mg) for more than 3 months significantly reduces in the rate of pneumonia. zinc pediatric intake may be required to be effective range 10～20 mg/d for 2019-CoV prevention, 10～30 mg/d for reduction of COVID-19 bronchitis, and 20～30 mg/d for recovery from COVID-19 pneumonia, in which Zn2+ could bind with viral surface proteins by Zn2+ions-centered tetrahedrally coordination pattern. On the other hand, for aults, the zinc-homeostatic immune concentration may provide a protective role against the COVID-19 pandemic, likely by improving the host’s resistance against viral infection. 50 mg of zinc per day might provide an additional shield against the COVID-19 pandemic, possibly by increasing the host resistance to viral infection to minimize the burden of the disease. In order to prevent that an outbreak of respiratory sickness caused by a novel coronavirus (COVID-19) has become a serious public threat and disrupted many lives,assessing the efficacy of FDA-approved Zn-ejector drugs such as disulfiram combined with interferon to treat COVID-19 infected patients has been proposed. The key strategies for preventing lung damages include avoiding direct lung infection, altering host-virus interactions, promoting immune responses, diluting virus concentrations in lung tissues by promoting viral migration to the rest of the body, maintaining waste removal balance, protecting heart function and renal function, avoiding other infections, reducing allergic reactions and anti-inflammatory. The interactions had been found on the binding specificity by Zn2+ ions-centered tetrahedral geometric coordination of the inhibitors against 3C and 3C-like proteases. In addition, transient zinc chelation TPEN and EPDTC have been noted as preventing virus replication. Zinc-induced ROS production in COVID-19 respiratory ailment and pneumonia occurs both in children and adults. In children. ROS production in zinc (Ⅱ)-immune pediatric patient with COVID-19 bronchitis and pneumonia cannot be elucidated yet. In adults, zinc induced ROS generation in pulmonary COVID-19 infected cells is that alterations of ROS-producing and scavenging pathways that are caused by respiratory viral infections are implicated in inflammation, lung epithelial disruption, and tissue damage, and, in some cases, even pulmonary fibrosis. The involvement of oxidative stress in cell deaths caused during RNA virus infection and ROS production is correlated with host cell death.

The case is that of 83 year-old African American man with hypertension, hepatitis C induced decompensated cirrhosis with ascites, end-stage renal disease (ESRD) on hemodialysis, fluid overload with peripheral edema and chronic hypotension. The patient was referred to the dialysis access center of Pittsburgh, PA for evaluation of his prolonged bleeding from the left upper arm brachial-basilic arterial-venous fistula (BBAVF).

Pulmonary embolism (PE) is an age-related disorder which is potentially fatal, but frequently misdiagnosed. However, the true prevalence of pulmonary embolism is unknown. Inaccurate estimates of PE prevalence might, in part, be attributable to underrecognition of atypical presentations of this disorder. If true prevalence is unknown, the positive predictive values of both typical and atypical symptoms and signs of PE will be unreliable. The negative predictive value of those parameters will, likewise, be unreliable. The aim of this review is to make clinicians more aware of atypical manifestations of PE, thereby increasing the likelihood of correct diagnosis and, hence, ascertainment of the true prevalence of PE. The range of atypical manifestations was explored by a literature search, using MEDLINE from 1946 to February 2019, and EMBASE, from 1947 to February 2019, and Pubmed, from February 2014 to February 2019, using the search terms atypical, uncommon, unusual, pulmonary embolism, lung embolism, pulmonary thromboembolism. This search revealed atypical presenting features such as non pleuritic retrosternal pain, abdominal pain, atypical breathing patterns, pulmonary oedema, Dressler’s syndrome, atypical radiographic manifestations, atypical electrocardiographic features, manifestations associated with oxygen saturation of 95% or more, coexistence of acute myocardial infarction and pulmonary embolism, coexistence of thoracic aortic dissection and pulmonary embolism, neurological manifestations other than stroke, paradoxical embolism, acute venous thrombosis of atypical location, and pulmonary embolism with normal D-dimer levels.

Dissecting aortic aneurysm with ST segment elevation, and pulmonary embolism with ST segment elevation are two of a number of clinical entities which can simulate ST segment elevation myocardial infarction. Objective: The purpose of this review is to analyse clinical features in anecdotal reports of 138 dissecting aortic aneurysm patients with STEMI-like presentation, and 102 pulmonary embolism patients with STEMI-like presentation in order to generate insights which might help to optimise triage of patients with STEMI-like clinical presentation. Methods: Reports were culled from a literature search covering the period January 2000 to March 2020 using Googlescholar, Pubmed, EMBASE and MEDLINE. Reports were included only if there was a specification of the location of ST segment elevation and an account of the clinical signs and symptoms. Search terms were “ST segment elevation”,”aortic dissection”, “pulmonary embolism”, “myocardial infarction”, and “paradoxical embolism”. Fisher’s exact test was utilised for two-sided comparison of proportions. Proportion was calculated for each group as the number of patients with that parameter relative to the total number of patients assessed for that parameter. Findings: There were 138 patients with aortic dissection, 91 of whom were either fast-tracked to coronary angiography (81 patients) or fast-tracked to thrombolytic treatment (10 patients). There were 47 patients managed with neither of those strategies. There were 102 patients with pulmonary embolism, 71 of whom were fast tracked to coronary angiography, and 31 who did not receive that evaluation. Compared with their dissecting aortic aneurysm counterparts, those dissecting aortic aneurysm patients initially managed by percutaneous coronary intervention or by thrombolysis were significantly (p = 0.0003) more likely to have presented with chest pain, and significantly (p = 0.018) less likely to have presented with breathlessness. The preferential fast-tracking to coronary angiography prevailed in spite of comparable prevalence of back pain in fast tracked and in non-fast tracked subjects. Use of transthoracic echocardiography was also comparable in the two subgroups of dissecting aortic aneurysm patients. Pulmonary embolism patients fast tracked to percutaneous coronary intervention were significantly (p = 0.0008) more likely to have presented with chest pain than their pulmonary embolism counterparts who were not fast-tracked. The prevalence of paradoxical embolism was also significantly (p = 0.0016) higher in fast-tracked patients than in counterparts not fast-tracked. Cardiac arrest was significantly (p = 0.0177) less prevalent in fast-tracked pulmonary embolism patients than in pulmonary embolism patients who were not fast-tracked. Preferential fast-tracking to coronary angiography prevailed in spite of the fact that prevalence of documented deep vein thrombosis was comparable in fast-tracked subjects and in subjects not fast-tracked. The prevalence of use of transthoracic echocardiography was also similar in fast-tracked pulmonary embolism patients vs counterparts not fast tracked. Overall, however, transthoracic echocardiography had been utilised significantly (p = 0.007) less frequently in dissecting aneurysm patients than in pulmonary embolism patients. Conclusion: Given the high prevalence of STEMI-like presentation in aortic dissection there is a need for greater use of point-of-care transthoracic echocardiography to mitigate risk of inappropriate percutaneous coronary intervention(which might delay implementation of aortic repair surgery) and inappropriate thrombolysis(which might precipitate hemorrhagic cardiac tamponade) (75) during triage of patients presenting with ST segment elevation simulating ST segment elevation myocardial infarction (STEMI). Furthermore, during triage of patients with STEMI-like clinical presentation, the combined use of point-of -care echocardiography and evaluation for deep vein thrombosis will facilitate the differentiation between acute myocardial infarction, STEMI-like aortic dissection, and STEMI-like pulmonary embolism. Among STEMI-like patients in whom DAA has been ruled out by point of care TTE, fast tracking to PCI might generate an opportunity to identify and treat paradoxical coronary artery embolism by thrombectomy. Thereby mitigating the mortality risk associated with coronary occlusion. Concurrent awareness of PE as the underlying cause of paradoxical embolism also generates an opportunity to relieve the clot burden in the pulmonary circulation, either by pulmonary embolectomy or by thrombolysis. Above all, frontline clinicians should have a greater awareness of the syndrome of STEMI-like presentation of aortic dissection and STEMI-like pulmonary embolism so as to mitigate the risk of inappropriate thrombolysis and inappropriate percutaneous coronary angiography which seems to prevail even in the presence of red flags such as back pain (for aortic dissection) and deep vein thrombosis(for pulmonary embolism). 

Sleep related breathing disorders (SRBD) are among seven well-established major categories of sleep disorders defined in the third edition of The International Classification of Sleep Disorders (ICSD-3), and Obstructive Sleep Apnea (OSA) is the most common SRBD [1,2]. Several studies have demonstrated that obstructive sleep apnea treatment increases the quality of life in OSA patients [3-8]. Indeed, excessive daytime sleepiness (EDS), cognitive impairment (e.g., deficits in attention-concentration, memory, dexterity, and creativity), traffic accidents, and deterioration of social activities are frequently reported in untreated patients [9-11]. Furthermore, an increase in cardiovascular morbidities and mortality (systemic hypertension, stroke, cardiac arrhythmias, pulmonary arterial hypertension, heart failure) [12], metabolic dysfunction, cerebrovascular ischemic events and chemical/structural central nervous system cellular injuries (gray/white matter) has been reported in OSA patients [13-17].  Continuous positive airway pressure (CPAP) therapy is considered the gold standard for treatment of moderate-severe OSA, nevertheless there is an increasing body of evidence supporting the usefulness of mandibular advancement devices (MADs) for improving quality of life and respiratory parameters even among patients with a high severity of OSA burden [5,10,18,19]. According to the standard of care of the American Academy of Sleep Medicine (AASM), MADs are indicated for mild to moderate OSA particularly in the context of CPAP intolerance or refusal, surgical contraindication, or the need for a short-term substitute therapy [9,15,20-22]. In Cuba, CPAP machines are not readily available; they are expensive and the majority of OSA patients cannot obtain this mode of therapy. Taking into account this problem, our hypothesis was based in the scientific evidences of MAD effectiveness, considering that low cost MADs could offer a reasonable alternative treatment for patients with OSA where CPAP technology are not handy. In this way our purpose was to assess the efficacy of one of the most simple, low cost, manufactured monoblock MAD models (SAS de Zúrich) in terms of improvements in cerebral function, sleep quality and drowsiness reports in a group of Cuban OSA patients with mild to severe disease. Outcome measures included changes in the brain electrical activity, sleep quality, and respiratory parameters, measured by EEG recording with qEEG analysis and polysomnographic studies correspondingly, which were recorded before and during treatment with an MAD, as well as subjective/objective improvements in daytime alertness. 

A 61-year-old Brazilian black woman consulted with a nephrologist due to proteinuria identified on a routine urine test. She has a personal history of thymoma resection five years ago, followed by multiple episodes of pulmonary infections including mycobacteriosis, recurrent mucocutaneous candidiasis, and paraneoplastic pemphigus. Physical examination showed no edema or hypertension and laboratory tests identified proteinuria of 2.43 g/day without hematuria, serum creatinine of 0.69 mg/dl, urea 34 mg/dl, serum albumin of 2.4 g/dl, hemoglobin 10.9 g/dl, platelets 292,000/mm3, leukocytes 4950/mm3, lymphocytes 594/mm3 and neutrophils 3910/mm3. The hemolysis tests were negative and serum iron was low. Analysis of glicemia and serum lipids levels were normal as well as serum complement and imunoglobulins, except for an IgM level of 283 mg/dl (normal values 40 to 230 mg/dl) and undetectable IgE. Serologies for Syphilis, HIV, hepatitis B, C and antibodies for autoimmune diseases were negative. 

Granulomatosis with polyangiitis (GPA), a form of ANCA-associated vasculitis (AAV), is a rare disease with an often-occult presentation. It is more common in 4th and 5th decades of life but can be seen in all ages. This case report details a 76-year-old female presenting with abdominal pain, generalized weakness, and malaise, who was found to have pulmonary nodules on chest imaging. Biopsy of the lung nodule showed organizing pneumonia. Initially, antibiotics were used to treat the patient. However, she developed acute renal failure a few days after presentation and found to have positive serum C-ANCA as well as elevated ANCA-PR3 serologies. A subsequent kidney biopsy demonstrated pauci-immune necrotizing and crescentic glomerulonephritis that was consistent with GPA and the patient was started immediately on combination immunosuppressive therapy, plasmapheresis, and hemodialysis. GPA’s clinical and radiological presentation can mimic other common conditions such as pneumonia, malignancy, bacterial sinusitis, pulmonary tuberculosis, sarcoidosis, and urinary tract infection. Because of this, a high level of suspicion is required for early diagnosis and treatment to alter the high mortality rate in this disease entity. All forms of ANCA-associated vasculitis (AAV) should be in the differential diagnosis for all patients presenting with multiorgan system involvement particularly in individuals with pulmonary and renal manifesations.

Introduction: Acute kidney injury (AKI) is one of the complications associated with severe COVID-19 infection, and it can present in up to 20% to 40% of the cases; of these, approximately 20% will require renal replacement therapy (RRT). Objective: To establish clinical and laboratory characteristics in a group of patients from Colombia with COVID-19 infection and AKI that received intermittent and prolonged RRT with the GENIUS® 90 technology in between March and July 2020. Design: Cross-sectional study. Results: 78.9% of participants were men and 21.1% were women. The main comorbidities were the following: Hypertension (65.3%), diabetes mellitus (38.9%), obesity (26.3%), cancer (5.3%), Chronic obstructive pulmonary disease (11.6%), cardiovascular disease (23.2%), active smoking (11.6%). 33.7% had chronic kidney disease (CKD) in the average serum creatinine on admission was 4.4 mg/dl. The following inflammatory markers were elevated: C-reactive protein (CRP), d-dimer and ferritin (20.3 mg/dl, 931mcg/l and 1174 ng/ml, respectively). 63.5% of patients underwent sustained low-efficiency dialysis (SLED) (6 to 12 hours) and the rest of the patients (36.35%) underwent conventional hemodialysis (less than 4 hours). The mortality of the total patient sample was 36.9%, lower in patients with CKD than in patients with no previous renal disease history (18.7% and 40.1%, respectively). Conclusion: Renal complications are frequent in patients with severe COVID-19. The development of AKI could be an isolated prognostic marker associated with an increase in mortality in patients with COVID-19, and one of the options is intermittent and prolonged RRT with the GENIUS® 90 system.

Diffuse alveolar hemorrhage (DAH) is a rare complication of systemic lupus erythematosus (SLE) and carries a high mortality. It was first described by Osler in 1904 as the most devastating pulmonary complication of SLE. We describe a case of a 23-year-old girl recently diagnosed with SLE associated by a class III nephritis treated with oral corticoids and mycophenolate mofetil who developed a Diffuse Alveolar Hemorrhage DAH a few days later. The early diagnosis and the aggressive therapy allowed us to have a favorable outcome.

Systemic arterial air embolism (SAAE) is a rare but serious complication of CT-guided hook wire localization of pulmonary nodule usually with catastrophic and poor outcome. Hook wire needle localization is done pre-operatively by placing wire around or into the pulmonary nodule to provide the thoracic surgeon accurate location guidance of the target nodule for Video-Assisted Thoracoscopic Surgery (VATS) wedge resection with safety margins. Physicians should be aware of this possible complication during the procedure in order to rescue the patient promptly as it requires rapid diagnosis and management. We describe a 55-year-old male who underwent a CT-guided hook wire needle localization of left upper lobe lung cancer and left lower lobe pulmonary nodule prior to planned VATS wedge resection who developed altered mental status and bilateral lower extremities paralysis after wire placement was completed. His CT head demonstrated small air embolism in the left occipital area, confirming the diagnosis of cerebral air embolism and follow up CT and MRI of the head revealed multiple areas of brain infarction. In addition, he was diagnosed with anterior spinal cord syndrome (ACS), most likely due to anterior spinal artery ischemia from micro air embolism on the basis of clinical findings but with negative ischemic changes on MRI of the spinal cord. His mental status recovered but he remained paraplegic and transferred to inpatient rehabilitation service.