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Coronavirus Disease 19 (COVID-19) evolved into a pandemic to torment the world since the last 15 months and has resulted in millions of individuals getting affected. It has caused significant strain on the health care systems in developed and developing countries alike. It has killed more than two million patients globally. The potential of this virus to cause multi-organ dysfunction with associated significant mortality and morbidity has made it the most formidable enemy we have faced since the great plague. COVID-19 is becoming a mystery with its plethora of typical and atypical clinical presentations. Its ability to get attached to widely distributed human angiotensin-converting enzyme-2 (hACE2) receptors, has enabled it to cause multi-organ dysfunction and extensive disease. In this chapter, we review the pulmonary and extra-pulmonary manifestations of SARS-CoV-2 and try to elucidate organ-specific patho-physiology. Organ dysfunction leading to a myriad of cardiac dysfunction, symptoms related to gut and liver, nervous system involvement, renal and ocular injury is being discussed in this chapter. An effort to raise awareness of the potential to cause long covid syndrome is being made to identify the possible burden of morbidity we might have to experience post covid 19 pandemic. © The Author(s), under exclusive licence to Springer Nature Singapore Pte Ltd. 2021.
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Introduction: Patients who have had a stroke or transient ischaemic attack (TIA) are at high risk of recurrent events. Around 90% of strokes are associated with ten modifiable risk factors. The prevalence of modifiable risk factors is high, with 89% of stroke clinic patients at Guy's and St. Thomas' Hospital having at least one. This study aimed to explore the patient experience of a novel virtual dietetic secondary prevention service, between November and December 2020, developed in response to the COVID-19 pandemic. Method(s): A questionnaire was developed to explore patients' experience of receiving virtual consultation with the Specialist Stroke Dietitian for the secondary stroke or TIA prevention. The questionnaire, informed by a literature review, was piloted with dietitians and patients. The Questionnaire was used to develop a topic guide for structured in-depth telephone interviews. Patients (n=8) who completed a telephone consultation with the Stroke Dietitian were invited to participate in a structured telephone interview with the researcher. The Framework method was used for thematic analysis. Result(s): Six patients aged 30-69 years discussed their experience of secondary prevention dietetic consultations. Thematic analysis suggests that new knowledge obtained, nutrition education provided, and the Dietitian's interpersonal communication style were key factors that improved confidence, facilitated behaviour change and contributed to a positive patient experience. Participants expressed a preference for telephone appointments rather than face-to-face or video. Conclusion(s): Exploration of patient experience is central to the design of novel clinical services. Our pilot questionnaire can be modified for use in future stroke service development.
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Introduction: Incidence of AKI reported varies from 0.5% to 37%.These incidence cannot be extrapolated in our patients as the severity of COVID-19 infection, the ethnicity of the patients l, the clinical profile and the healthcare delivery system is different.The aim of this study was to explore whether urinary cell cycle arrest markers and other renal biomarkers have a role in predicting AKI in critically ill patients with COVID-19 and acute respiratory disease Methods: This prospective, longitudinal cohort study included critically ill COVID-19 patients without AKI at study entry. Patients aged more than 18 years with moderate or severe respiratory disease as defined by Berlin criteria were subsequently recruited from November 2020 to May 2021. Urine samples were collected on admission to critical care areas for determination of KIM1, NGAL, IL-18,IGF-BP-7, TIMP -2 at the time point of study inclusion, 12h, 24h, 48h, after inclusion. The demographic information, comorbidities, clinical, and laboratory data were recorded. The study outcomes were the development of AKI and mortality during hospitalization. Result(s): [Formula presented] ROC analysis was done to determine the diagnostic performance of the various urinary biomarkers;AUC was 0.655 for normalised IL-18, 0.685 for normalised NGAL, 0.658 for normalised TIM-1, and so on Conclusion(s): AKI was common in critically ill COVID-19 patients. Raised values of urinary biomarkers with clinical information, are useful for the identification of AKI in critically ill COVID-19 patients. No conflict of interestCopyright © 2023
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Introduction: The Sentinel Stroke National Audit Programme (SSNAP) includes a biennial 'snap-shot' of the organisation of stroke services in acute hospitals in England, Wales, and Northern Ireland. The timing of the 2019 and 2021 audits, before and during the COVID-19 pandemic, provides an opportunity to assess its impact on acute stroke care services. Method(s): A web-based proforma was sent to eligible acute hospitals requesting details of the organisation of acute stroke care services on 3rd June,2019 and 1st October,2021. In 2019, 183 acute services representing 4,847 acute beds were included. In 2021, 182 acute services were included representing 4,707 acute beds. This represents 100% participation of eligible providers. Result(s): 82% of sites (128/157) made changes in response to COVID-19 and as of October 1st, 2021, 90% reported that these changes remained in place. The number of sites reaching minimum staffing levels in several criteria fell. The availability of band 6 or 7 specialist nurses per ten beds at weekends reduced (58%-46%, p=0.03), and sites with at least one stroke consultant vacancy rose to 52%. Hospitals with a qualified psychologist on the acute unit remained low (7%-9%). A decrease was seen in sites meeting the minimum number of nurses on duty at the weekend (30%-23%,p=0.13). Conclusion(s): A large majority of sites made changes in service provision due to COVID-19 and many of these remained in place in October 2021. Reductions in the number and availability of senior clinical staff over the pandemic are reflected in these changes over time, which may have implications for the recovery of services.
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INTRODUCTION: Admissions to the intensive care unit (ICU) for children with hyperglycemic crisis (HGC, defined as diabetic ketoacidosis, hyperglycemic hyperosmolar syndrome, or hyperosmolar ketoacidosis) increased during the COVID-19 pandemic, possibly from social distancing resulting in decreased or delayed health care access. We sought to determine if severity of illness for HGC changed from pandemic year 1 to year 2 as social distancing restrictions lightened. METHOD(S): Retrospective study of children <= 18 y/o hospitalized from 3/2017 to 3/2022 in the Pediatric Health Information System for HGC. PreCOVID years (3/2017- 3/2020), COVID-19 year 1 (3/2020-3/2021), and COVID-19 year 2 (3/2021-3/2022). The primary outcome was ICU admission. Secondary outcomes included ICU length of stay (LOS) >3 days, use of therapies for neurologic compromise, and cost. RESULT(S): From 42 hospitals, 46,220 patients were admitted with HGC, of these, 19,889 patients were admitted to the ICU. There was a decrease in ICU admissions from COVID-19 year 1 (47.4%) to year 2 (44.6%) but both remained higher than PreCOVID (40.7%). Median admission cost remained elevated in year 1 ($11,134 [IQR $6,412, $13,060) and year 2 ($11,057 [IQR $7,974, $15,997]) compared to PreCovid ($9,206 [IQR $7,741, $16,069]). In multivariable analysis, when compared to PreCOVID, ICU admissions for HGC were higher in COVID-19 year 1 (OR 1.31 [95%CI 1.25-1.37], p< 0.01) and year 2 (OR 1.16 [95% CI 1.10-1.22], p< 0.01) after controlling for confounding variables. However, ICU admissions were higher in year 1 than year 2 (OR 1.13, 95% CI [1.075-1.20], p=< 0.01). ICU LOS >3days increased when compared to PreCOVID years (COVID-19 Year 1: OR 1.70, [95% CI: 1.38-2.09], p< 0.01, Year 2: OR: 1.6 [95% CI 1.3-1.97], p< 0.001) but there was no difference between year 1 and 2 (p=0.6). Therapies for neurologic compromise increased in COVID-19 year 1 (p< 0.01) and year 2 (p < 0.01) in comparison to PreCOVID years but there was no change between COVID-19 years (p=0.15). CONCLUSION(S): During the COVID-19 pandemic, children with HGC were admitted with a higher severity of illness than pre-COVID. This pattern continued during Covid-19 year 2 despite reduction in social distancing although need for ICU admission was higher in COVID-19 Year 1 than Year 2.
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SARS-CoV-2 is highly infectious and has ability to mutate into newer, more contagious, and lethal strains. Moreover, presence of comorbidities and low immunity increases the COVID-19 susceptibility and severity. Thus, COVID-19 is challenging to treat and eradicate globally. This increase stress and anxiety among the patients, worsening their condition. Even health care workers (HCWs) are distressed and anxious while managing the COVID-19. Mental stress and depression increases risk of COVID-19. Yogic breathing techniques may be beneficial in improving immunity and reducing stress and anxiety. The present study investigated the effectiveness of short and controlled Yoga-based breathing protocols in COVID-positive, COVID-recovered and HCWs. Study subjects were recruited from Postgraduate Institute of Medical Education and Research, Chandigarh, India from 13th October, 2020 to 7th January 2021. Each group was randomly divided into intervention or yoga group and non-intervention or control group. COVID-positive practiced a 5-min routine and COVID-recovered and HCW practiced 5-min and 18-min routines for 15 days. Pre-post estimation of neuropsychological parameters and heart rate variability and baseline, 7th and 15th day estimation of biochemical parameters, 6-minute walk and 1-minute sit-stand tests were conducted. Based on Ayurveda, Prakriti-type was assessed. WBC count was elevated in COVID-positive intervention (p<0.001) and control groups (p=0.003). WBC count (p=0.002) and D-dimer (p=0.002) was decreased in COVID-recovered intervention. A non-significant reduction in perceived stress and tension was noted in COVID-positive intervention. Tension was reduced and quality of life improved in HCW intervention (p>0.05). The Kapha Prakriti (48.9 %) was dominant among COVID-19 infected (positive and recovered) subjects. Distance covered in 6-min increased after intervention in COVID-positive (p=0.01) and HCW (p=0.002). The covered distance was more after intervention in all groups than control sub-group. COVID-positive intervention group shows reduced heart rate (p>0.05) and high-frequency power (p=0.01). The interventions were capable of improving exercise capacity in patients and HCW and reduced cardiovascular risk in COVID-19. The studied breathing protocol can be integrated for the management of COVID-19 and is beneficial to HCWs.
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Background: The COVID-19 pandemic has been reported as affecting the quality and outcomes of stroke care around the world. The impact of the first and second waves of the pandemic in the UK are compared. Methods: Data were extracted from the Sentinel Stroke National Audit Programme database of stroke admissions in England, Wales and Northern Ireland. Care quality and outcomes for 72,698 patients admitted during the first (1 March - 30 June 2020) and second (27 September 2020 - 31 March 2021) pandemic waves were compared. Results: From the first to second wave, there was an increase in mild strokes admitted (40.3% to 41.3%;p=0.002) and median NIHSS on arrival decreased (5 vs 4, p<0.001). The second wave was characterised by a decrease in direct stroke unit admission (79.8% to 76.6% ;p<0.001). Time to initial assessment by all specialists increased. Time to stroke consultant assessment increased by 34 minutes (262 vs 296 minutes;p<0.001). Complications (pneumonia: 8.6% to 9.4%, UTI: 3.3% to 3.9%;both p < 0.001) and in-hospital mortality (10.6% to 12.4%;p<0.001) increased significantly. Moderate and moderately-severe disability were more prevalent at discharge (18.1 to 18.6%, 18.3% to 19.9% respectively;p<0.001). Early supported discharge increased from 39.1% to 44.5% (p>0.001). Conclusions: Hospital avoidance by patients with mild stroke seen in the first wave was not replicated in the second wave. COVID-19 pressures on hospitals in the second wave appeared to result in fewer direct stroke unit admissions, delays in acute assessment, more complications, and more in-hospital deaths. (Figure Presented).
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Background: Covid-19 like other viruses, can change the immunohematological profile of the infected patients and timely identification of these changes can help in the management of these patients. There are various reports which have shown decline in haemoglobin in covid patients due to autoimmune red cell hemolysis. One recent study has shown that patients admitted in ICU have higher chances of DAT positivity as compared to non-covid patients. Aims: • To assess the Immunohematological profile of COVID-19 positive patients. • To find any correlation between the immunohematological profile and clinical spectrum of COVID-19 disease. Methods: It was a prospective observational study. Blood grouping, Direct antiglobulin test (DAT) and antibody screening (ABS) were performed on RT-PCR confirmed COVID-19 positive and COVID-19 negative patients admitted in Intensive care units and General wards of our institute. The immunohematological findings were also correlated with the patient clinical laboratory profiles. Results: A total of 205 patients were recruited. Out of which 102 were RT-PCR Covid-19 positive and 103 were negative. There was difference in blood group distribution with significantly less O group individuals in RT-PCR negative group. The overall DAT positivity was seen in 24.4% of the total 203 patients enrolled in the study. The DAT positivity was significantly higher (p value 0.01) in COVID-19 positive patients (32%) than COVID-19 negative patients (16.7%). However, there was no significant difference in the percentage of DAT positivity among patients admitted in ICU or general ward patients. Among COVID-19 positive patients, the mean haemoglobin was statistically significantly (p value 0.02) lower in DAT positive (Mean Hb: 8.5gm/dl) as compared to DAT negative patients (Mean Hb 9.6gm/dl). Also, DAT positive patients among COVID-19 positive patients were found to have significantly higher C-Reactive protein levels (p value: 0.05). There was no significant difference in other biochemical parameters between COVID-19 positive and COVID-19 negative individuals. DAT positivity was not associated with any drug intake or co-morbid state. Summary/Conclusions: Like other bacterial and viral infections, COVID-19 is also associated with DAT positivity indicating some autoimmune phenomenon due to exposure of the crypt antigens. The specificity of antibodies involved in DAT are mainly IgG and hence it may present as autoimmune hemolytic anaemia. And its association with increased inflammatory makers can help us in decision making by blood transfusion services and better management of COVID-19 patients requiring blood transfusion. .
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Objective: To describe two cases of intentional paraquat ingestion as self-harm in patients with COVID-19 infection. Methods: We retrospectively analysed poisoning cases (accidental and suicidal), admitted to a dedicated COVID-19 care facility at our institute. As a protocol, all patients coming to our emergency department were reverse transcriptase-PCR tested for novel coronavirus disease 2019 (nCOVID-19) before being admitted to a high dependency unit (HDU) intensive care unit (ICU). If they tested positive for COVID they were transferred to a dedicated COVID care facility. These patients were treated according to the protocol developed for poisoned patients. All patients were followed until discharge or death. We describe the details of 2 patients with intentional paraquat ingestion. Results: We received nine patients at our dedicated COVID care facility created at our institute during the pandemic. Of these 9, 2 patients had ingested paraquat and presented with acute respiratory distress syndrome (ARDS). Both patients were in the third decade of life and the economic crisis due to the pandemic was the trigger for the ingestion of paraquat. Both had ingested a significant amount of commercially available paraquat. They had significant acute kidney and liver injury at presentation and required dialysis. Haemoperfusion was not performed as the charcoal filters were not available. The clinical picture and chest X-rays were similar to the findings observed in severe COVID-19 patients. Since patients were hypoxic at presentation, monoclonal antibodies were not indicated and were not administered. Both patients were given dexamethasone (6mg daily), as per the “COVID treatment protocol”. We did not administer pulse doses of methylprednisolone or cyclophosphamide due to concerns over exacerbating COVID infection. One of the patients developed significant oesophageal ulceration leading to massive haematemesis. Both developed spontaneous pneumomediastinum and succumbed to their illness after an average stay of 8 days in the HDU. Conclusion: During the pandemic, paraquat ingestion for selfharm with COVID-19 infection poses a challenge to treating physicians. Since the clinical picture of ARDS, is similar to severe COVID infection, the management with immunosuppressive agents becomes difficult.
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Introduction: The cause of respiratory distress by the novel corona virus is an acute hyper inflammatory “cytokine storm”. Besides glucocorticoids, tocilizumab, a recombinant monoclonal antibody, directed against the IL-6 receptor, has been used as a treatment modality with variable results [1]. Factors affecting poor response to tocilizumab remain unrecognized. We report a model to predict worse outcomes among patients with severe COVID-19 pneumonia treated with tocilizumab. Methods: In this retrospective study, patients with severe COVID 19 pneumonia admitted to the intensive care unit of our hospital who received Inj. tocilizumab besides the standard treatment between July 2020 to July 2021, were included. Electronic records of such patients were accessed and demographic, biochemical and outcome measures were recorded. Patients were divided into survivor cohort and mortality cohort. To predict mortality as an outcome, a multivariate logistic regression model was constructed. Results: Total of 101 patients were included, 71 in survival cohort and 30 in mortality cohort. Lactate dehydrogenase (LDH), neutrophil to lymphocyte ratio (NL ratio), creatine kinase myocardial band (CKMB) and partial pressure of oxygen to fraction of inspired oxygen ratio (PFR) on day of drug administration differed significantly among the two cohorts after correction for multiple comparison. However, on multivariable logistic regression analysis, a model incorporating LDH, NL ratio, pro-brain natriuretic peptide levels (ProBNP) and PFR best predicted mortality (Fig. 1). A nomogram was also created to estimate probability of mortality using the model parameters. Conclusions: LDH, ProBNP, NL ratio and PFR at Tocilizumab administration are independently associated with mortality. A model incorporating the combination of these parameters at admission can predict mortality among patients with severe COVID-19 pneumonia with good accuracy. (Figure Presented).
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Background: Although hydroxychloroquine (HCQ) lacks benefit in patients with moderate-to-severe COVID-19, its role in asymptomatic and mildly symptomatic disease needs better elucidation. Methods: This multi-centre cohort study included asymptomatic and mildly symptomatic, RT-PCR confirmed COVID-19 cases between 30 March and 20 May, 2020. Patients were categorized into two groups (HCQ-treated and untreated) based on exposure to HCQ. Dose of HCQ used was 400 mg twice daily (day one) followed by once daily for seven days. HCQ-untreated patients were managed supportively without any active antiviral or immunomodulatory therapy. Nasopharyngeal SARS-CoV-2 clearance by RT-PCR (primary outcome) was compared between HCQ-treated and untreated patients using Kaplan-Meier analysis and Cox proportional-hazards regression. Clinical efficacy and safety profile of HCQ were assessed (secondary outcomes). Results:162 patients [84 (51·9%) males;mean age 38·2 (15·2) years] were included. Forty-four (27·2%) patients had mild disease, rest 118 (72·8%) were asymptomatic. Seventy-five (46·3%) patients received HCQ. Median time to virological negativity was lesser in HCQ-treated (13 days) versus untreated patients (15 days) (log-rank<0·001) in both asymptomatic and mildly symptomatic patients. Treatment with HCQ was the only independent predictor of virological negativity (hazard-ratio=2·24;adjusted p-value<0·001). Two (5·4%) mildly symptomatic patients progressed to severe disease within 24 hours (two doses) of HCQ initiation, compared to none in the HCQ-untreated group. Five HCQ-treated patients developed minor gastrointestinal side effects, not requiring drug discontinuation. Conclusion: HCQ reduced the time to virologic negativity (by 2 days) in asymptomatic and mildly symptomatic COVID-19, without any serious adverse events. However, no obvious clinical benefit was noted. © 2022 Journal of Association of Physicians of India. All rights reserved.
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OBJECTIVE: To elucidate the aetiopathogenesis of facial neuritis in coronavirus disease 2019 associated mucormycosis. METHODS: A retrospective review was conducted of coronavirus disease 2019 associated mucormycosis patients who presented with peripheral facial nerve palsy from January 2021 to July 2021. The clinico-radiological details of four patients were assessed to examine the potential mechanism of facial nerve involvement. RESULTS: Serial radiological evaluation with contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging revealed infratemporal fossa involvement in all cases, with the inflammation extending along fascial planes to reach the stylomastoid foramen. Ascending neuritis with an enhancement of the facial nerve was demonstrated in all cases. CONCLUSION: The likely explanation for facial palsy in patients with coronavirus disease 2019 associated mucormycosis, backed by radiology, is the disease abutting the facial nerve at the stylomastoid foramen and causing ascending neuritis of the facial nerve.
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COVID-19 , Facial Nerve Diseases , Facial Paralysis , Mucormycosis , Neuritis , Radiology , COVID-19/complications , Facial Nerve/diagnostic imaging , Facial Nerve/pathology , Facial Paralysis/etiology , Humans , Magnetic Resonance Imaging/adverse effects , Mucormycosis/complications , Mucormycosis/diagnostic imaging , Neuritis/complications , Neuritis/pathologyABSTRACT
Introduction: Severe acute respiratory syndrome coronavirus 2 (SARSCoV- 2) is a known respiratory pathogen, its impact on other organs including the pancreas has been reported. Only case reports and few retrospective studies have linked coronavirus disease 2019 (COVID-19) to acute pancreatitis (AP) and pancreatic injury (PI). Aims & Methods: This prospective study was planned to look at the incidence of PI in COVID-19 positive patients and its implications. All consecutive patients of established COVID-19 positive cases presenting to a tertiary care center in India between July and October 2020 were assessed. Detailed symptomatology was documented including respiratory and gastrointestinal (GI) symptoms. Prior co-morbidities, drug history and medical history were documented, and patients on pancreatic enzyme level influencing drugs were excluded. All patients, on admission, underwent blood cytology, biochemical parameters and serum inflammatory markers estimation. Pancreatic injury (PI) was defined as any abnormal value of amylase (normal 0-100 U/L) or lipase (normal 0-60 U/L). Patients having clinical AP or any pre-existing GI diseases were excluded. Outcome measures such as need for ICU, oxygen requirement, need for ventilation and mortality were noted. Results: Out of 244 patients screened, 40 were excluded. Of the 203 patients, (128 males;63.1%) studied, 72 (35.5%) had PI. Comparing patients with PI and those without (Table 1) showed that both groups had similar respiratory and/or GI symptoms profile, while asymptomatic cases had less pancreatic enzyme elevation (p=0.035). PI was noted in the older age group (49.83 vs 37.12 yrs., p=0.01) with a male predominance. PI group had a higher proportion of severe disease (29.2% vs 8.4%;p<0.0001) with significantly higher levels of serum ferritin, D-dimer, fibrinogen, procalcitonin and C-reactive protein (CRP) and higher baseline triglyceride (TG) levels. PI group showed higher ICU (p<0.0001), oxygen (p<0.0001) & mechanical ventilation (p=0.003) requirements and mortality (p=0.018). Multivariate regression analysis showed that the severity of the disease was a significant predictor (aOR-4.68;p=0.003) of PI. Diabetes was found to be higher in the PI group (p<0.0001), but not so when adjusted for disease severity. Of all PI patients, 7(3.45%) had enzyme elevation >3 times the upper limit of the normal (ULN), more in severe disease (Severe-4;12.5% vs moderate-2;4% vs mild-1;0.8%, p=0.005). Conclusion: Incidence of PI was seen in more than 1/3rd of the COVID-19 positive patients. PI is not uncommon in COVID-19 patients and is a harbinger of severe disease with greater inflammatory burst and higher intensive care requirement with poorer outcome.