New Insights on the Mechanisms of Myocardial Injury in Hypertensive Patients With COVID-19.

PURPOSE: Myocardial injury is common in hypertensive patients with 2019 coronavirus disease (COVID-19). Immune dysregulation could be associated to cardiac injury in these patients, but the underlying mechanism has not been fully elucidated. METHODS: All patients were selected prospectively from a multicenter registry of adults hospitalized with confirmed COVID-19. Cases had hypertension and myocardial injury, defined by troponin levels above the 99th percentile upper reference limit, and controls were hypertensive patients with no myocardial injury. Biomarkers and immune cell subsets were quantified and compared between the two groups. A multiple logistic regression model was used to analyze the associations of clinical and immune variables with myocardial injury. RESULTS: The sample comprised 193 patients divided into two groups: 47 cases and 146 controls. Relative to controls, cases had lower total lymphocyte count, percentage of T lymphocytes, CD8+CD38+ mean fluorescence intensity (MFI), and percentage of CD8+ human leukocyte antigen DR isotope (HLA-DR)+ CD38-cells and higher percentage of natural killer lymphocytes, natural killer group 2A (NKG2A)+ MFI, percentage of CD8+CD38+cells, CD8+HLA-DR+MFI, CD8+NKG2A+MFI, and percentage of CD8+HLA-DR-CD38+cells. On multivariate regression, the CD8+HLA-DR+MFI, CD8+CD38+MFI, and total lymphocyte count were associated significantly with myocardial injury. CONCLUSION: Our findings suggest that lymphopenia, CD8+CD38+MFI, and CD8+HLA-DR+MFI are immune biomarkers of myocardial injury in hypertensive patients with COVID-19. The immune signature described here may aid in understanding the mechanisms underlying myocardial injury in these patients. The study data might open a new window for improvement in the treatment of hypertensive patients with COVID-19 and myocardial injury.

Why teach with cases?: Reflections on philosophy and practice

This is the first book for educators that combines case pedagogy at a philosophical level with evidence from practical experience into a single volume. It is an implementation ready resource that converges with a time of change in the field of education, as a result of the COVID-19 pandemic. © 2023 Cle-Anne Gabriel. All rights reserved.

Service Evaluation: The Role of Same Day Emergency Care in Managing Acute Neurological Presentations

Background and aim During the COVID-19 pandemic, the neurology department at St Mary's Hospital had to direct the bulk of its acute work to a newly expanded 'hot clinic' running Monday to Friday through Same Day Emergency Care (SDEC). Face to face clinic appointments were also halted and instead triaged to SDEC when examination of the patient was necessary. Patients were referred through a number of routes directly to the neurology consultants or on-call registrar, and subsequently seen on an urgent basis. We were interested in evaluating the types of referrals made to this service as well as their final outcomes. Results A total of 255 patients were seen between 3 March 2021 and 3 August 2021. Approximately a third were from the A&E department and just less than a third were from the Western Eye Hospital, our local ophthalmology A&E. Most referrals were for headache or visual change, and 61% of patients did not need to re-attend SDEC. Importantly, a quarter were discharged home after specialist review, and none required admission from clinic. Thus our emergency service was successful in avoiding admissions while ensuring patients received the care they required in a timely fashion.

Hybrid model for early identification post-Covid-19 sequelae.

Artificial Intelligence techniques based on Machine Learning algorithms, Neural Networks and Naïve Bayes can optimise the diagnostic process of the SARS-CoV-2 or Covid-19. The most significant help of these techniques is analysing data recorded by health professionals when treating patients with this disease. Health professionals' more specific focus is due to the reduction in the number of observable signs and symptoms, ranging from an acute respiratory condition to severe pneumonia, showing an efficient form of attribute engineering. It is important to note that the clinical diagnosis can vary from asymptomatic to extremely harsh conditions. About 80% of patients with Covid-19 may be asymptomatic or have few symptoms. Approximately 20% of the detected cases require hospital care because they have difficulty breathing, of which about 5% may require ventilatory support in the Intensive Care Unit. Also, the present study proposes a hybrid approach model, structured in the composition of Artificial Intelligence techniques, using Machine Learning algorithms, associated with multicriteria methods of decision support based on the Verbal Decision Analysis methodology, aiming at the discovery of knowledge, as well as exploring the predictive power of specific data in this study, to optimise the diagnostic models of Covid-19. Thus, the model will provide greater accuracy to the diagnosis sought through clinical observation.

Hybrid model for early identification post-Covid-19 sequelae

Artificial Intelligence techniques based on Machine Learning algorithms, Neural Networks and Naïve Bayes can optimise the diagnostic process of the SARS-CoV-2 or Covid-19. The most significant help of these techniques is analysing data recorded by health professionals when treating patients with this disease. Health professionals' more specific focus is due to the reduction in the number of observable signs and symptoms, ranging from an acute respiratory condition to severe pneumonia, showing an efficient form of attribute engineering. It is important to note that the clinical diagnosis can vary from asymptomatic to extremely harsh conditions. About 80% of patients with Covid-19 may be asymptomatic or have few symptoms. Approximately 20% of the detected cases require hospital care because they have difficulty breathing, of which about 5% may require ventilatory support in the Intensive Care Unit. Also, the present study proposes a hybrid approach model, structured in the composition of Artificial Intelligence techniques, using Machine Learning algorithms, associated with multicriteria methods of decision support based on the Verbal Decision Analysis methodology, aiming at the discovery of knowledge, as well as exploring the predictive power of specific data in this study, to optimise the diagnostic models of Covid-19. Thus, the model will provide greater accuracy to the diagnosis sought through clinical observation.

Novel intraoperative near-infrared imaging strategy to identify abnormalities in the anterior mediastinum.

Thoracic surgeons are frequently asked to biopsy suspicious tissues in the anterior mediastinum to discriminate between a reactive versus malignant pathology such as lymph nodes. The most common benign cause of a mediastinal lymph node is a reactive lymph node from a prior infection or inflammatory process such as post-COVID or granulomatous disease. The most common malignant cause is a lymphoproliferative disorder but also metastatic disease from neck, breast and other regional cancers. Biopsies in this location are challenging because they are far from the trachea and the sternum is a barrier to most diagnostic procedures. Thus, a surgical biopsy is frequently required and a common procedure for Thoracic surgeons. Technically, identifying these lesions can be challenging, particularly for small lesions or those in patients with high body mass index. In order to improve contrast between diseased tissue in the anterior mediastinum and surrounding adipose tissue, we have been studying near-infrared imaging during surgery using indocyanine green (ICG) to give contrast to the abnormal tissues and to avoid an unnecessary extended resection. We developed a modified technique to give ICG to a patient during a biopsy in the anterior mediastinum to specifically highlight abnormal tissues. As a proof-of-principle, we present a case of a young woman with a suspicious 2 cm mediastinal lymph node that required surgical biopsy.

Risk of SARS-CoV-2 infection in high and low-risk cohabitants, in Loures and Odivelas, Portugal : Inês Mateus Cunha

Background Effective contact tracing, vaccination, and isolation of cases of SARS-CoV-2 infection and their high-risk contacts constituted measures to contain the spread of COVID-19. In Portugal, in October 2021, low-risk cohabitants were lifted the obligation to isolate. The aim of this study was to estimate the relative risk of infection for close contacts, regarding the type of close contact and being cohabitants. Methods A descriptive longitudinal study, with an analytical component was performed. Sociodemographic and epidemiologic data from close contacts and confirmed cases in Loures and Odivelas, between October and November 2021, was collected from a regional database and from Trace COVID-19 platform. We performed a descriptive analysis and estimated the relative risk of SARS-CoV-2 positive test, stratified by type of contact and cohabitation, with 95% confidence level. Results We identified 200 confirmed cases and 428 people who were close contacts, corresponding to 502 different close contacts (59 people had contact with more than a case). From 502 close contacts, 268 were classified as low-risk and 230 as high-risk. Full time cohabitation was present in 310 of close contacts. Between contact tracing day and the next 4 weeks, 58 (10.9%) of close contacts tested positive. Risk of high-risk contacts testing positive was 2.7 [1.5-4.6], compared with low-risk contacts. Risk of cohabitants testing positive was 3.5 [1.6-7.7], compared with non-cohabitants. Risk of a high-risk cohabitant testing positive was 2.2 [1.1-4.4], compared with low-risk cohabitants. There was no higher risk of high-risk cohabitants testing positive compared with high-risk non-cohabitants. Same was true for low-risk cohabitants and non-cohabitants. Conclusions These results allow us to understand how to better stratify close contacts and apply isolation measures, according to the risk of testing positive. Further studies should be developed to assess the impact of other variables. Key messages • We identified an increased risk of testing positive in high-risk contacts, and in cohabitants. • Cohabitants could be stratified regarding being high or low-risk, with different measures being applied.

Containing diversity: Canada and the politics of immigration in the 21st century

Although Canada is known internationally as a leader among industrialized countries for inclusive practices towards immigrants and refugees, the twenty-first century has witnessed a rise in the number of refugees and temporary migrant workers who are often denied citizenship and may also experience detention and deportation. Containing Diversity examines to what extent Canada's long-standing support for immigration, multiculturalism, and citizenship has shifted in favour of discourses, policies, and practices that "contain" diversity. This book reflects on how diversity is being "contained" through practices designed to insulate the Canadian settler-colonial state. In assessing the Canadian government's policies towards refugees and asylum seekers, economic migrants, family-class migrants, temporary foreign workers, and multiculturalism, the authors show the various contradictory practices in effect. Containing Diversity reflects on policy changes, analysed alongside the resurgence of right-wing political ideology and the realities of the COVID-19 pandemic. Ultimately, Containing Diversity highlights the need for a re-imagining of new forms of solidarity that centre migrant and Indigenous justice. © University of Toronto Press 2023.

Troponin in COVID-19: To Measure or Not to Measure? Insights from a Prospective Cohort Study.

Myocardial injury (MI), defined by troponin elevation, has been associated with increased mortality and adverse outcomes in patients with coronavirus disease 2019 (COVID-19), but the role of this biomarker as a risk predictor remains unclear. Data from adult patients hospitalized with COVID-19 were recorded prospectively. A multiple logistic regression model was used to quantify associations of all variables with in-hospital mortality, including the calculation of odds ratios (ORs) and confidence intervals (CI). Troponin measurement was performed in 1476 of 4628 included patients, and MI was detected in 353 patients, with a prevalence of 23.9%; [95% CI, 21.8-26.1%]. The total in-hospital mortality rate was 10.9% [95% CI, 9.8-12.0%]. The mortality was much higher among patients with MI than among those without MI, with a prevalence of 22.7% [95% CI, 18.5-27.3%] vs. 5.5% [95% CI, 4.3-7.0%] and increased with each troponin level. After adjustment for age and comorbidities, the model revealed that the mortality risk was greater for patients with MI [OR = 2.99; 95% CI, 2.06-4.36%], and for those who did not undergo troponin measurement [OR = 2.2; 95% CI, 1.62-2.97%], compared to those without MI. Our data support the role of troponin as an important risk predictor for these patients, capable of discriminating between those with a low or increased mortality rate. In addition, our findings suggest that this biomarker has a remarkable negative predictive value in COVID-19.

Kidney Transplantation From Deceased Donors With Vaccine-induced Immune Thrombocytopenia and Thrombosis: An Updated Analysis of the UK Experience.

BACKGROUND: The emergence and attendant mortality of vaccine-induced immune thrombocytopenia and thrombosis (VITT) as a consequence of vaccination against severe acute respiratory syndrome coronavirus 2 have resulted in some patients with VITT being considered as deceased organ donors. Outcomes after kidney transplantation in this context are poorly described. Because the disease seems to be mediated by antiplatelet factor 4 antibodies, there is a theoretical risk of transmission via passenger leukocytes within the allograft. METHODS: We analyzed the experience of kidney transplantation from donors with VITT in the United Kingdom between January and June 2021. We followed-up all recipients of kidney-only transplants from donors with VITT to detect major postoperative complications or features of disease transmission and assess graft survival and function. RESULTS: There were 16 kidney donors and 30 single kidney transplant recipients in our study period. Of 11 preimplantation biopsies, 4 showed widespread glomerular microthrombi. After a median of 5 mo, patient and graft survival were 97% and 90%, respectively. The median 3-mo estimated glomerular filtration rate was 51 mL/min/1.73 m 2 . Two recipients had detectable antiplatelet factor 4 antibodies but no evidence of clinical disease after transplantation. Major hemorrhagic complications occurred in 3 recipients, all of whom had independent risk factors for bleeding, resulting in the loss of 2 grafts. The involvement of VITT could not be completely excluded in one of these cases. CONCLUSIONS: The UK experience to date shows that favorable outcomes are possible after kidney transplantation from donors with VITT but highlights the need for ongoing vigilance for donor-related complications in these patients.

Issues regarding COVID-19 in kidney transplantation in the ERA of the Omicron variant: a commentary by the ERA Descartes Working Group.

The Omicron variant, which has become the dominant strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) worldwide, brings new challenges to preventing and controlling the infection. Moreover, the widespread implementation of vaccination policies before and after transplantation, and the development of new prophylactic and treatment strategies for coronavirus disease 2019 (COVID-19) over the past 12-18 months, has raised several new issues concerning kidney transplant recipients. In this special report, the ERA DESCARTES (Developing Education Science and Care for Renal Transplantation in European States) Working Group addresses several questions related to everyday clinical practice concerning kidney transplant recipients and to the assessment of deceased and live kidney donors: what is the current risk of severe disease and of breakthrough infection, the optimal management of immunosuppression in kidney transplant recipients with COVID-19, the role of passive immunization and the efficacy of antiviral drugs in ambulatory patients, the management of drug-to-drug interactions, safety criteria for the use of SARS-CoV-2-positive donors, issues related to the use of T cell depleting agents as induction treatment, and current recommendations for shielding practices.

Effects of a healthy lifestyle intervention and COVID-19-adjusted training curriculum on firefighter recruits.

There are knowledge gaps regarding healthy lifestyle (HLS) interventions in fire academy settings and also concerning the impacts of the pandemic on training. We enrolled fire recruits from two fire academies (A and B) in New England in early 2019 as the historical control group, and recruits from academies in New England (B) and Florida (C), respectively, during the pandemic as the intervention group. The three academies have similar training environments and curricula. The exposures of interest were a combination of (1) an HLS intervention and (2) impacts of the pandemic on training curricula and environs (i.e. social distancing, masking, reduced class size, etc.). We examined the health/fitness changes throughout training. The follow-up rate was 78%, leaving 92 recruits in the historical control group and 55 in the intervention group. The results show an HLS intervention improved the effects of fire academy training on recruits healthy behaviors (MEDI-lifestyle score, 0.5 ± 1.4 vs. - 0.3 ± 1.7), systolic blood pressure (- 7.2 ± 10.0 vs. 2.9 ± 12.9 mmHg), and mental health (Beck Depression score, - 0.45 ± 1.14 vs. - 0.01 ± 1.05) (all P < 0.05). The associations remained significant after multivariable adjustments. Moreover, a 1-point MEDI-lifestyle increment during academy training is associated with about 2% decrement in blood pressures over time, after multivariable adjustments (P < 0.05). Nonetheless, the impacts of pandemic restrictions on academy procedures compromised physical fitness training, namely in percent body fat, push-ups, and pull-ups.

Coping strategies during legally enforced quarantine and their association to psychological distress level: a cross-sectional study.

OBJECTIVES: The non-pharmacological measures to contain the COVID-19 pandemic may lead to considerable psychological distress. The aim of the CoCo-Fakt study was to investigate possible coping strategies and their effects on psychological distress during legally enforced quarantine of infected persons (IPs) and their close contacts (CPs). STUDY DESIGN: This was a cross-sectional cohort study. METHODS: From 12 December 2020 to 6 January 2021, all IPs and their CPs (n = 8232) registered by the public health department (Cologne, Germany) were surveyed online. Psychosocial distress and coping were measured using sum scores; free-text answers related to specific strategies were subsequently categorised. RESULTS: Psychosocial distress was higher in IPs than in CPs (P < .001). Although the mean coping score did not differ between both groups, it was influenced by the reason for quarantine (IP vs CP) besides gender, age, socio-economic status, living situation, psychological distress, resilience, physical activity and eating behaviour. This final regression model explained 25.9% of the variance. Most participants used active coping strategies, such as contact with the social environment, a positive attitude and hobbies. CONCLUSIONS: Although psychological distress was higher in IPs than in CPs during the quarantine period, the mean coping score did not differ. The strategies most frequently used by IPs and CPs were activating social networks, a healthy lifestyle and professional support systems, such as the health department helpline. Appropriate advice should be implemented to prevent long-term psychological consequences when supporting affected people.

Correlation of Clinical and Histopathological Findings with Viral Variant in the Gastrointestinal Tract of COVID-19 Autopsy Cases

Background: Initial evidence has shown the occasional presence of SARS-CoV-2 in enterocytes in the intestines of patients with COVID-19. Our aim is to further assess the clinical and pathologic changes in the gastrointestinal tract caused by the highly contagious Delta (B.1.617.2) variant as compared to viral variants originating earlier in the pandemic. Design: Intestinal samples from 32 patients with death due to COVID-19 were obtained at autopsy. Decedents were males and females, with an age range of 32-73 years. Twenty-one of the decedents self-identified as Black/African American, eight as Caucasian, and three as Hispanic. Two groups were differentiated by viral genome RNA sequencing from autopsy tissue: those with Delta variant (n=16), and those with non-Delta variant (n=16). SARS-CoV-2 expression in the intestine was evaluated by immunohistochemical (IHC) detection of the SARS-CoV-2 nucleocapsid protein (N-protein). Results: Clinically, the Delta group reported diarrhea more frequently (25%) as compared to the non-Delta group (6%). Patients in the Delta group had a shorter time interval between the onset of gastrointestinal symptoms and death (mean = 19 days), as compared to the non-Delta group (mean = 25 days). Histologic examination revealed mostly normal to mild, non-specific chronic inflammation within the epithelium and lamina propria in both groups. Macrophages with positivity for N-protein IHC were present beneath the epithelium, most notably within the Delta group. N-protein positivity occurred most frequently in small submucosal and mesenteric blood vessels. Patchy positivity for N-protein in enterocytes was seen frequently in cases of Delta variant in which the time from initial symptoms to death was short (<14 days). Figure 1 - 11 Conclusions: As in prior studies, intestinal microscopic changes in COVID-19 were minimal, though our findings indicate that SARS-CoV-2 may be detected within enterocytes more frequently in the Delta group. Patients with the Delta variant experienced both a higher rate of diarrhea and a shorter interval between gastrointestinal symptom onset and death. Whether increased Nprotein in enterocytes is a result of the Delta variant itself, or earlier intestinal sampling relative to symptoms in this group, remains to be determined. Autopsy studies can add to our understanding of the effects of COVID-19 on the digestive system, by allowing a greater volume of tissue sampling, as well as temporal sampling relative to disease onset that is not always possible at endoscopy.

Pathologic Features of Post-Acute Sequelae of COVID-19 (PASC) at Autopsy

Background: Across the globe, cases of post-acute sequelae of COVID-19 (PASC) are characterized by the delayed effects of SARS-CoV-2 infection in multiple organ systems. Patients may have appeared to recover from the initial infection, but experience sequelae of the disease weeks to months later. Autopsy studies of PASC have only initially begun. Our research aims to compare the pathology of cases in which patients experienced a prolonged, progressive decline, to the cases of patients who recovered from the initial infection of SARS-CoV-2, but experienced sequelae of the condition numerous weeks to months later. Design: Autopsies were performed on 17 male and female decedents with an age range of 31-79 years with cause of death related to COVID-19 infection confirmed by SARS-CoV-2 PCR, and time between the onset of symptoms and death ranging from 30 to 112 days. Cases in which the time between the onset of symptoms and death exceeded 30 days, with evidence of initial recovery, were considered potentially PASC-related. The cases were separated into two groups based upon the timeline of first positive PCR to time of death: those who succumbed to the initial COVID-19 infection after an extended hospital course, and those with potential PASC-related disease. Clinical, gross and microscopic findings from both groups were compared, as well as PCR and IHC for SARS-CoV-2 at autopsy. Results: The most common clinical comorbidity seen in both groups was hypertension (85.7%), followed by obesity and diabetes. Common microscopic findings in the lungs included proliferative to organizing diffuse alveolar damage (DAD). Findings in PASC-related cases included extensive alveolar fibrosis, fibrosing organizing pneumonia, and thrombi within medium-sized blood vessels. Two patients in their 30s presented with vasculitis/endotheliitis involving small blood vessels of the lungs and heart, consistent with Multisystem Inflammatory Syndrome. Additionally, late thrombotic events, and cardiac inflammation including macrophage infiltration appeared to be present in cases of PASC. Immunostaining for SARS-CoV-2 nucleocapsid and PCR at the time of autopsy did not reveal a persistence of virus in cases attributed to PASC. Figure 1 - 7 Conclusions: Our findings suggest that there may be pathologic differences between a prolonged course of acute COVID-19, and PASC-related disease. Characteristics of PASC included evidence of new or continued small vessel inflammation, macrophage infiltration, and/or fibrotic disease of affected organs.

Severe aplastic anaemia after serial vaccinations for SARS-CoV-2, pneumococcus and seasonal influenza.

We present a 67-year-old woman who developed progressive pancytopenia over 10 months, concomitant with administration of severe adult respiratory syndrome coronavirus-2 (SARS-CoV-2), pneumococcal and influenza vaccines. She developed mild leukopenia ∼2 weeks after the SARS-CoV-2 mRNA vaccine sequence, with progressive symptoms after subsequent vaccines, eventually developing severe aplastic anaemia (SAA). While there have been several reports of vaccine-related SAA, at time of submission, our case is the first reported to develop after the Moderna mRNA SARS-CoV-2 vaccine, as well as the first to document the gradual development of SAA over the course of many vaccine exposures. Physicians should be cognizant of vaccine-associated SAA, considering current widespread coronavirus disease 2019 vaccination efforts.

Vascular retinal findings after COVID-19 vaccination in 11 cases: a coincidence or consequence?

PURPOSE: The primary purpose of this study was to assess vascular retinal findings temporally related to COVID-19 vaccination. With greater information regarding all possible future adverse events, we hope to understand the real dimension and relevance of what was presented. METHODS: Eleven patients with visual complaints after COVID-19 vaccination were enrolled. Data on the following were included: age, sex, vaccine, time of symptom onset, systemic findings, medical history, best-corrected visual acuity, and ocular findings by slit-lamp biomicroscopy as well as multimodal retinal imaging (color fundus, red-free photography, spectral-domain optical coherence tomography, optical coherence tomography angiography, and fluorescein-angiography). Inclusion criteria were the presence of ophthalmologic signs within 30 days after the first or second dose of any COVID-19 vaccine. RESULTS: Of 11 patients, five had arterial occlusion (45.4%), four had venous occlusion (36.4%), and two (18.2%) had nonspecific vascular alterations suggestive of retinal ischemia such as cotton-wool spots. The mean age was 57 (SD = 16; range: 27-84) years. The mean time of symptoms onset was 10 (SD = 5.4; range: 3-16) days. Nine patients were female (81.8%). Systemic risk factors were observed in 36.4% of patients. Two patients had both neurological and visual symptoms, with arterial occlusion. Overall, 36.4% patients had COVID-19 in the previous year. Seven patients (63.6%) received ChAdOx1 nCoV-19 (AZD1222) vaccine. CONCLUSIONS: Our data suggest that retinal events temporally related to COVID-19 vaccination are possible but are very rare. The relationship of these events with post-COVID-19 vaccination warrants further attention to derive a meaningful conclusion.