Successful Kidney Transplantation from Covid-19 Positive Donors

Introduction: Covid-19 results in a wide spectrum of illness ranging from asymptomatic, mild to severe respiratory disease and multi-organ involvement. Transplant recipients are at increased risk of severe Covid-19. The risk of transmission from a Covid-19 positive donor to recipient in kidney transplantation is unknown. National Health Service Blood and Transplant, UK recommended respiratory polymerase chain reaction (PCR) testing for all donors for Covid-19 and advice against organ donation if positive within the last 28 days. However, a recent amendment of guideline (www.odt.nhs.uk, POL304/3) supports organ donation from selected donors with positive or indeterminate SARS-CoV-2 PCR results. Method(s): We report two cases of kidney transplantation including one unvaccinated recipient where donors had tested SARS-CoV-2 PCR positive. Result(s): 1: Mrs A is a 38-year old Caucasian with end-stage kidney disease (ESKD) secondary to reflux nephropathy, established on haemodialysis (HD). She had declined Covid-19 vaccinations. The donor died of traumatic brain injury and he had a positive lateral flow test 3 weeks prior. The PCR test was positive. Decision was made to proceed with deceased donor kidney transplantation. She was high immunological risk with a HLA antibody calculated reaction frequency (CRF) of 79%, donor specific antibody negative. She was given Basiliximab induction followed by Tacrolimus, Mycophenolate Mofetil and steroids. Graft function was immediate and at 3 week post-transplant, she is well with excellent graft function and no evidence of Covid-19. 2: Mrs B is a 63-year old Asian with ESKD secondary to diabetes and hypertension. She was established on HD and fully vaccinated (three doses of Pfizer-BNT162b2 mRNA vaccine). The donor died of subarchnoid haemorrhage. He had a positive lateral flow test 15 days prior with flu-like symptoms. Respiratory PCR for SARS-CoV-2 was positive. The decision was to proceed with deceased donor transplantation. She was low immunological risk with a HLA antibody CRF of 0%. There were no peri-operative complications and she had immediate graft function. She had Basiliximab induction and was discharged on Tacrolimus and Mycophenolate mofetil with prednisolone withdrawn on day 7 (our low immunological risk protocol). At 3 week post-transplant, she is well with no evidence of Covid-19 and excellent graft function. Conclusion(s): We report 2 cases of kidney transplantation from Covid-19 positive donors in whom the cause of death was not Covid-19 pneumonia. Covid-19 status of the donor was discussed with the patients who both consented. Neither recipient developed Covid-19 in the early post-transplant period, despite being heavily immunosuppressed. Although there remains a theoretical risk, there are no reports of transmission of Covid-19 to kidney transplant recipients from positive donors. Prophylactic antivirals or monoclonal antibodies for the recipient post-transplant or spike antibody test to guide decision making are not currently recommended. We used clinical details of the donor and virology advice which accounts for PCR cycle threshold value to make a decision to transplant. The outcomes of 2 patients reported along with similar experience from other centres is encouraging and supports use of kidneys from selected SARS-CoV-2 positive deceased donors after obtaining virological advice and appropriate consent. No conflict of interestCopyright © 2023

Global virtual strabismus surgery teaching for ophthalmology residents during COVID-19

Introduction: In response to the COVID-19 pandemic, the World Society of Pediatric Ophthalmology and Strabismus (WSPOS) piloted strabismus surgery simulation webinars providing real-time surgical instruction using an accessible model eye. The purpose of this study was to demonstrate improvement in confidence level with strabismus surgery among ophthalmology residents who participated in the webinar. Method(s): Five strabismus surgeons (from 5 different countries) taught 10 beginning ophthalmology residents (from 5 different countries) using a homemade model eye and a cell phone streaming the surgical view. Surgical techniques taught included needle handling, scleral passes, and suturing extraocular muscles. Residents watched a video demonstrating techniques prior to the webinar. Three surveys completed Pre-Video, Post-Video, and Post-Webinar evaluated comfort level in surgical skills using Likert scales. Survey responses were analyzed using paired t tests and repeated measures ANOVA (SPSS v24). Queen's University Health Sciences Research Ethics Board approval was obtained. Result(s): Nine of 10 trainees answered the surveys: 66% were 25-29 years old;62.5% were second-year residents. Paired t test showed a statistically significant increase in comfort level in performing scleral passes, suturing an extraocular muscle, and creating a locking bite at the muscle pole between Pre-Video to Post-Webinar surveys (P < 0.05). Exploratory repeated measures ANOVA revealed improvements in scores for 4 of the 5 questions (P < 0.05). Conclusion/Relevance: Our pilot study demonstrates effective teaching of strabismus surgery techniques virtually using an accessible model eye. Virtual teaching allows delivery of world expertise teaching to trainees worldwide, diminishing barriers to learning and improving eye care to patients globally. Copyright © 2022

Does the wearing of masks change voice and speech parameters?

PURPOSE: The authors aim to review available reports on the potential effects of masks on voice and speech parameters. METHODS: A literature search was conducted using MEDLINE and Google Scholar databases through July 2021. Several targeted populations, mask scenarios and methodologies were approached. The assessed voice parameters were divided into self-reported, acoustic and aerodynamic. RESULTS: It was observed that the wearing of a face mask has been shown to induce several changes in voice parameters: (1) self-reported-significantly increased vocal effort and fatigue, increased vocal tract discomfort and increased values of voice handicap index (VHI) were observed; (2) acoustics-increased voice intensity, altered formants frequency (F2 and F3) with no changes in fundamental frequency, increased harmonics-to-noise ratio (HNR) and increased mean spectral values in high-frequency levels (1000-8000 Hz), especially with KN95 mask; (3) aerodynamics-maximum phonatory time was assessed in only two reports, and showed no alterations. CONCLUSION: Despite the different populations, mask-type scenarios and methodologies described by each study, the results of this review outline the significant changes in voice characteristics with the use of face masks. Wearing a mask shows to increase the perception of vocal effort and an alteration of the vocal tract length and speech articulatory movements, leading to spectral sound changes, impaired communication and perception. Studies analyzing the effect of masks on voice aerodynamics are lacking. Further research is required to study the long-term effects of face masks on the potential development of voice pathology.

Methemoglobinemia and AKI in patients with COVID-19: Don't forget G6PD deficiency

Introduction: Patients with COVID-19 can be asymptomatic or have severe illness. Oxidative stress may be a cause of increased severity and mortality in COVID-19 patients. Methaemoglobinaemia (MetHb) and haemolysis can occur as a result of oxidative stress. MetHb is associated with sepsis, exposure to drugs and inborn errors of metabolism. Glucose-6-phosphate dehydrogenase (G6PD) deficiency may also manifest with MetHb and severe haemolysis. Case Description: A 31-year old man, originally from West Africa, with no comorbidities, presented with dyspnoea, cough, anosmia and oligo-anuria. He had type 1 respiratory failure and stage 3 AKI, which led to critical care admission for intubation, ventilation and haemofiltration. COVID-19 pneumonia was confirmed by nasopharyngeal swab and radiological imaging. He developed haemolytic anaemia. The MetHb was 3.5% (normal <1.5%). It rose to a peak of 10.7% with persisting anaemia and further investigations showed G6PD deficiency. He had no exposure to medications known to trigger haemolytic crises, such as Hydroxychloroquine. He was treated with supportive management including red cell transfusions and also with Tocilizumab for COVID-19. He was extubated after 15 days and recovered renal function. Data on 9 other patients admitted during this period to the ITU with COVID-19 and AKI showed 7 had normal MetHb levels and 2 had modest elevations (<3%). Discussion: Triggers of G6PD deficiency include stress from infections, fava beans, or drugs e.g Hydroxychloroquine. It typically presents as haemolytic anaemia, jaundice and AKI. Although MetHb is linked to severe illness including sepsis, little is known about a possible association with COVID-19. Our report highlights the importance of considering alternative diagnoses of very high MetHb levels such as G6PD deficiency in COVID-19 patients. This is of particular relevance as Hydroxychloroquine has been used as experimental treatment for COVID-19 and in the current climate, G6PD deficiency should be suspected in COVID-19 patients with AKI, acute haemolytic anaemia and signikficantly elevated MetHb, particularly in those from regions of high prevalence and those treated with known triggers such as Hydroxychloroquine.