Pneumomediastinum in the COVID-19 era: to drain or not to drain?

Pneumomediastinum (PNM) is a rare clinical finding, usually with a benign course, which is managed conservatively in the majority of cases. However, during the COVID-19 pandemic, an increased incidence of PNM has been observed. Several reports of PNM cases in COVID-19 have been reported in the literature and were managed either conservatively or surgically. In this study, we present our institutional experience of COVID-19 associated PNM, propose a management algorithm, and review the current literature. In total, 43 Case Series were identified, including a total of 747 patients, of whom 374/747 (50.1%) were intubated at the time of diagnosis, 168/747 (22.5%) underwent surgical drain insertion at admission, 562/747 (75.2%) received conservative treatment (observation or mechanical ventilation. Inpatient mortality was 51.8% (387/747), while 45.1% of the population recovered and/or was discharged (337/747). In conclusion, with increased incidence of PNM in COVID-19 patients reported in the literature, it is still difficult to assign a true causal relationship between PNM and mortality. We can, however, see that PMN plays an important role in disease prognosis.  Due to increased complexity, high mortality, and associated complications, conservative management may not be sufficient, and a surgical approach is needed.

The role of imaging in the diagnosis of acute appendicitis during the COVID-19 pandemic: a retrospective cohort study.

Acute appendicitis is one of the most common general surgical emergencies worldwide; however, its diagnosis remains challenging, with a high proportion of negative appendicectomies. The purpose of this study was to investigate the benefit of routine use of pre-operative imaging for the evaluation of suspected appendicitis. This retrospective cohort study included all cases of appendicectomies performed for suspected acute appendicitis during the first and second peaks of the COVID-19 pandemic, between March 2020 and February 2021. The control group included all cases of appendicectomies performed for suspected acute appendicitis in the previous 12 months (March 2019-February 2020). One hundred and four patients underwent appendicectomy in the study group, compared to 209 in the control group, with similar gender distribution but a significantly higher median age in the study group (33 vs. 28, p = 0.001). The two groups had similar rates of perforation and similar median white cell count (WCC) and CRP. Imaging was used in 80.77% of the patients in the study group, compared to 61.72% in the control group (p = 0.001), with 55.77% of patients in the study group undergoing CT scans. Despite this, the negative appendicectomy rate (NAR) in the two groups did not differ significantly (11.54% vs. 15.79%, p = 0.320). The increase in the use of imaging for the diagnosis of acute appendicitis during the COVID-19 pandemic did not lead to a significantly lower negative appendicectomy rate. Registration: The study was pre-registered at ClinicalTrials.gov (NCT05205681).

Complement-mediated microvascular injury and thrombosis in the pathogenesis of severe COVID-19: A review.

Coronavirus disease 2019 (COVID-19) causes acute microvascular thrombosis in both venous and arterial structures which is highly associated with increased mortality. The mechanisms leading to thromboembolism are still under investigation. Current evidence suggests that excessive complement activation with severe amplification of the inflammatory response (cytokine storm) hastens disease progression and initiates complement-dependent cytotoxic tissue damage with resultant prothrombotic complications. The concept of thromboinflammation, involving overt inflammation and activation of the coagulation cascade causing thrombotic microangiopathy and end-organ damage, has emerged as one of the core components of COVID-19 pathogenesis. The complement system is a major mediator of the innate immune response and inflammation and thus an appealing treatment target. In this review, we discuss the role of complement in the development of thrombotic microangiopathy and summarize the current data on complement inhibitors as COVID-19 therapeutics.

Persistent Hiccups as an Atypical Presentation of SARS-CoV-2 Infection: A Systematic Review of Case Reports.

Symptoms, such as fever, dry cough, dyspnoea, and respiratory distress, are commonly described in patients infected with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Recently, a growing number of cases pertained to persistent hiccups have been reported by SARS-CoV-2 infected patients. The aim of this systematic review was to screen the current literature and provide a summary of the reported cases of SARS-CoV-2 infected patients presenting with persistent hiccups. According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed, Scopus, and Web of Science databases were searched from inception until October 2021. Case reports or case series that provided a separate clinical description for patients with presenting complaints of persistent hiccups before or after COVID-19 diagnosis were retrieved. The critical appraisal checklist for case reports provided by the Joanna Briggs Institute (JBI) was employed to evaluate the overall quality of the eligible studies. We identified 13 eligible studies that included 16 hospitalized COVID-19 patients who complained of persistent hiccups. The mean duration of hiccups was 4.6 days reported in 88% (14/16) patients. Hypertension was the most common comorbidity present in 50% (8/16) of patients followed by diabetes mellitus (4/16). Moreover, 44% (7/16) of patients received only one medication for managing the hiccups with metoclopramide (5/16) followed by chlorpromazine and baclofen (4/16) used as primary treatment. Equally, 44% of patients (7/16) received dexamethasone followed by azithromycin (5/16), ivermectin (4/16), and ceftriaxone (4/16) for managing the infection from SARS-CoV-2. The majority of patients (14/16) improved after initiation of treatment. Persistent hiccups are possibly a rare symptom that clinicians may expect to encounter in patients infected with SARS-CoV-2. Although there is not ample proof to propose causation, increased awareness about the diversity of presentations of SARS-CoV-2 infection could be crucial in the early recognition of the disease.

Heart and Lung Transplantation in the Era of COVID-19: Early Recommendations and Outcomes.

The severe acute respiratory syndrome coronavirus 2 pandemic has dramatically changed medical practices worldwide. These changes have been aimed both to reallocate resources toward fighting the novel coronavirus and to prevent its transmission during nonurgent medical and surgical interventions. Heart and lung transplantation could not be an exception, as most transplant centers have either restricted their activity to only urgent, lifesaving procedures or stopped these surgical procedures for various periods of time depending on the local virus epidemiology. The effect of this infection on the immunosuppressed heart and lung transplant recipient is still questionable; however, there are limited reports suggesting that there is no increased risk of transmission or more severe disease course compared with that shown in the general population. Transplant organizations have disseminated early recommendations as a guidance in a yet evolving situation. Finally, data suggest that lung transplant could potentially serve as an ultimate, lifesaving procedure for COVID-19-related end-stage respiratory failure in carefully selected patients.