ABSTRACT
OBJECTIVE: Herpes simplex virus type1 (HSV-1) reactivation have been described in patients with invasive mechanical ventilation and recently in patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 with higher rates of reactivation than were detected previously in critical care, and although the diagnosis of HSV-1 pneumonia is not easy, its presence is associate with an increase in morbidity and mortality. The objective of this study is to determinate if the identification of HSV-1 in lower airway of patients with ARDS secondary to COVID-19 have influence in clinical outcome and mortality. METHOD: Two hundred twenty-four admitted patients in intensive care unit (ICU) of Complejo Hospitalario Universitario de Toledo diagnosed of severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) were reviewed and were selected those with mechanical ventilation who had undergone (BAL). It was registered all results of HSV-1 PCR (negative and positive). RESULTS: During the study period (November 28, 2020 to April 13, 2021) was admitted 224 patients in ICU diagnosed of SARS-CoV-2 pneumonia. Eighty-three patients of them had undergone BAL, with HSV-1 PCR positive result in 47 (56%), and negative result in 36 (43.4%). We performed pathological anatomy study in BAL samples on 26 of the total BAL realized. Typical cytopathic characteristics of HSV-1 were found in 13 samples (50%) and 11 of them (84.6%) have had HSV-1 PCR positive result. Thirty days mortality was significantly higher in the group of patients with HSV-1 PCR positive result (33.5% vs. 57.4%, P=.015). This difference was stronger in the group of patients with HSV-1 findings in the pathological anatomy study (30.8% vs. 69.2%, P=.047). CONCLUSION: Our results suggest that ARDS secondary to SARS-CoV-2 pneumonia is highly associated to HSV-1 reactivation and that the finding of HSV-1 in lower airway is associated with a worst prognostic and with significantly mortality increase. It is necessary to carry out more extensive studies to determinate if treatment with acyclovir can improve the prognosis of these patients.
ABSTRACT
Objective Herpes simplex virus type 1 (HSV-1) reactivation have been described in patients with invasive mechanical ventilation and recently in patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 with higher rates of reactivation than were detected previously in critical care, and although the diagnosis of HSV-1 pneumonia is not easy, its presence is associate with an increase in morbidity and mortality. The objective of this study is to determinate if the identification of HSV-1 in lower airway of patients with ARDS secondary to COVID-19 have influence in clinical outcome and mortality. Method Two hundred twenty-four admitted patients in intensive care unit (ICU) of Complejo Hospitalario Universitario de Toledo diagnosed of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were reviewed and were selected those with mechanical ventilation who had undergone (BAL). It was registered all results of HSV-1 PCR (negative and positive). Results During the study period (November 28, 2020 to April 13, 2021) was admitted 224 patients in ICU diagnosed of SARS-CoV-2 pneumonia. Eighty-three patients of them had undergone BAL, with HSV-1 PCR positive result in 47 (56%), and negative result in 36 (43.4%). We performed pathological anatomy study in BAL samples on 26 of the total BAL realized. Typical cytopathic characteristics of HSV-1 were found in 13 samples (50%) and 11 of them (84.6%) have had HSV-1 PCR positive result. Thirty days mortality was significantly higher in the group of patients with HSV-1 PCR positive result (33.5% vs. 57.4%, p = 0.015). This difference was stronger in the group of patients with HSV-1 findings in the pathological anatomy study (30.8% vs. 69.2%, p = 0.047). Conclusion Our results suggest that ARDS secondary to SARS-CoV-2 pneumonia is highly associated to HSV-1 reactivation and that the finding of HSV-1 in lower airway is associated with a worst prognostic and with significantly mortality increase. It is necessary to carry out more extensive studies to determinate if treatment with acyclovir can improve the prognosis of these patients.
ABSTRACT
Objective: Herpes simplex virus type 1 (HSV-1) reactivation have been described in patients with invasive mechanical ventilation and recently in patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 with higher rates of reactivation than were detected previously in critical care, and although the diagnosis of HSV-1 pneumonia is not easy, its presence is associate with an increase in morbidity and mortality. The objective of this study is to determinate if the identification of HSV-1 in lower airway of patients with ARDS secondary to COVID-19 have influence in clinical outcome and mortality. Method: Two hundred twenty-four admitted patients in intensive care unit (ICU) of Complejo Hospitalario Universitario de Toledo diagnosed of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were reviewed and were selected those with mechanical ventilation who had undergone (BAL). It was registered all results of HSV-1 PCR (negative and positive). Results: During the study period (November 28, 2020 to April 13, 2021) was admitted 224 patients in ICU diagnosed of SARS-CoV-2 pneumonia. Eighty-three patients of them had undergone BAL, with HSV-1 PCR positive result in 47 (56%), and negative result in 36 (43.4%). We performed pathological anatomy study in BAL samples on 26 of the total BAL realized. Typical cytopathic characteristics of HSV-1 were found in 13 samples (50%) and 11 of them (84.6%) have had HSV-1 PCR positive result. Thirty days mortality was significantly higher in the group of patients with HSV-1 PCR positive result (33.5% vs. 57.4%, pâ¯=â¯0.015). This difference was stronger in the group of patients with HSV-1 findings in the pathological anatomy study (30.8% vs. 69.2%, pâ¯=â¯0.047). Conclusion: Our results suggest that ARDS secondary to SARS-CoV-2 pneumonia is highly associated to HSV-1 reactivation and that the finding of HSV-1 in lower airway is associated with a worst prognostic and with significantly mortality increase. It is necessary to carry out more extensive studies to determinate if treatment with acyclovir can improve the prognosis of these patients.
Objetivo: Las reactivaciones del virus herpes simple (VHS) están descritas en los pacientes en ventilación mecánica invasiva y recientemente en el síndrome de distrés respiratorio agudo (SDRA) por COVID-19, con tasas más altas que las descritas previamente en pacientes críticos, y aunque el diagnóstico de neumonía por VHS es difícil, su presencia se asocia con aumento de la morbimortalidad. El objetivo de este estudio es determinar si la identificación de VHS en el tracto respiratorio inferior en pacientes en ventilación mecánica con SDRA por COVID-19 influye sobre la evolución clínica y la mortalidad. Método: Se revisaron 224 pacientes ingresados en el servicio de medicina intensiva del Complejo Hospitalario de Toledo con el diagnóstico de neumonía por SARS-CoV-2 y se seleccionaron los pacientes en ventilación mecánica a los que se les había realizado lavado broncoalveolar (LBA). Se registraron todos los resultados de la PCR, tanto si fue positiva como si fue negativa para VHS. Resultados: Durante el periodo de estudio (del 28 de noviembre de 2020 hasta el 13 de abril de 2021) ingresaron 224 pacientes en la UCI con el diagnóstico de neumonía por SARS-CoV-2. De ellos, en 83 se realizó lavado broncoalveolar (LBA), siendo la PCR para VHS-1 positiva en 47 y negativa en 36 (56,6%). Realizamos estudio anatomopatológico en muestras de LBA a 26 pacientes del total de la muestra. Se encontraron características citopáticas típicas de infección por herpes en 13 (50%), de los cuales 11 (84,6%) tenían PCR positiva. La mortalidad a los 30 días fue significativamente mayor en el grupo de pacientes con PCR positiva (33,5% vs 57,4%, pâ¯=â¯0,015). Esta diferencia fue aún más marcada en el grupo con hallazgos anatomopatológicos compatibles con neumonía por VHS (30,8% versus 69,2%, pâ¯=â¯0,047). Conclusión: Nuestros resultados sugieren que el SDRA secundario a neumonía por SARS-CoV-2 se asocia a una alta reactivación del VHS y que su hallazgo en el tracto respiratorio inferior se asocia con un peor pronóstico y un aumento significativo de la mortalidad. Son necesarios estudios más amplios para determinar si el tratamiento con aciclovir puede mejorar el pronóstico de estos pacientes.
ABSTRACT
Background and Objectives: Post-infarct ventricular septal rupture (PIVSR) continues to have significant morbidity and mortality, despite decreased prevalence. Impella and venoarterial extracorporeal membranous oxygenation (VA-ECMO) have been proposed as strategies to correct hemodynamic derangements and bridge patients to delayed operative repair when success rates are higher. This review places VA-ECMO and Impella support strategies in the context of bridging patients to successful PIVSR repair, with an additional case report of successful bridging with the Impella device. Materials and Methods: We report a case of PIVSR repair utilizing 14 days of Impella support. We additionally conducted a systematic review of contemporary literature to describe the application of VA-ECMO and Impella devices in the pre-operative period prior to surgical PIVSR correction. Expert commentary on the advantages and disadvantages of each of these techniques is provided. Results: We identified 19 studies with 72 patients undergoing VA-ECMO as a bridge to PIVSR repair and 6 studies with 11 patients utilizing an Impella device as a bridge to PIVSR repair. Overall, outcomes in both groups were better than expected from patients who were historically managed with medicine and balloon pump therapy, however there was a significant heterogeneity between studies. Impella provided for excellent left ventricular unloading, but did result in some concerns for reversal of shunting. VA-ECMO resulted in improved end-organ perfusion, but carried increased risks of device-related complications and requirement for additional ventricular unloading. Conclusions: Patients presenting with PIVSR in cardiogenic shock requiring a MCS bridge to definitive surgical repair continue to pose a challenge to the multidisciplinary cardiovascular team as the diverse presentation and management issues require individualized care plans. Both VA-ECMO and the Impella family of devices play a role in the contemporary management of PIVSR and offer distinct advantages and disadvantages depending on the clinical scenario. The limited case numbers reported demonstrate feasibility, safety, and recommendations for optimal management.
ABSTRACT
Background: The combination of venetoclax (Ven) with hypomethylating agents (VenHMA) has shown promising results both in newly diagnosed and relapsed or refractory acute myeloid leukaemia (AML) patients, ineligible for intensive chemotherapy. Due to our expertise acquired in at-home management of diverse complex haematological procedures, we initiated in February 2020 an at-home (AH) programme for the VenHMA regimen. This AH-VenHMA programme included the initial dose ramp-up to prevent tumour lysis syndrome (TLS), a phase usually recommended to be performed as an inpatient hospital admission. Aims: Herein we present preliminary results of our AH experience during the first two cycles of VenHMA treatment for AML patients. Methods: Before implementation of AH-VenH programme, ramp-up was performed during a hospital admission (n=29, reference cohort). In Feb 2020, we initiated the VenH programme;outcome of in this patient cohort are compared with the reference cohort. In AH programme, prior to VenHMA initiation, medical evaluation is performed by a haematologist and a liaison nurse. Medical history, potential drug interactions and TLS risk are thoroughly evaluated. Laboratory tests (LT) including blood count and biochemistry are completed. Extensive health education is provided to patient and caregiver before the first cycle. A peripheral insertion intravenous catheter (PICC) is placed to all patients before starting ramp-up. Intravenous (IV) fluids by a portable pump (PP) are started 24hrs before the beginning of VenHMA, as well as uricosurics agents;patients are advised to maintain oral hydration. Daily morning visits during ramp-up are performed by trained nurses who complete vital sign, obtain LT, review therapeutic compliance, replaced PP and administer hypomethylating agent. Patients are started on Ven in an escalation schedule of 100mg on day 1, 200mg on day 2, and 400mg on day 3 of the cycle, they are advised to take Ven after dinner, following an explicit indication of our team given after daily LT review. An appropriate dose reduction is performed in patients receiving concomitantly CYP3A4 inhibitors. After achieving planned Ven full dose, IV fluids are ceased (Image 1). Patients are followed throughout the whole cycle by the AH team. Platelet transfusions are administered at-home while red cell concentrates are administered at the hospital, due to our transfusion policy. Results: Between February 2020 and January 2021, 22 AML patients (40 cycles) received VenHMA at-home. Fourteen patients were men (63.6%), with a median age of 73 years (23-83). Main characteristics were well balance in both patient cohorts. Neutropenia (86.3%), thrombocytopenia (90.9%) and anaemia (86.4%) were the most frequent adverse events (AEs). A trend to a lower proportion of febrile episodes was observed in the AH program (19/29 vs. 8/22, p=0.074). Hospital readmission rate after ramp-up was markedly low in the AH cohort, significantly lower than in the reference cohort (4/22 vs. 19/29, p = 0.001). TLS was not observed in any group. Main AEs are shown in table 1. Median days of at-home treatment were 49 (19-187). Discontinuation was due to refractoriness in 5 (22.7%) patients. Two patients presented SARS-CoV-2 infection in early March 2020, resulting in death in both cases. Summary/Conclusion: Home care during the ramp-up and early phase of VenHEM regimen is a feasible and safe option. An AH programme was followed by a low readmission rate and offers diverse benefits such as optimization of health resources and increase of the comfort and well-being of patients and their caregivers.