Importance of Confirmatory Tests for Sars-Cov-2 Infection in Hemodialysis Patients: A Multicenter Mexican Registry.

Background: Since the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, patients with chronic kidney disease vulnerable to suffering more severe COVID-19 disease and worse outcomes have been identified. Objectives: Our study's aim was to determine the incidence, characteristics, and outcomes of SARS-CoV-2 infection in patients of hemodialysis (HD) units in Mexico and to describe the availability of confirmatory testing. Methods: This study was multicentric study of 19 HD units, conducted between March 2020 and March 2021. Results: From a total of 5779 patients, 955 (16.5%) cases of suspicious COVID-19 were detected; a SARS-CoV-2 reverse transcription polymerase chain reaction test was done in only 50.6% of patients. Forty-five percentages were hospitalized and 6% required invasive mechanical ventilation (IMV). There was no significant difference in mortality between confirmed (131/483) and suspicious (124/472) cases (p = 0.74). The percentage of patients in need of hospitalization, IMV, and deceased was greater than in the rest of the study population. Conclusions: The study revealed that 49.4% of the cases were not confirmed, a worrisome observation given that this is a highly vulnerable population (higher probability of contagion and worse outcomes), in which 100% of patients should have a confirmatory test.

Quality assurance for non-contrast CT of the abdomen and pelvis during a period of supply chain disruption leading to iodinated contrast shortage in the emergency department setting.

Objectives: Iodinated contrast media (ICM) shortage crisis due to COVID-19 lockdowns led to a need for alternate imaging protocols consisting of non-contrast computed tomography (CT) for abdominal complaints and related trauma indications in emergency department (ED) settings. This quality assurance study aims to evaluate clinical outcomes of protocol modifications during ICM shortage and identify potential imaging misdiagnosis of acute abdominal complaints and related trauma. Material and Methods: The study included 424 ED patients with abdominal pain, falls, or motor vehicle collision (MVC)-related trauma who had non-contrast CT of the abdomen and pelvis in May 2022. We accessed the initial complaint, order indication, non-contrast CT results, any acute or incidental findings, and any follow-up imaging of the same body region with their results. We evaluated their association utilizing Chi-squared tests. We assessed sensitivity, specificity, and positive/negative predictive values using follow-up scan confirmation. Results: Across initial complaint categories, 72.9% of cases were abdominal pain, and 37.3% received positive findings. Only 22.6% of patients had follow-up imaging. Most confirmed original reports were for abdominal pain. We also found three reports of missed findings. There were significant associations between complaint categories and initial non-contrast CT report results (P < 0.001), as well as initial complaint categories and whether the patient received follow-up imaging or not (P < 0.004). No significant associations were found between follow-up imaging results and initial report confirmation. Non-contrast CT had 94% sensitivity and 100% specificity, with positive and negative predictive values 100% and 94%, respectively. Conclusion: Rate of missed acute diagnoses using non-contrast CT for patients presenting to the ED with acute abdominal complaints or related trauma has been low during the recent shortage, but further investigation would be needed to verify and quantify the implications of not routinely giving oral or intravenous contrast in the ED.

What did we learn about coronavirus disease-19-associated acute kidney injury during the pandemic?

Initial reports suggested that kidney involvement after coronavirus disease 19 (COVID-19) infection was uncommon, but this premise appears to be incorrect. Acute kidney injury can occur through various mechanisms and complicate the course of up to 25% of patients with COVID-19 hospitalized in our Institution, and of over 50% of those on invasive mechanical ventilation. Mechanisms of injury include direct kidney injury and predominantly tubular, although glomerular injury has been reported, and resulting from severe hypoxic respiratory failure, secondary infection, and exposure to nephrotoxic drugs. The mainstay of treatment remains the prevention of progressive kidney damage and, in some cases, the use of renal replacement therapy. Although the use of blood purification techniques has been proposed as a potential treatment, results to date have not been conclusive. In this manuscript, the mechanisms of kidney injury by COVID-19, risk factors, and the mainstays of treatment are reviewed.

Can COVID-19 worsen racial disparities in breast cancer screening and diagnosis?

Background: Health disparities among minority groups, especially African Americans, can limit their access to quality medical care and lead to disproportionate medical management and disease outcomes. The aim of this study was to compare the COVID-19-related change in mammogram volumes and cancer detection at two affiliated academic breast centers, one that serves a predominantly African American patient population and one that serves a predominantly non-African American patient population. Materials and methods: For the purpose of anonymity, racial demographics were collected and the center with a higher African American patient population was designated as institution A, while the center with a higher non-African American patient population was designated as institution B. Careful selection of the two breast centers was instituted in order to limit the impact of potential confounders other than race.An Institutional Review Board (IRB) exemption was obtained and two Mammography Quality Standards Act (MQSA) reports were generated; one for March 2020 through September 2020, during the height of the COVID-19 pandemic, and one for March 2019 through September 2019 to serve as the pre-pandemic control group. The i2b2 Query Analysis Tool® was used to obtain racial demographic data and compare the percent change in screening and diagnostic mammograms, image-guided biopsies, total cancers diagnosed by imaging, and percent of minimal cancers for both institutions. Results: Screening mammograms and breast cancer detection decreased in 2020 compared to 2019 at both institutions. However, the percent change from 2019 to 2020 was greater at institution A than at institution B. Percent minimal cancers, an indicator of early-stage breast cancer also decreased more drastically at institution A than at institution B. Interestingly, the total number of diagnostic exams and image-guided biopsies increased in 2020 at institution B, whereas both decreased at institution A. Conclusion: The COVID-19 pandemic may lead to worsening racial disparities in breast cancer screening. In an effort to narrow future disparity, it is crucial for radiologists and other health care providers to be aware of this inequality and educate all women on the importance of obtaining routine screening mammography. More studies are needed.

[Clinical and histopathological patterns of dermatosis in COVID-19 positive patients treated in the Unidad Médica de Alta Especialidad del Bajío, IMSS-T1, de León, Guanajuato]. / Patrones clínicos e histopatológicos de dermatosis en pacientes con infección por COVID-19 en la Unidad Médica de Alta Especialidad del Bajío, IMSS-T1, de León, Guanajuato.

BACKGROUND: COVID-19 disease, besides presenting respiratory manifestations, can affect other organs such as kidneys, gastrointestinal system, heart, and skin. So far, five clinical variants of dermatoses have been described. Few reports discuss the severity associated with the cutaneous manifestations of COVID-19 and the prognosis. AIM: To describe the clinical and histopathological patterns of dermatoses in patients with COVID-19 infection. PATIENTS AND METHODS: Prospective cohort study conducted in patients admitted to "IMSS T1" in Leon, Guanajuato, Mexico from September 2020 to January 2021. We identified those with COVID-19 dermatosis from the moment they were admitted; and those who developed them during hospitalization. Patients were invited to participate for a clinical evaluation and biopsy. The biopsies were described by an expert pathologist. RESULTS: The frequency of dermatological lesions was 15.7%. Those who developed dermatosis during their hospital stay presented higher mortality (p = 0.001) and severity of COVID-19 (p = 0.001) Vasoocclusive lesions were the most frequent in the hospital setting, and were associated to higher mortality (p = 0.003). The most frequent histopathological feature was superficial and deep thrombosis (58%). CONCLUSIONS: Patients who developed dermatologic lesions during hospitalization and those with vaso-occlusive dermatoses had higher morbi-mortality. Vaso-occlusive lesions could be considered as a poor prognostic factor.

Community- and Hospital-Acquired Acute Kidney Injury in COVID-19: Different Phenotypes and Dismal Prognosis.

INTRODUCTION: Acute kidney injury (AKI) is common in coronavirus disease 2019 (COVID-19). It is unknown if hospital-acquired AKI (HA-AKI) and community-acquired AKI (CA-AKI) convey a distinct prognosis. METHODS: The study aim was to evaluate the incidence and risk factors associated with both CA-AKI and HA-AKI. Consecutive patients hospitalized at a reference center for COVID-19 were included in this prospective cohort study. RESULTS: We registered 349 (30%) AKI episodes in 1,170 hospitalized patients, 224 (19%) corresponded to CA-AKI, and 125 (11%) to HA-AKI. Compared to patients with HA-AKI, subjects with CA-AKI were older (61 years [IQR 49-70] vs. 50 years [IQR 43-61]), had more comorbidities (hypertension [44 vs. 26%], CKD [10 vs. 3%]), higher Charlson Comorbidity Index (2 points [IQR 1-4] vs. 1 point [IQR 0-2]), and presented to the emergency department with more severe disease. Mortality rates were not different between CA-AKI and HA-AKI (119 [53%] vs. 63 [50%], p = 0.66). In multivariate analysis, CA-AKI was strongly associated to a history of CKD (OR 4.17, 95% CI 1.53-11.3), hypertension (OR 1.55, 95% CI 1.01-2.36), Charlson Comorbidity Index (OR 1.16, 95% CI 1.02-1.32), and SOFA score (OR 2.19, 95% CI 1.87-2.57). HA-AKI was associated with the requirement for mechanical ventilation (OR 68.2, 95% CI 37.1-126), elevated troponin I (OR 1.95, 95% CI 1.01-3.83), and glucose levels at admission (OR 1.05, 95% CI 1.02-1.08). DISCUSSION/CONCLUSIONS: CA-AKI and HA-AKI portend an adverse prognosis in CO-VID-19. Nevertheless, CA-AKI was associated with a higher comorbidity burden (including CKD and hypertension), while HA-AKI occurred in younger patients by the time severe multiorgan disease developed.

Prolonged Intermittent Renal Replacement Therapy for Acute Kidney Injury in COVID-19 Patients with Acute Respiratory Distress Syndrome.

INTRODUCTION: Patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 frequently develop severe acute kidney injury (AKI). Although continuous renal replacement therapy is the standard of care for critically ill patients, prolonged intermittent renal replacement therapy (PIRRT) may be a feasible option. We aimed to describe the tolerability and security of PIRRT treatments in COVID-19 patients with ARDS who required mechanical ventilation and developed severe AKI. METHODS: We prospectively analyzed patients who underwent PIRRT treatments at a COVID-19 reference hospital in Mexico City. Intradialytic hypotension was defined as a systolic blood pressure decrease of ≥20 mm Hg or an increase of 100% in vasopressor dose. RESULTS: We identified 136 AKI cases (60.7%) in 224 patients admitted to the intensive care unit. Among them, 21 (15%) underwent PIRRT (130 sessions) due to stage 3 AKI. The median age of the cohort was 49 (range 36-73) years, 17 (81%) were male, 7 (33%) had diabetes, and the median time between symptoms onset and PIRRT initiation was 12 (interquartile range [IQR] 7-14) days. The median of PIRRT procedures for each patient was 5 (IQR 4-9) sessions. In 108 (83%) PIRRT sessions, the total ultrafiltration goal was achieved. In 84 (65%) PIRRT procedures, there was a median increase in norepinephrine dose of +0.031 mcg/kg/min during PIRRT (IQR 0.00 to +0.07). Intradialytic hypotensive events occurred in 56 (43%) procedures. Fifteen (12%) PIRRT treatments were discontinued due to severe hypotension. Vasopressor treatment at PIRRT session onset (OR 6.2, 95% CI 1.4-28.0, p: 0.02) and a pre-PIRRT lactate ≥3.0 mmol/L (OR 4.63, 95% CI 1.3-12.8, p: 0.003) were independently and significantly associated with the risk of hypotension during PIRRT. During follow-up, 11 patients (52%) recovered from AKI and respiratory failure and 9 (43%) died. Several adaptations to our PIRRT protocol during the COVID-19 outbreak are presented. CONCLUSIONS: PIRRT was feasible in the majority of COVID-19 patients with ARDS and severe AKI, despite frequent transitory intradialytic hypotensive episodes. PIRRT may represent an acceptable alternative of renal replacement therapy during the COVID-19 outbreak.

[Prevention and control of SARS-CoV-2 (Covid-19) coronavirus infection in hemodialysis units.] / Prevención y control de la infección por coronavirus SARS-CoV-2 (Covid-19) en unidades de hemodiálisis.

The SARS-CoV-2 pandemic is of hich risk for patients on chronic hemodialysis due to their immunosuppressed state, advanced age, and the coexistence of significant comorbidities, in particular cardiovascular disease, diabetes mellitus, and others. Additionally, they constitute a closed conglomerate since they come to treatment regularly, spending hours in the treatment places, exposed to a possible acquisition of the infection. Finally, going to their treatment regularly prevents them from remaining in home isolation and with potential exposure. These recommendations summarize the interventions proposed by three international organizations and add some suggested by national experts, with the aim to early identify the patients and health personnel at risk and reducing the risk of infection.

La pandemia del SARS-CoV-2 representa un riesgo especial para los pacientes en hemodiálisis crónica por su estado de inmunosupresión, edad avanzada y coexistencia de comorbilidades importantes, en particular patología cardiovascular, diabetes mellitus y otras. Adicionalmente, esta población constituye un conglomerado cerrado ya que los pacientes acuden a tratamiento con regularidad y permanecen horas en los lugares de tratamiento, expuestos a una posible adquisición de la infección. El hecho de acudir necesaria y regularmente a su tratamiento impide que permanezcan en aislamiento domiciliario y con exposición potencial en el traslado. Las presentes recomendaciones resumen las intervenciones propuestas por tres organizaciones internacionales, a las que se agregan algunas sugeridas por expertos nacionales, con el objetivo de identificar precozmente a los pacientes y personal de la salud en riesgo para disminuir el riesgo de infección.