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Introduction: COVID-19 infection has been associated with acute myocardial dysfunction. However, long-term effects of myocardial injury during COVID-19 infection are not well characterized. Novel speckle tracking echocardiography (STE) may lend further insights into COVID-19 myocardial dysfunction. Method(s): Patients hospitalized with acute COVID-19 infection from March 2020 to September 2021 who underwent STE and had evidence of myocardial dysfunction (defined as left ventricular ejection fraction (LVEF) less than 55% and/or global longitudinal strain (GLS) less negative than -18%) were enrolled in follow-up 3-12 months after hospitalization. Clinical and laboratory data were collected, and follow-up STE was performed, including LVEF, GLS, myocardial work index (MWI) and myocardial work efficiency (MWE) measurements. Statistical analysis was performed to determine risk factors for worsening myocardial dysfunction at follow-up. Result(s): Twenty-four patients were enrolled at an average 239+/-102 days after the initial hospitalization echocardiogram: 13 (54%) male, 14 (58%) Black, and average age 56+/-14 years. Average duration of initial admission was 24+/-25 days;14 patients (58%) were admitted to the intensive care unit. Ten (42%) patients had acute respiratory distress syndrome, 1 (4%) had ST-elevation myocardial infarction and 1 (4%) had cardiac arrest. Eleven (46%) patients required mechanical ventilation and 2 (8%) required extracorporeal membrane oxygenation. Five (21%) patients had elevated troponin on admission and average peak troponin was 1.35+/-3.83 ng/ml. Follow-up STE showed significant improvement in average GLS (-13.7+/-3.2% vs -16.0+/-3.7%, P=0.03). There were no significant changes in average LVEF (55.9+/-12.6% vs 55.5+/-8.8%, P=0.90), MWI (1519+/-425 vs 1681+/-412, P=0.24) and MWE (93+/-4 vs 92+/-4, P=0.65) at follow-up compared to during COVID-19 infection. Patients with lower LVEF at follow-up as compared to acute infection (n=11, 46%) were more likely to have had longer duration of symptoms prior to initial presentation (11+/-5 days vs 6+/-5 days, P=0.02) and higher peak erythrocyte sedimentation rate (94+/-30 mm/h vs 44+/-36 mm/h, P=0.007) compared to those with stable or improved LVEF. Conclusion(s): Approximately 8 months after COVID-19 infection, average GLS was significantly improved in patients with myocardial dysfunction during acute COVID-19 infection. Close follow-up is recommended for patients with evidence of myocardial injury during COVID-19 infection, especially those who present with prolonged symptoms and those with high inflammatory markers.Copyright © 2022
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Context: The COVID-19 pandemic has impacted the volume and nature of pediatric primary care visits nationwide. Objective: This study aimed to identify trends in pediatric visits during COVID-19 at our institution to reveal challenges and opportunities to improve care. Study Design: Retrospective chart review of all pediatric visits from January 1, 2019 through September 30, 2021 using the electronic health record (EHR). Descriptive statistics were used for data analysis. Setting or Dataset: Single family medicine clinic within a large academic medical center in Northern California. Data collected for each pediatric primary care visit included age, sex, type of visit (preventive or problem-focused), reason for visit (if problem-focused), and mode of visit (in-person or video). Population Studied: Pediatric patients (<18 years old). Intervention/Instrument: N/A Outcome Measures: Volume and nature of pediatric primary care visits. Results: A total of 4,846 pediatric visits occurred during the study period. Visit volume dropped 9% from 2019- 2020, mostly during April-May 2020, and recovered afterward to pre-pandemic baseline through 2021. There were no significant changes to age, sex, or type of visit during the study period with one exception: the proportion of problem-focused visits increased 23% (p=0.004) from 2019-2021 in adolescents aged 12-<18, driven largely by a 107% increase (p<0.001) in the proportion of behavioral health visits (14% in 2019, 18% in 2020, and 29% in 2021). Video visits accounted for 4% of all visits in 2019, 39% in 2020, and 35% in 2021. Video visit volume decreased from 2020-2021 in all age categories except for adolescents aged 12-<18, which remained stable at 43% of all visits. Conclusions : A sharp increase in behavioral health concerns among adolescents stands out as the most notable impact of COVID-19 on pediatric care at our institution. Our findings raise questions about how behavioral health care can be optimized for children and adolescents now and in the post-pandemic era. Copyright © 2023 Annals of Family Medicine, Inc.
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Coronavirus disease 2019 (COVID-19) has been associated with a wide spectrum of cardiovascular manifestations. Since the beginning of the pandemic, echocardiography has served as a valuable tool for triaging, diagnosing and managing patients with COVID-19. More recently, speckle-tracking echocardiography has been shown to be effective in demonstrating subclinical myocardial dysfunction that is often not detected in standard echocardiography. Echocardiographic findings in COVID-19 patients include left or right ventricular dysfunction, including abnormal longitudinal strain and focal wall motion abnormalities, valvular dysfunction and pericardial effusion. Additionally, some of these echocardiographic abnormalities have been shown to correlate with biomarkers and adverse clinical outcomes, suggesting an additional prognostic value of echocardiography. With increasing evidence of cardiac sequelae of COVID-19, the use of echocardiography has expanded to patients with cardiopulmonary symptoms after recovery from initial infection. This article aims to highlight the available echocardiographic tools and to summarize the echocardiographic findings across the full spectrum of COVID-19 disease and their correlations with biomarkers and mortality.
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The social and economic losses caused by viruses such as SARS-CoV, MERS-CoV, and SARS-CoV-2 has been serious. In this study, the size of airborne droplet nuclei particles and the number of virions generated by speaking or coughing were analyzed. Particle collection efficiencies of E11 and H13 grade air filters used in commercial air purifiers were evaluated for different particle sizes and the possibility of removing the airborne droplet nuclei particles by air purifiers was studied. In addition, the reduction of SARS-CoV-2 virion concentration and dose by using air purifiers was theoretically investigated for elementary school classrooms. When an infected student continuously emits virions with a rate of 6.0x10(5) virions/h in a 165 m(3)-sized classroom, the virion concentration and dose was estimated to be reduced by more than 60% by using an air purifier of clean air delivery rate (CADR) 780 m(3)/hr and by more than 70% by using two air purifiers (that is, CADR 1560 m(3)/h) compared to when not in use of the air purifier. However, to prevent the spread of infection by the air stream generated by the air purifier, it is necessary to operate an instruction for using the air purifier such as facing the air outlet toward the ceiling and installing at least 50 cm away from occupants.
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SESSION TITLE: Lessons from the ICU: What have We Learned about the Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: SARS-CoV2 is known for causing atypical pneumonia with rapidly progressive respiratory failure requiring intubation. Usage of steroids have been shown to be of benefit in similar disease processes caused by other coronaviruses specifically SARS/MERS. Currently in the literature there is lack of consensus regarding steroids use in severely ill patients with COVID-19 pneumonia. We conducted a retrospective analysis to evaluate the efficacy of systemic corticosteroids and outcomes in COVID-19 patients with severe respiratory symptoms requiring ICU admission in a community hospital in Michigan. METHODS: This retrospective cohort study was conducted with 181 patients of COVID-19 with severe respiratory symptoms requiring ICU admission in a community hospital in Michigan March 18 to April 15, 2020. Patients were then divided into 2 groups, with or without steroid treatment. Treatment group received oral prednisone, doses range from 10 to 60mg twice daily for an average of 5 days, most of which received a loading dose of intravenous methylprednisolone. The primary outcome for the study was mortality rate, secondary outcome was extubation rate. RESULTS: 177 patients met inclusion criteria and among those, 93 patients received systemic steroids. Of the total 93 patients in the treatment group, 42 patients were admitted to ICU, 38 of which were intubated. Of the total 84 patients in the control group, 14 patients were admitted to ICU and 10 were intubated. The mortality rate was 53% in the treatment group compared to 57% in the control group (p>0.05);the extubation rate was 71% in the treatment group compared to 50% in the control group (p>0.05). Our results showed a clinically important difference between the two groups. CONCLUSIONS: Existing evidence from literature is inconclusive regarding use of steroids in COVID-19. Currently, Surviving Sepsis Campaign recommends using low-dose corticosteroid in intubated COVID-19 patients with ARDS, IDSA guidelines recommend use of steroid only in the setting of clinical trials, and National institutes of Health states that there is insufficient evidence for or against use of steroid in COVID-19 patients. Multiple retrospective cohort studies have shown variability in the benefit of steroid use in patients infected with SARS/MERS, which may not be applicable to COVID-19 patients. Our study indicates that in severely ill patients with COVID-19, systemic steroids with short-term application was associated with lower ICU mortality rates and higher extubation rates. CLINICAL IMPLICATIONS: Though our results did not achieve statistical significance, it was observed that there was an improved mortality rate and increased extubation rate in those who received corticosteroid. We suggest further studies, in form of a multi-center randomized control trial to assess additional benefits of systemic steroids in COVID-19 treatment. DISCLOSURES: No relevant relationships by Radha Kishan Adusumilli, source=Web Response No relevant relationships by Laith Al-janabi, source=Web Response No relevant relationships by Padmini Giri, source=Web Response No relevant relationships by Gloria Hong, source=Web Response No relevant relationships by Sarwan Kumar, source=Web Response No relevant relationships by Manishkumar Patel, source=Web Response No relevant relationships by Bernadette Schmidt, source=Web Response No relevant relationships by Jurgena Tusha, source=Web Response
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SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The SARS-CoV2 virus is well known for causing atypical pneumonia in addition to other symptoms. Various neurological symptoms have been reported including anosmia, headaches, and stroke like symptoms. Here we report a case of a critically ill patient who developed encephalopathy with evidence of multiple bilateral acute strokes. CASE PRESENTATION: 68-year-old African American male with no significant past medical history presented with shortness of breath, cough, and fever. He was tested positive for COVID-19. Patient quickly desaturated after admission requiring intubation and ICU care. During his hospital course, he developed severe renal injury which required hemodialysis. Despite daily dialysis in attempt to correct uremia and cessation of all sedations, patient remained minimally responsive. CT head without contrast was unremarkable for any acute process. Despite improvement in his respiratory status and azotemia, patient remained encephalopathic, unable to be extubated. He was subsequently treated empirically with Keppra for possible subclinical seizures and methylphenidate for neurostimulation, no improvement was seen. Due to the hospital protocol to limit exposure, our patient was one of the first in our hospital to receive a brain MRI after 29 days of hospitalization, which revealed numerous small areas of restricted diffusion throughout the centrum semiovale bilaterally compatible with extensive small acute infarct. There was also an acute infarct adjacent to the frontal horn. Based on the locations of the infarcts, they were determined to be most likely ischemic in nature. The patient remained intubated in the ICU with guarded prognosis without improvement in his status, he later entered hospice care as per family’s wishes. DISCUSSION: The neurological manifestations of SARS-CoV2 virus vary. According to a series of 13 cases studied showed 2 of 13 patients with brain MRI had single acute ischemic strokes. (3) Our case showed multiple bilateral infarcts on MRI, which has scarcely been reported. It was concluded that his encephalopathy was related to these cerebral infarcts. The varied coagulopathy features seen in COVID patients is well known and cases of microthrombi have been reported. Our patient was given full dose anticoagulation after admission but, altered mentation made extubating impossible. CONCLUSIONS: Our patient was able to fight COVID pneumonia but incurred extra pulmonary consequences. This presentation emphasizes early MRI should be done as reversible causes may be ruled out. Acute CVA should be a top differential in unexplained encephalopathy. This case brings to light that although it is possible for patients, even the most severe cases who require intubation, to fight this atypical pneumonia, they can rapidly develop extra-pulmonary complications which if goes unrecognized can leave lethal penalties. Reference #1: Avula A, Nalleballe K, Narula N, et al. COVID-19 presenting as stroke [published online ahead of print, 2020 Apr 28]. Brain Behav Immun. 2020;S0889-1591(20)30685-1. doi:10.1016/j.bbi.2020.04.077 Reference #2: Pleasure SJ, Green AJ, Josephson SA. The Spectrum of Neurologic Disease in the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic Infection: Neurologists Move to the Frontlines. JAMA Neurol. Published online April 10, 2020. doi:10.1001/jamaneurol.2020.1065 Reference #3: Helms J, Kremer S, Merdji H, et al. Neurologic Features in Severe SARS-CoV-2 Infection. New England Journal of Medicine. 2020. doi:10.1056/nejmc2008597. DISCLOSURES: No relevant relationships by Padmini Giri, source=Web Response No relevant relationships by Gloria Hong, source=Web Response No relevant relationships by Han Lam, source=Web Response No relevant relationships by DANYAL TAHERI ABKOUH, source=Web Response