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Background. The superinfection of multidrug-resistant bacteria is an important complication in critically ill COVID-19 patients. An outbreak of carbapenemresistant Acinetobacter baumannii (CRAB) occurred in an isolation ward for COVID-19. We performed an outbreak investigation, and successfully controlled the outbreak with the enhanced environmental cleaning and additional gowning and gloving. Methods. This study analyzed all COVID-19 patients with CRAB in any specimen, who admitted to an isolation ward for COVID-19 of a tertiary hospital in South Korea from October to November 2021. Results. During the outbreak period, a total of 23 patients with COVID-19 and CRAB were identified (Figure 1). Index case was 85-year old female patient who was referred from a long-term care facility. The mean age of cases was 72.9 and 14 (60.9%) patients were male. In most patients (91.3%), CRAB were identified in sputum culture, two were identified in blood culture at initial, and four patients were identified in sputum and blood culture at the same time. Most of the patients were applying high flow nasal cannula (26.1%) or mechanical ventilation (60.9%)(Table1). As shown in figure2, CRAB outbreak occurred mainly in the wards around the index case, and in particular, environmental culture was carried out in the area marked with a rectangle. CRAB was cultured on the floor, air inlet, air outlet, and window frame of the ward except for wards 3305 and 3319. Phenotypic antimicrobial resistance patterns of CRAB isolates from patients and environment were identical, and additional whole genome sequencing analyses are ongoing to find the clonality of isolates. We applied the infection control measures with the enhanced environmental cleaning using sodium hypochlorite(NaClO) 1000ppm and phenolic compounds more than twice a day, enhanced hand hygiene, and additional gowning and gloving over personal protective equipment (PPE) mandatory for COVID-19 on 29th October. No additional CRAB cases occurred since 2nd November 2021 for two weeks. Conclusion. Even when PPEs and precautions for COVID-19 are applied to isolation wards for COVID-19, it is helpful for preventing transmission of multidrug-resistant bacteria to apply additional contact precautions and environmental cleaning.
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Background. Invasive aspergillosis (IA) is a great threat to the severely immunocompromised and patients with coronavirus disease (COVID-19). However, diagnosis of IA is often difficult due to need for invasive biopsy and low sensitivity of other diagnostic tests. Next-generation sequencing (NGS) of plasma cell free DNA (cfDNA) can be a novel non-invasive diagnostic modality. We evaluated the clinical accuracy and utility of microbial cfDNA NGS for the diagnosis of IA in patients with hematologic malignancy (HM) and COVID-19. Methods. A single-center prospective study of plasma microbial cfDNA NGS was conducted in a tertiary-care hospital in South Korea. We enrolled adult patients with HM and COVID-19, who suspected IA and performed conventional diagnostic tests for IA. The results of NGS were compared with the diagnosis of IA through conventional methods. IA cases were diagnosed according to EORTC/MSG definitions in patients with HM, and modified AspICU criteria in patients with COVID-19. (Figure 1). Figure 1. Flow chart for the participant selection method used in this study Results. Between March 2021 and January 2022, a total of 33 participants (22 [64.7%] male, median age 66.0 [50.5, 72.0]) were enrolled;19 participants with HM and 15 with COVID-19 were analyzed (Figure1 and Table1). In participants with HM, aspergillus cfDNA was detected in 100% of both proven (1/1) and probable (12/12) IA cases, and 33.3% of both possible (1/3) and no IA (1/3) cases. In participants with COVID-19, 46.2% of probable IA (6/13) showed positive aspergillus cfDNA. Detection rate of aspergillus cfDNA was significantly higher in proven/probable IA cases in participants with HM compared to participants with COVID-19. (100% vs 46.2%, p=0.005) (Figure 2). As shown in Table 2, among proven/probable IA cases, participants with positive aspergillus cfDNA showed significantly higher rate of having uncontrolled hematologic disease, receiving stem cell transplantation and recent chemotherapy. In three participants with HM, non-aspergillus strains confirmed by cfDNA NGS were in accordance with pathogens identified through conventional culture methods. Conclusion. Detection of aspergillus cfDNA showed high concordance in the results of conventional diagnostic methods in proven/probable IA of patients with HM and could be a helpful non-invasive approach to IA diagnosis in those populations.
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Background. COVID-19 increase the risk of invasive pulmonary aspergillosis. However, the risk factors and fungal origin of COVID-19 associated pulmonary aspergillosis (CAPA) is not fully defined yet. We aim to identify the risk factors for CAPA in severe COVID-19 and evaluate association between fungal contamination within the air of negative pressure rooms and diagnosis of CAPAs. Methods. We performed a retrospective case-control study to identify risk factors for CAPA with 420 severe COVID-19 patients from March 2020 to January 2022 who admitted to a tertiary care hospital in South Korea. CAPA was defined with modified AspICU criteria. Control, matched by admission date and severity of COVID-19 at admission, was selected for each case. Air sampling and fungal culture was done on Jan 2022 with a microbial air sampler (MAS-100NT) at 11 spaces in the COVID-19 designated isolation ward including 9 negative pressure isolation rooms (IRs). A cross-sectional comparison between rooms with and without airborne fungal contamination was performed. Results. A total of 420 COVID-19 patients were hospitalized during the study period, and 51 patients were diagnosed with CAPA (prevalence 12.14%, incidence 6.26 per 1000 patient.day). Multivariate analysis showed that older age (odds ratio [OR] 1.051, 95% confidence intervals [CI] 1.006-1.009, p=0.025), mechanical ventilator use (OR 2.692, 95% CI 1.049-6.911, p=0.04), and lymphopenia (OR 4.353, 95% CI 1.727-10.975, p=0.02) were independent risk factors for CAPA. (Table 1, 2) Aspergillus spp. was identified within the air from 7 out of 11 spaces including 6 IRs and 1 doctors' room. (Figure 1). All 6 IRs with positive aspergillus culture were being occupied by patients at least 8 days. Among 6 patients, 3 had already been diagnosed with CAPA whereas the other 3 were not diagnosed with CAPA through the observation period. Among 4 patients in isolation rooms without airborne aspergillus contamination, one patient had been diagnosed as CAPA before air sampling. (Table 3). Conclusion. Association between CAPA and airborne aspergillus contamination within the negative pressure room could not be demonstrated in this study. Rather than environmental factors, patient factors such as older age, ventilator care, and lymphopenia were found to be associated with CAPA diagnosis.
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Background. During the novel coronavirus SARS-CoV-2 pandemic, a considerable number of pneumothorax and pneumomediastinum associated with COVID-19 have been reported, and the incidence was higher in critically ill patients. Despite using a protective ventilation strategy, barotrauma still occurs in COVID-19 patients with invasive mechanical ventilation. This study aims to identify the risk factors and clinical characteristics of pneumothorax and pneumomediastinum in COVID-19 by a matched case-control study. Methods. This retrospective study enrolled adult patients diagnosed with a COVID-19, admitted to a critical care unit in South Korea from 2020 March 1st to 2022 January 31st. COVID-19 patients with pneumothorax and pneumomediastinum were compared, in a 1 to 2 ratio, to a control group of COVID-19 patients without pneumothorax and pneumomediastinum, matched on age, gender, and worst National Institute of Allergy and Infectious Diseases ordinal scale (NIAID-OS). Conditional logistic regression analysis was performed to assess the risk factors for pneumothorax and pneumomediastinum in COVID-19. Results. A total of 427 patients with COVID-19 were admitted during the study period. Of these patients, 24 patients were diagnosed as pneumothorax or pneumomediastinum. When comparing the characteristics of both groups, body mass index (BMI) was significantly lower in the case group (22.8 kg/m2 and 24.7 kg/m2;P = 0.048). BMI was statistically significant risk factor for barotrauma in univariate conditional logistic regression analysis (Odds ratio (OR), 0.85;Confidence interval (CI), 0.72-0.996;P = 0.044) but not in multivariate analysis. For the patients with invasive mechanical ventilation, the period from symptom onset to intubation was longer in the case-patients (13 and 9.5 days;P = 0.032). Univariate conditional logistic regression analysis showed the statistical significance of the period from symptom onset to intubation (OR, 1.14;CI, 1.006-1.293;P = 0.041). Conclusion. In this case-control study with age, gender, severity matching, lower BMI was associated with the pneumothorax in COVID-19, and delayed application of invasive mechanical ventilation might contribute to this complication.
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This chapter discusses my personal experience in the fast changing Korean education field due to the COVID-19 pandemic. As discussed in this chapter, schools are continuing to provide positive education activities despite needing to rely on distance learning during these troubling times. Like preparation in all educational systems, what is vital during emergencies like the COVID-19 pandemic is the development of innovative teaching materials and the revitalization of teachers learning communities. While many teachers are struggling, we can wisely overcome this crisis and more effectively communicate with students to adapt to the new normal era. © 2022 selection and editorial matter, Curtis J. Bonk and Meina Zhu;individual chapters, the contributors.
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OBJECTIVE: The effects of SARS-CoV-2 were initially studied in the respiratory system, but research has now shown manifestations in multiple organ systems. SARS-CoV-2 is known to enter target cells through the ACE- 2 receptor, which is expressed in the testes. Due to this, the testes has been purported to be a potential target for SARS-CoV-2 infection. To date, studies have suggested that there is only a minor risk for shedding of SARS-CoV-2 into the semen.1 The objective of this study is to compare semen analysis parameters in a subset of healthy sperm donors prior to, during, and after testing positive for COVID-19. MATERIALSAND METHODS: The study included semen analyses (SA) from qualified sperm donors aged 19-38, with 2-5 days of abstinence who donated sperm prior to COVID infection, during active COVID infection, and post COVID infection. Semen was collected in the course of sperm bank operation and samples were collected concurrent with incidental positive test results obtained through COVID screening. Primary outcomes included ejaculate volume (mL), average concentration (M/mL), and percent motility (%). The standard operating procedure for sperm donation dictated that morphology is performed when they are first accepted into the program, thus was not recorded for these samples. Data were compared and analyzed by ANOVA. RESULTS: A total of five qualified sperm donors met inclusion criteria for this study. When comparing semen analyses across the three time points, there was not a significant difference in concentration (p=0.7460), percent motility (p=0.9135), or ejaculate volume (p=0.9241) [Table 1]. CONCLUSIONS: Sperm quality measures as evidenced in qualified, healthy sperm donors are not significantly different when comparing sperm samples prior to COVID infection, during active COVID infection, and after recovery from COVID infection. Although limited by a small sample size, our findings are reassuring to those with SARS-CoV-2 infection, as there appears to be no adverse association with sperm quality. IMPACT STATEMENT: Sperm quality in healthy, qualified donors is not affected by active SARS-CoV-2 infection.
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OBJECTIVE: The coronavirus (COVID-19) pandemic reshaped access to assisted reproductive technology (ART) treatment. Following ASRM's March 2020 recommendation to halt all ART treatments, many patients were unable to pursue parenthood until resumption of clinical care. Our study assesses patient progression to reproductive care before, during and after the declaration of the COVID-19 pandemic. MATERIALS AND METHODS: The study includes patients who sought ART treatment from January 1, 2018 to October 1, 2020. Only patients who underwent an initial consultation were included in the study. Patients were grouped by month in the years of 2018, 2019, and 2020. Patient progression to treatment was confirmed only if the ART procedure occurred within 90 days after initial consultation. RESULTS: A total of 27,626 initial consultations from patients who sought ART treatment were evaluated in the study. Treatment progression rates for 2018 and 2019 showed high correlation with nearly identical rates per month from March to July [Table 1]. Patient progression declined to 47.9% starting in January 2020 compared to 57.3% in 2018 and 59.4% in 2019 of the same month. Thereafter, progression to treatment dropped to an all-time low (February-March 2020 (32.0-33.0%)). Progression rate increased by late April 2020 (47.7%);and then surged in May 2020 (55.7%) superseding treatment progression rates between the same months during 2018 (47.4%) & 2019 (47.9%). By the end of August and throughout September 2020 progression to treatment restored itself to rates in 2018 & 2019 [Table 1]. CONCLUSIONS: As compared to cohorts in 2018 and 2019, our study demonstrated a marked decline in progression to ART treatment that coincided with the onset of the COVID pandemic and when many regions of the country restricted all but urgent medical procedures. As COVID-related restrictions lifted, treatment progression rates sharply rebounded and then stabilized by September 2020. The recovery to treatment progression displays fertility care as essential to patients and reaffirms a strong desire to have children. IMPACT STATEMENT: The barriers related to the onset of the COVID pandemic were short-lived for patients who sought ART treatment. Even with COVID's introduction of new normal, patients can be reassured that they have the ability to access reproductive care and achieve parenthood.
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OBJECTIVE: Two decades ago, a small RCT concluded that embryos with an incision in the zona pellucida could be protected from an immune response by administering systemic corticosteroids1. The utilization of corticosteroids remains a standard practice at many ART centers 2,3. In early 2020, during the peak of the Sars-Cov-2 pandemic, some reports showed that corticosteroid intake associated with an extended time of viral shedding which associated to higher mortality among patients with coronavirus pneumonia4. Our center therefore discontinued standard of methylprednisolone in frozen embryo transfer (FET) cycles. Our study aims to evaluate IVF pregnancy outcomes of patients who underwent a short course of oral steroids compared to those that were not treated with corticosteroids. MATERIALS AND METHODS: All patients who underwent IVF from 2016 - 2021 were included. All cases underwent PGT-A with NGS. Only patients who underwent a single euploid FET under a synthetic endometrial preparation cycle were included. Cohorts were separated by use of steroids prior to ET (Group A: Oral methylprednisolone Treatment (16mg for 7 days);Group B: non-treatment controls). Patients with RPL, implantation failure and uterine factor were excluded. Baseline, demographic characteristics and cycle outcomes were recorded. Comparative statistics and a multivariate regression analysis fitted with a GEE were utilized for statistical analysis. A sample size of 1,437 FET's per group was calculated to have an 80% power to detect a difference of 5% on implantation rates, a=0.05. RESULTS: A total of 7,172 cycles were included in the analysis, 5,002 cycles with methylprednisolone utilization were compared against 2,170 controls. No differences were found in oocyte age, age at FET, BMI, AMH, FSH, previous cycles, days of endometrial preparation, endometrial thickness at FET and embryo quality at FET among cohorts. When comparing IVF outcomes, in an unadjusted-analysis a difference was found in implantation rates among patients that used methylprednisolone compared with controls (75.8% vs 72.8%, p=0.008), clinical pregnancy, ongoing pregnancy and clinical pregnancy loss rates were comparable among groups. In a multivariate analysis after adjusting for oocyte age, day of biopsy, embryo quality, BMI, AMH, and endometrial thickness at ET, no association was found with the utilization of Methylprednisolone and higher implantation (OR 1.1 CI95% 0.9-1.2), clinical pregnancy (OR1.02;0.9-1.1), ongoing pregnancy (OR 0.9;0.8-1.08) or higher odds of clinical pregnancy loss (OR 1.1;0.9-1.4) CONCLUSIONS: Systemic corticosteroids use continues to be a controversial, yet widespread, adjuvant treatment during IVF cycles in many modern ART centers. Our study demonstrated the utilization of methylprednisolone is not associated with increased odds of implantation, ongoing pregnancy or decreased odds of pregnancy loss after a single euploid FET. IMPACT STATEMENT: Our findings add to the growing body of evidence suggesting that the standard use of peri-implantation corticosteroids does not enhance nor impact reproductive outcomes in FET cycles.
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OBJECTIVE: It has been suggested that geographic variations in environmental toxins may impact sperm quality. Previously, we published findings that demonstrated a decline in sperm quality over an eleven year period across six regions of the United States (US).1 The current study investigates whether there was a decrease in sperm quality from a diverse set of US sperm donors across six regions in the US over a sixteen year period. Additionally, this study sought to evaluate changes between semen analysis (SA) parameters in an era of sperm collection during the COVID-19 pandemic. MATERIALS AND METHODS: Semen analyses (SA) from sperm donors aged 19-38, with 2-5 days abstinence, from 9 different geographic regions from January 2005-April 2021 were examined. The sperm donors originated from one of the following regions: Palo Alto, Los Angeles, Westwood, International Nordic Cryo Bank Denmark, Indianapolis, Cambridge, New York, Houston, and Spokane, WA. Donation date, BMI, and geographic region were recorded. Data was analyzed as a whole as well as by individual region. Primary outcomes were ejaculate volume (mL), average concentration (M/mL), motility (%), and total motile count (M). Data was analyzed using a general estimate equation (GEE) model with an exchangeable working correlation structure to account for repeated measures. RESULTS: A total of 176,706 SA specimens (from 3,532 unique donors) were analyzed. Controlling for BMI, there was a significant decline in average concentration (M/mL) (β=-1.89, p<0.0001), sperm motility (%) (β=-0.2892, p<0.0001) and total motile sperm (M) (β=-4.53, p<0.0001) over the 16-year study period. There were significant decreases in SA parameters within all geographic regions (Spokane only had two unique donors and could not be examined). Indianapolis showed a significant decrease in sperm concentration and total motile sperm, but also displayed an increase in sperm motility over the study period. CONCLUSIONS: Time related decline in sperm quality continues to be evident at a national level in young, healthy sperm donors. There was a decline across all geographic regions in all parameters except for ejaculate volume. How this decline in sperm counts impacts fertility has yet to be determined. Our modern environment involves increased exposures to endocrine disruptors and changes to lifestyle (including smoking, diet, and stress) that are postulated to impair male fertility by interfering with spermatogenesis. While a causative link to these risk factors remains to be elucidated further studies are necessary to evaluate whether this temporal decline in sperm count correlates with decreased fecundity. IMPACT STATEMENT: Sperm concentration, motility, and total motile sperm continue to decline across young, healthy sperm donors across the continental United States.
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OBJECTIVE: Concerns have arisen in the lay press regarding a theoretical impact of the COVID-19 vaccine on fertility and early pregnancy. These concerns originate from speculation regarding homology between the COVID- 19 spike protein targeted by the vaccine and syncitin-1 protein, which mediates cytotrophoblast and syncytiotrophoblast fusion and placental development. 1 While this theory has been deconstructed by immunology experts, robust clinical studies have yet to examine a relationship between the mRNA COVID-19 vaccines and reproductive potential. This study aims to assess whether COVID-19 vaccination status impacts early pregnancy outcomes in patients undergoing IVF. MATERIALS AND METHODS: This study included patients who underwent single euploid frozen-thawed embryo transfer (FET) at a single academic center. Vaccinated patients who received the second dose of the Pfizer or Moderna mRNA vaccine two weeks prior to single euploid FET were compared to non-vaccinated patients who underwent single euploid FET during the same time period. Patients who received vaccine doses less than 14 days prior to FET were excluded. Outcomes included pregnancy rate (HCG R2.5IU/L), clinical pregnancy rate (presence of a gestational sac on ultrasound), ongoing pregnancy rate, and pregnancy loss rate. Statistical analysis was performed using Chi-square, Student's t-test, and multivariable logistic regression to control for confounders. RESULTS: Of the 65 patients who underwent single euploid FET two weeks after their final vaccine dose, 28 patients received the Pfizer vaccine and 37 received the Moderna vaccine. Fully vaccinated patients underwent FET between February-April 2021. During that time period 328 non-vaccinated patients underwent single euploid FET and comprised the control group. Baseline characteristics including age, oocyte age, BMI, AMH, BAFC, and endometrial thickness were similar between the groups. Vaccinated and non-vaccinated patients had similar pregnancy rates (75.6% vs. 73.0%, p=.72) and clinical pregnancy rates (63.4% vs. 56.9%, p=.43). No significant differences were seen in pregnancy loss rates (11.8% vs. 23.2%, p=.13) or ongoing pregnancy rates (66.7% vs. 56.1%, p=.18) between the groups. Controlling for age, BMI, AMH, and endometrial thickness revealed no association between vaccination and early pregnancy outcomes (Pregnancy: aOR 1.15, 95% CI 0.49- 2.75, p=.75;Clinical pregnancy: aOR 1.42, 95% CI 0.65-3.10, p=.38;Ongoing pregnancy: aOR 1.67, 95% CI 0.77-3.61, p=.19;Pregnancy loss: aOR 0.39, 95% CI 0.11-1.37, p=.14). CONCLUSIONS: Administration of COVID-19 mRNAvaccines does not interfere with early pregnancy in patients who undergo transfer of genetically screened embryos. There is no relationship between immune response to the COVID-19 spike protein and placental development. IMPACT STATEMENT: Patients who are planning pregnancy can be reassured that COVID-19 vaccination does not adversely impact early pregnancy outcomes. Our findings serve to debunk circulating myths and substantiate that the risk/benefit ratio supports vaccination in women who are trying to conceive.
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Novel disease emergence with associated outbreaks and pandemics have become increasingly common in the last several decades. For centuries, people have utilized various forms of collaboration to control outbreaks. Modern global health frameworks now play a central role in guiding a targeted and coordinated international disease response;recent pandemics have shown that such systems have both strengths and vulnerabilities. This report assesses the existing global health infrastructure for pandemic response and discusses how the World Health Organization (WHO) and global health infrastructure has responded to recent public health threats.
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BACKGROUND: Non-pharmacologic programs can improve function and quality of life in people with memory loss (PWML), but in-person programs are not available in many communities. We previously developed the interactive, livestreaming, group-based, Moving TogetherTM program for PWML and their caregivers (CGs). This study assesses feasibility, satisfaction, and qualitative outcomes in four groups that participated during the COVID-19 pandemic. METHOD: We assessed feasibility based on number of participants and attendance. We administered an online survey at the end of the 12-week program to assess satisfaction. The survey included a 6-item Class Experience scale (e.g., feeling accepted, energized) and the 4-item PROMIS Social Isolation scale, both using 4-point Likert response scales. Open-ended questions asked about changes noticed in themselves and others during the program. We used a previously established coding scheme informed by a biopsychosocial framework to code free-text survey responses and refined codes as we identified new concepts. RESULTS: We offered four 12-week class series (1 hour, 2 days/week) from April to July 2020 that included 8 to 14 participants each (total N=39: 24 PWML, 15 CGs). Average attendance was 78% (range: 58% to 98%). Surveys were sent to 31 participants who completed the program, of whom 25 (16 PWML, 9 CGs) responded. Nearly all respondents reported that they often, mostly or always felt acceptance and well-being during classes (6-items, 88% to 100%), and most reported that they rarely or never felt social isolation (4 items, 50% to 100%). Qualitative analyses of free-text responses identified self-reported improvements in both PWML and CGs in several areas: 1) emotional well-being, including better mood, lower stress, and increased relaxation;2) social connection, such as friendship and camaraderie;3) physical function, including more energy, increased activity, improved movement, and increased mind-body awareness;and 4) cognitive function such as better focus. CONCLUSION: This study demonstrates that the interactive, livestreaming, group-based, Moving TogetherTM program is feasible and associated with high satisfaction among both PWML and their CGs. Technology offers tremendous potential to increase accessibility to evidence-based, non-pharmacologic programs that people with memory loss (PWML) and caregivers (CGs) can participate in from the safety of their homes. © 2021 the Alzheimer's Association.
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Objective: Fertility practices have been profoundly impacted by the global COVID-19 pandemic, leading to a rapid increase in the utilization of new forms of virtual communication with patients. This study aimed to assess the use of telemedicine compared to conventional in-person consultation with regard to the rate of patient progression to treatment. Materials and Methods: The study included patients who sought reproductive treatment and underwent an initial consultation during from March 2, 2020 to December 22, 2020. Patients were grouped by in person or telemedicine at initial consultation. Patients who met in person underwent a physical exam and ultrasound the same day as the initial consultation. Patients who met via telemedicine were contacted after the initial consultation to schedule a physical exam and ultrasound at a later date. All patients were followed up with by a clinical team member and financial coordinator either in person or virtually following initial consultation. Study outcomes included number of patients who progressed to treatment. Secondary outcome included time to treatment. Treatment was defined as a patient who underwent a diagnostic procedure, surgical procedure, timed intercourse cycle, intrauterine insemination cycle, in vitro fertilization cycle, egg freezing cycle, laboratory procedure, or embryo transfer cycle. A 90 day censoring interval was applied to account for heterogeneity between initial consultation date and progression to treatment event. Results: Of the 2730 patients included in the study, 2153 (79.9%) received in person consultation and 550 (20.1%) communicated via telemedicine. The percentage of patients who progressed to treatment within 90 days of initial consultation was nearly identical between in person (35.4 %) and telemedicine patients (34.0 %). Patients who underwent in person consultation advanced to treatment 3 days faster (41.1 days) compared to telemedicine patients (44.0 days) within the 90 day censoring interval [Table 1]. [Formula presented] Conclusions: The COVID-19 pandemic has forever changed society, healthcare, and reproductive medicine. While infertility patients who utilize telemedicine for initial consultation take longer to initiate treatment, they are equally likely to enter treatment. Impact Statement: Use of telemedicine breaks down barriers to treatment and provides the opportunity for patients everywhere to access reproductive care in their journey to parenthood.
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Introduction Typical orofacial manifestations of granulomatosis with polyangiitis (GPA) include rhinitis and sinusitis, but salivary gland involvement is rare. Treatment of GPA increases risk of opportunistic infections. In light of the recent SARS-CoV-2 pandemic, this places this population in a particularly vulnerable position. Here we describe a case of suppurative parotitis as the presenting sign of GPA, treated with prednisone and cyclophosphamide, subsequently complicated by SARS-CoV-2 infection, disseminated MRSA infection, and invasive pulmonary aspergillosis (IPA) with aspergillosis of the pancreas. Presentation A 71-year-old male with COPD was admitted to hospital for progressive facial pain with left parotid gland swelling despite outpatient antibiotics. Basic laboratory workup was unremarkable. He developed hemoptysis, and CT chest revealed a new left upper lobe (LUL) cavitary lesion with bilateral nodules. Diagnostic bronchoscopy showed thickened, nodular mucosa in the LUL with luminal narrowing. Endobronchial biopsy showed inflammation with necrosis but no malignancy;culture showed no microorganisms. Parotid gland pus grew normal oral flora. CT-guided core biopsy of the LUL lesion showed fibrotic and necrotic tissue with inflammation and multi-nucleated giant cells, again without tumor cells. Initial autoimmune workup revealed ANA positivity, but he elected for discharge to outpatient autoimmune workup. Four weeks later he was admitted to another hospital with acute renal failure where testing revealed hypocomplementemia, elevated c-ANCA and anti-PR-3 antibodies. Renal biopsy demonstrated focal necrotizing and diffuse crescentic glomerulonephritis. A diagnosis of GPA was made and treatment with prednisone and cyclophosphamide was initiated. After three months of this regimen, he was re-admitted to our facility for SARSCoV- 2 infection. Hospital course was complicated by MRSA endocarditis and presumed fungal pneumonia. Despite aggressive treatment of both, he developed septic shock and ultimately expired. Autopsy revealed invasive aspergillus in the lungs and necrotizing pancreatitis from aspergillus. Discussion Salivary gland involvement is a rare manifestation of GPA and documented infrequently in case reports. The presence of parotitis in a patient with hemoptysis and negative malignant or infectious workup should prompt the consideration of GPA. Importantly, IPA associated with SARS-CoV-2 infection in immunocompetent patients has been frequently documented in the literature, and immunosuppressed individuals such as this patient are surely at increased risk. The rare, incidental finding of aspergillus invading the pancreas on autopsy was likely related to his immunocompromised state. Given the high mortality rate, there should be a low threshold to treat for presumed IPA in patients with SARS-CoV-2 infection for which secondary infection is suspected.
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Objective: The coronavirus (COVID-19) pandemic has forever reshaped the United States health care system. However, assisted reproductive technology (ART) treatment remains an essential form of medicine. Reproductive practices have since incorporated vigilant practices regarding social distancing, ample use of Personal Protective Equipment (PPE), and consistent decontamination protocols in order to mitigate risk of COVID-19 infection. Altogether, changes to standard operating procedures within ART treatment centers are anticipated to support patient safety without compromising quality of reproductive care. Finally, there is ample evidence of the mental health burden stemming from this pandemic with regard to anxiety and depression in both healthcare workers and patients. Given the current uncertainty, our study evaluates IVF cycle outcome in a New York City patient cohort prior to and subsequent to the ASRM COVID-19 task force’s recommended treatment pause. Design: Retrospective cohort analysis. Materials and Methods: The study includes patients who underwent a single, euploid frozen-thawed embryo transfer (FET) from January 1st, 2020 to May 18th, 2020. Cohorts were separated into two groups based on period of IVF treatment (Group 1: Treatment prior to the COVID-19 pandemic pause;Group 2: Treatment subsequent to the COVID-19 pause). Primary outcome included early pregnancy rates. Chi squared test was used and statistically significance was considered at p= <0.05. Results: A total of 601 single, euploid FET cycles in which pregnancy outcomes coming prior to the COVID-19 pandemic pause (n=526) were compared to outcomes subsequent to COVID-19 (n=75). No differences were found in early pregnancy rates among cohorts (Table 1). [Formula presented] Conclusions: The COVID-19 pandemic has placed an unprecedented burden on patients, physicians, and the entire healthcare system. Urgent treatments, including reproductive care, were postponed, as scarce resources needed to be re-directed. Resumption of treatment required modification in workflow, staffing, decontamination protocols, and utilization of PPE. Although the patient experience has changed, our study is first to demonstrate implantation rates were not compromised in an era of COVID-19. Importantly, our preliminary data suggests that the stress and anxiety that pervade modern COVID-era reproductive care do not alter outcomes. With an abundance of caution, a modern fertility clinic can work to “flatten the curve,” abide by guidelines, and deliver safe and effective patient care.