ABSTRACT
Introduction: Hypertensive emergencies and urgencies represent a frequent challenge for physicians in Emergency Department. Rapid and careful assessment of the clinical presentation is crucial in order to allow prompt recognition of Hypertensive Emergencies that require appropriate treatment targeted to the affected organ(s). Aim(s): to evaluate the prevalence, clinical presentation and treatment of patients admitted for hypertensive emergencies or hypertensive urgencies in ED. Method(s): Medical records of consecutive patients aged at least 18 years, admitted to the ED of "Antonio Cardarelli"' hospital in Naples (Italy) over a one month period and presenting with SBP at least 180 mmHg and/or DBP at least 110 mmHg were prospectively analyzed. Result(s): We screened 3500 patients and enrolled 63 (1.8%). The mean age of the participants was 65 +/- 13 and 65% were men. 73% of the patients had hypertension, 25% had coronary heart disease and 19 % diabetes. Overall, 31 had hypertensive emergency and 32 had hypertensive urgency. Five patients (8%) tested positive for Covid 19 infection, all hospitalized for hypertensive emergency. Among hypertensive emergencies, the different forms of organ damage were: acute coronary syndrome (39%), abdominal aorta fissure (3.2%), acute heart failure (23%), hemorrhagic stroke (16%) and ischemic stroke (19%). SBP values and heart rate (HR) were higher in patients with emergencies than in those with urgencies (BP 195 +/- 17 vs 186 +/- 24 mmHg and 93 +/- 20 vs 83 +/- 22 bpm), but the analysis showed no statistically significant differences between the two groups. (p = 0.12 and p = 0.087 respectively). Chest pain was the most common presenting symptom in hypertensive emergency (42%) followed by neurological deficit (35%) and dyspnoea (22.6%). Patients with hypertensive urgencies were prevalently asymptomatic (29%) o presented headache (28%). Twelve patients with hypertensive emergency (38.7%) were assigned a yellow code. Mortality was 8%;they were admitted for hypertensive emergency and 3 of the 5 deceased patients were affected by SARS COVID 19 infection. Conclusion(s): The high prevalence of hypertensive emergency can be explained as our hospital is a reference center for percutaneous coronary intervention and stroke. Covid infection may have adversely affected the prognosis of patients with hypertensive emergency.
ABSTRACT
Background: The COVID-19-associated multisystem infammatory syndrome in children (MIS-C) is characterized by Kawasaki disease (KD)-like features and circulatory shock [1]. The genesis of SARS-CoV-2 variants triggered successive waves of mass infections followed by MIS-C outbreaks. Objectives: To compare MIS-C phenotypes across the waves of the COVID-19 pandemic. To identify predictors of pediatric intensive care unit (PICU) admission and treatment with biologic agents. Methods: Youth aged 0-18 years, fulflling the WHO case defnition of MIS-C, and admitted to the Alberta Children's Hospital during the COVID-19 pandemic (May 2020-December 2021) were included. Clinical, laboratory, imaging, and treatment data were captured (KD-like manifestations, signs of shock and/or hypotension, peak C-reactive protein (CRP) and ferritin, platelet count nadir, peak NT-proBNP and troponin, liver enzyme abnormalities, sodium and albumin nadir, echocardiogram fndings, biologic agents). Results: 57 consecutive MIS-C patients (median age 6 years, IQR 4-6;72% males) were included. 31 patients (54%) required PICU admission. All received immunoglobulins, 44 (77%) received corticosteroids, 8 patients (14%) were treated with biologic agents. Patients presenting during the third (mainly driven by Alpha variant) or fourth wave (mainly driven by Delta variant) presented with higher ferritin and NT-proBNP levels, and more liver enzyme abnormalities, hypoalbuminemia and thrombocytopenia compared to those presenting during the frst or second wave (Table 1, Figure 1). PICU admission was associated with the presence of shock/hypotension, higher CRP, ferritin, and NT-proBNP levels, lower albumin levels, and the presence of ventricular dysfunction on echocar-diogram (Table 1). A logistic regression model combining peak NT-proBNP, tro-ponin and ferritin levels explained 70% (Nagelkerke R2) of the variance in PICU admission and correctly classifed 91% of the cases. NT-proBNP was the sole signifcant contributor (p=0.017). Treatment with biologic agents was associated with higher CRP (mean 148.8 mg/l versus 251.7 mg/l;p=0.024) and ferritin (797 μg/l versus 1280 μg/l;p=0.049) levels. Conclusion: A shift in MIS-C phenotype was identifed across the successive COVID-19 waves, including the predominance of features associated with macrophage activation syndrome in later stages. These fndings may refect the impact of distinct SARS-CoV-2 variants. NT-proBNP emerged as the most important MIS-C feature predicting PICU admission, underscoring the importance of monitoring.
ABSTRACT
In this case series study, we aimed to evaluate the feasibility of a subacute rehabilitation program for mechanically ventilated patients with severe consequences of COVID-19 infection. Data were retrospectively collected from seven males (age 37-61 years) who were referred for inpatient rehabilitation following the stay in the ICU (14-22 days). On admission, six patients were still supported by mechanical ventilation. All patients were first placed in isolation in a special COVID unit for 6-22 days. Patients attended 11-24 treatment sessions for the duration of rehabilitation stay (13-27 days), including 6-20 sessions in the COVID unit. The treatment included pulmonary and physical rehabilitation. The initially nonventilated patient was discharged prematurely due to gallbladder problems, whereas all six mechanically ventilated patients were successfully weaned off before transfer to a COVID-free unit where they stayed for 7-19 days. At discharge, all patients increased limb muscle strength and thigh circumference, reduced activity-related dyspnea, regained functional independence and reported better quality of life. Rehabilitation plays a vital role in the recovery of seriously ill post-COVID-19 patients. Facilities should develop and implement plans for providing multidisciplinary rehabilitation treatments in various settings to recover functioning and prevent the development of long-term consequences of the COVID-19 disease.