Cognitive function and impact on driving after SARS-COV-2 infection in a man with long-standing HIV infection: a case report.

A substantial number of individuals who experience COVID-19 infection experience prolonged physical and mental symptoms after resolution of their initial infection, and among them, many individuals experience cognitive difficulties including memory lapses and executive function difficulties, often referred to as "brain fog." The possible impact of COVID-19 infection on cognition in persons with HIV-related cognitive disorders is unknown. In this report, we describe post-COVID-19 cognitive and driving function in a 62-year-old man with HIV infection since the early 1990s.

Acute Hepatitis of Unknown Origin in Pediatric Age Group: Recent Outbreaks and Approach to Management.

Acute hepatitis has always been a public health concern, but the recent clustering of cases in various parts of the world has drawn some special attention. The sudden rise in cases has mainly been among the pediatric population of around 35 countries around the world, including developed countries such as the United States, the United Kingdom, and European countries. The outbreaks have had a devastating impact, with around 10% of the affected patients developing liver failure. The clinical presentation of patients resembles any other case of acute hepatitis, with the major symptoms being: jaundice (68.8%), vomiting (57.6%), and gastrointestinal symptoms such as abdominal pain (36.1%) and nausea (25.7%). Interestingly, the cases have tested negative for hepatotropic viruses Hep A, B, C, and E, thus giving rise to the terms Hepatitis of Unknown Origin or non-HepA-E hepatitis. Many causes have been attributed to the disease, with major evidence seen for adenovirus and SARS-CoV-2. International agencies have stressed on establishing diagnostic and management protocols to limit these outbreaks. As the understanding has evolved over time, diagnostic and management faculties have found more shape. The current review was designed to comprehensively compile all existing data and whittle it down to evidence-based conclusions to help clinicians.

Validation of COPDPredict™: Unique Combination of Remote Monitoring and Exacerbation Prediction to Support Preventative Management of COPD Exacerbations.

Background: COPDPredict™ is a novel digital application dedicated to providing early warning of imminent COPD (chronic obstructive pulmonary disease) exacerbations for prompt intervention. Exacerbation prediction algorithms are based on a decision tree model constructed from percentage thresholds for disease state changes in patient-reported wellbeing, forced expiratory volume in one second (FEV1) and C-reactive protein (CRP) levels. Our study determined the validity of COPDPredict™ to identify exacerbations and provide timely notifications to patients and clinicians compared to clinician-defined episodes. Methods: In a 6-month prospective observational study, 90 patients with COPD and frequent exacerbations registered wellbeing self-assessments daily using COPDPredict™ App and measured FEV1 using connected spirometers. CRP was measured using finger-prick testing. Results: Wellbeing self-assessment submissions showed 98% compliance. Ten patients did not experience exacerbations and treatment was unchanged. A total of 112 clinician-defined exacerbations were identified in the remaining 80 patients: 52 experienced 1 exacerbation; 28 had 2.2±0.4 episodes. Sixty-two patients self-managed using prescribed rescue medication. In 14 patients, exacerbations were more severe but responded to timely escalated treatment at home. Four patients attended the emergency room; with 2 hospitalised for <72 hours. Compared to the 6 months pre-COPDPredict™, hospitalisations were reduced by 98% (90 vs 2, p<0.001). COPDPredict™ identified COPD-related exacerbations at 7, 3 days (median, IQR) prior to clinician-defined episodes, sending appropriate alerts to patients and clinicians. Cross-tabulation demonstrated sensitivity of 97.9% (95% CI 95.7-99.2), specificity of 84.0% (95% CI 82.6-85.3), positive and negative predictive value of 38.4% (95% CI 36.4-40.4) and 99.8% (95% CI 99.5-99.9), respectively. Conclusion: High sensitivity indicates that if there is an exacerbation, COPDPredict™ informs patients and clinicians accurately. The high negative predictive value implies that when an exacerbation is not indicated by COPDPredict™, risk of an exacerbation is low. Thus, COPDPredict™ provides safe, personalised, preventative care for patients with COPD.

Hyperferritinemia and the Extent of Mucormycosis in COVID-19 Patients.

Introduction Coronavirus disease 2019 (COVID-19) disease attributed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has shown associations with various fungal opportunistic infections such as mucormycosis, invasive candidiasis, and aspergillosis, which have contributed to the mortality of the disease. In India, the incidence of mucormycosis had risen rapidly during the second wave. There is ample literature demonstrating the role of iron in the pathogenesis of mucormycosis. The hyperferritinemia associated with COVID-19 may have played a significant role in promoting the invasion and extent of the fungus. Aims and objectives The study aimed to analyze the association between serum ferritin levels and the extent of involvement of mucormycosis in patients affected with COVID-19. Methodology A single-center cross-sectional study was conducted using retrospective hospital record data. G*Power statistical analysis software was used to compute the sample size of 62 (31+31). The radiological data were used to determine the extent of involvement. Results A statistically significant difference was seen in levels of serum ferritin (p = 0.008) between the radiologically judged two groups of the mild extent of invasion of mucormycosis (rhinosinusitis) and severe extent of invasion (rhino-orbital/cerebral mucormycosis), with a severe extent seen with the group having higher levels of serum ferritin. Severe extent of invasion was seen in 53.6% of patients with diabetes mellitus and 62.5% of patients with both diabetes and hypertension. Conclusion The hyperferritinemia not only presents as a marker of the systemic inflammatory process in COVID-19 but also indicates increased free iron, which thereby aids the growth and extent of involvement by the fungus (R hizopus oryzae). In individuals with diabetes and hypertension, the severity was greater. Controlling catastrophic outcomes in individuals with high serum ferritin levels necessitates extra caution.

An educational evaluation of learner experiences in dentistry open-book examinations.

Introduction The COVID-19 pandemic resulted in substantial global disruptions, with many universities restructuring their examinations to open-book assessments. In this format, learners are allowed to use revision notes, textbooks and other permitted material during their examination. Traditionally, dentistry is assessed using closed-book examinations where the use of such materials is prohibited. Learners will have limited or no prior experience of open-book examinations in dentistry, hence this educational evaluation aimed to explore their experiences and assess suitability for continuity of this examination.Methods A retrospective anonymous survey was conducted on all undergraduate dentistry and oral health sciences learners on completion of their examination and once they received their results. The questionnaire was designed to contain both qualitative and quantitative data items, validated through previous published studies. All authors independently analysed the data through tallying quantitative parameters and thematically analysing qualitative free text.Results In total, 210 learners participated in the survey, with 52.4% strongly agreeing a preference for open-book examinations. In addition, 42.9% of learners either agreed or strongly agreed that less preparation was required for open-book examinations; however, 80.5% reported learning new information. Furthermore, 85.2% disagreed or strongly disagreed that open-book examinations were stressful. Thematic analysis highlighted four core themes: stress, memorisation of facts, motivation to learn and unfairness.Conclusions There were several learning points for both educators and learners that can be actioned for future open-book examinations, including tailoring exam questions to foster application of knowledge rather than resource-searching skills, intended learning objective mapping against curriculum requirements and learner preparation.

Family integrated care: Supporting parents as primary caregivers in the neonatal intensive care unit.

Family integrated care (FICare) is a collaborative model of neonatal care which aims to address the negative impacts of the neonatal intensive care unit (NICU) environment by involving parents as equal partners, minimizing separation, and supporting parent-infant closeness. FICare incorporates psychological, educational, communication, and environmental strategies to support parents to cope with the NICU environment and to prepare them to be able to emotionally, cognitively, and physically care for their infant. FICare has been associated with improved infant feeding, growth, and parent wellbeing and self-efficacy; important mediators for long-term improved infant neurodevelopmental and behavioural outcomes. FICare implementation requires multi-disciplinary commitment, staff motivation, and sufficient time for preparation and readiness for change as professionals relinquish power and control to instead develop collaborative partnerships with parents. Successful FICare implementation and culture change have been applied by neonatal teams internationally, using practical approaches suited to their local environments. Strategies such as parent and staff meetings and relational communication help to break down barriers to change by providing space for the co-creation of knowledge, the negotiation of caregiving roles and the development of trusting relationships. The COVID-19 pandemic highlighted the vulnerability within programs supporting parental presence in neonatal units and the profound impacts of parent-infant separation. New technologies and digital innovations can help to mitigate these challenges, and support renewed efforts to embed FICare philosophy and practice in neonatal care during the COVID-19 recovery and beyond.

An Unusual Cause of Gastrointestinal Perforation in an Adolescent Patient With Beta-Thalassemia on Deferasirox and SARS-CoV-2 Infection.

Chelation therapy is recognized as a safe and effective treatment option in patients with beta-thalassemia with iron overload. We report an 18-year-old male with acute abdomen and gastrointestinal bleeding with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection secondary to gastric perforation due to chelation therapy. This patient had a prolonged intensive care stay with complications of SARS-CoV-2 and a small bowel obstruction post-surgery that resolved after conservative management. Given the acute presentation, chelation therapy use and concomitant SARS-CoV-2 infection, clinicians should keep an open mind on the differential diagnosis of acute abdomen in patients with beta-thalassemia.

Linked Clusters of SARS-CoV-2 Variant B.1.351 - Maryland, January-February 2021.

In late January 2021, a clinical laboratory notified the Maryland Department of Health (MDH) that the SARS-CoV-2 variant of concern B.1.351 had been identified in a specimen collected from a Maryland resident with COVID-19 (1). The SARS-CoV-2 B.1.351 lineage was first identified in South Africa (2) and might be neutralized less effectively by antibodies produced after vaccination or natural infection with other strains (3-6). To limit SARS-CoV-2 chains of transmission associated with this index patient, MDH used contact tracing to identify the source of infection and any linked infections among other persons. The investigation identified two linked clusters of SARS-CoV-2 infection that included 17 patients. Three additional specimens from these clusters were sequenced; all three had the B.1.351 variant and all sequences were closely related to the sequence from the index patient's specimen. Among the 17 patients identified, none reported recent international travel or contact with international travelers. Two patients, including the index patient, had received the first of a 2-dose COVID-19 vaccination series in the 2 weeks before their likely exposure; one additional patient had a confirmed SARS-CoV-2 infection 5 months before exposure. Two patients were hospitalized with COVID-19, and one died. These first identified linked clusters of B.1.351 infections in the United States with no apparent link to international travel highlight the importance of expanding the scope and volume of genetic surveillance programs to identify variants, completing contact investigations for SARS-CoV-2 infections, and using universal prevention strategies, including vaccination, masking, and physical distancing, to control the spread of variants of concern.

Hereditary haemorrhagic telangiectasia and pulmonary arteriovenous malformations.

Hereditary haemorrhagic telangiectasia (HHT) also known as Osler-Weber-Rendu syndrome is an autosomal dominant disorder affecting 1 in 8000 individuals. The eponym recognises the 19th-century physicians William Osler, Henri Jules Louis Marie Rendu and Frederick Parkes Weber who each independently described the disease. It is characterised by epistaxis, telangiectasia and visceral arteriovenous malformations. Individuals with HHT have been found to have abnormal plasma concentrations of transforming growth factor beta and vascular endothelial growth factor secondary to mutations in ENG, ACVRL1 and MADH4. Pulmonary artery malformations (PAVMs) are abnormal communications between pulmonary arteries and veins and are found in up to 50% of individuals with HHT. The clinical features suggestive of PAVMs are stigmata of right to left shunting such as dyspnoea, hypoxaemia, cyanosis, cerebral embolism and unexplained haemoptysis or haemothorax. The authors present the case of a 33-year-old woman presenting with progressive dyspnoea during the COVID-19 pandemic. She had a typical presentation of HHT with recurrent epistaxis, telangiectasia and pulmonary arteriovenous malformations. Although rare, PAVM should be considered in individuals presenting to the emergency department with dyspnoea and hypoxaemia. Delayed diagnosis can result in fatal embolic and haemorrhagic complications.

International teleproctoring in neurointerventional surgery and its potential impact on clinical trials in the era of COVID-19: legal and technical considerations.

BACKGROUND: Existing travel restrictions limit the mobility of proctors, significantly delaying clinical trials and the introduction of new neurointerventional devices. We aim to describe in detail technical and legal considerations regarding international teleproctoring, a tool that could waive the need for in-person supervision during procedures. METHODS: International teleproctoring was chosen to provide remote supervision during the first three intracranial aneurysm treatments with a new flow diverter (currently subject of a clinical trial) in the US. Real-time, high-resolution transmission software streamed audiovisual data to a proctor located in Canada. The software allowed the transmission of images in a de-identified, HIPAA-compliant manner. RESULTS: All three flow diverters were implanted as desired by operator and proctor and without complication. The proctor could swap between images from multiple sources and reported complete spatial and situational awareness, without any significant lag or delay in communication. Procedural times and radiologic dose were similar to those of uncomplicated, routine flow diversion cases at our institution. CONCLUSIONS: International teleproctoring was successfully implemented in our clinical practice. Its first use provided important insights for establishing this tool in our field. With no clear horizon for lifting the current travel restrictions, teleproctoring has the potential to remove the need for proctor presence in the angiography suite, thereby allowing the field to advance through the continuation of trials and the introduction of new devices in clinical practice. In order for this tool to be used safely and effectively, highly reliable connection and high-resolution equipment is necessary, and multiple legal nuances have to be considered.

Asynchronous video messaging promotes family involvement and mitigates separation in neonatal care.

OBJECTIVE: To evaluate the parent and staff experience of a secure video messaging service as a component of neonatal care. DESIGN: Multicentre evaluation incorporating quantitative and qualitative items. SETTING: Level II and level III UK neonatal units. POPULATION: Families of neonatal inpatients and neonatal staff. INTERVENTION: Use of a secure, cloud-based asynchronous video messaging service to send short messages from neonatal staff to families. Evaluation undertaken July-November 2019. MAIN OUTCOME MEASURES: Parental experience, including anxiety, involvement in care, relationships between parents and staff, and breastmilk expression. RESULTS: In pre-implementation surveys (n=41), families reported high levels of stress and anxiety and were receptive to use of the service. In post-implementation surveys (n=42), 88% perceived a benefit of the service on their neonatal experience. Families rated a positive impact of the service on anxiety, sleep, family involvement and relationships with staff. Qualitative responses indicated enhanced emotional closeness, increased involvement in care and a positive effect on breastmilk expression. Seventy-seven post-implementation staff surveys were also collected. Staff rated the service as easy to use, with minimal impact on workload. Seventy-one percent (n=55) felt the service had a positive impact on relationships with families. Staff identified the need to manage parental expectations in relation to the number of videos that could be sent. CONCLUSIONS: Asynchronous video messaging improves parental experience, emotional closeness to their baby and builds supportive relationships between families and staff. Asynchronous video supports models of family integrated care and can mitigate family separation, which could be particularly relevant during the COVID-19 pandemic.