Maternal COVID-19 Infection: A Cause of Neonatal Stroke?

Perinatal arterial ischemic stroke (PAIS) is a rare cause of neonatal seizures, with an incidence of 1 in 2500 to 4000 live births, globally. This is a case of a neonate with PAIS due to transpla-cental passage of COVID-19 IgG antibodies from the mother. A term, male neonate, born to a primigravida with an unevent-ful antenatal history was presented on the second day of life with multiple episodes of focal clonic seizures involving the right upper and lower limbs. Magnetic resonance imaging revealed an acute infarct in the left frontal lobe, extending into the parietal region, anterior limb, and genu of internal capsule suggestive of arterial ischemic stroke. The known causes of PAIS were evaluated and ruled out. The result of reverse transcription polymerase chain reaction analysis for SARS-CoV-2 antigen was negative for both the mother and the neonate. COVID-19 IgG antibodies in the mother and neonate were elevated. Seizures were controlled with antiepileptics. The neonate had no further seizure episodes and was discharged on oral levetiracetam. The infant was developmentally and neurologically normal at 3 months of age. PAIS is a rare cause of neonatal seizures, and maternal COVID-19 infection may be associated with neonatal stroke.Copyright © 2022, Himalaya Wellness Company. All rights reserved.

Ophthalmology in a virtual world: The impact of the COVID-19 pandemic on specialty conferences

Purpose : The COVID-19 pandemic led to unprecedented cancellation or alteration of healthcare events and medical conferences around the world. Many ophthalmology conferences transitioned to virtual interfaces, and the impact of this transition on the ophthalmology community is unclear. The authors wish to objectively define the impact of the COVID-19 pandemic on subspecialty ophthalmology conferences. Methods : This study included data from the following five ophthalmology conferences from 2019, 2020, and 2021, as available: American Glaucoma Society (AGS), American Society of Ophthalmic and Plastic Reconstructive Surgery (ASOPRS), American Society of Cataract and Refractive Surgery (ASCRS), North American Neuro-Ophthalmology Society (NANOS), and Women in Ophthalmology (WIO). Data requested from organizations included the following, as available: Number of total conference attendees, number of attendees stratified by level of training, number of attendees stratified by identified gender, and number of research s or presentations (submitted and/or accepted). This study has been approved by the City University of New York Institutional Review Board. Results : In our study, 60% of organizations demonstrated an increase in number of attendees when using a virtual interface compared to their in-person events. 80% of organizations demonstrated a marked increase in attendance by trainees on their virtual interfaces. 60% of organizations displayed a decrease in number of submitted s when using a virtual interface. 40% of organizations experienced an increase in number of accepted posters and presentations through a virtual platform. Conclusions : Virtual conference interfaces have the potential to increase overall attendance and research participation within the ophthalmology community. Organizations should consider a hybrid model that incorporates aspects of both virtual and in-person interfaces to potentially maximize attendance, outreach, dissemination of information, opportunity, and minimize costs.

Excess mortality in India during the COVID 19 pandemic

Introduction: COVID 19 has proven to be the worst pandemic in the history of mankind. While the pandemic still continues to perplex the scientists globally, attempts are being made to quantify the mortality caused by the pandemic. The official Covid-19 figures in India grossly understate the true scale of the pandemic in the country. Definitions: A COVID-19 death is defined for surveillance purposes as a death resulting from a clinically compatible illness in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID-19 disease (e.g. trauma). Excess mortality is defined as the difference in the total number of deaths in a crisis compared to those expected under normal conditions. Methods: We researched multiple papers on Pubmed, Medline, Embase, MedRxiV pre print. Discussion: All the studies showed that the excess mortality was to the tune of almost three times the official figures. The model based excess mortality assumptions showed higher deaths as compared to the data based. However, there were lot of discrepancies in the data provided by various states along with variations observed in between the two waves as well. Health survey data suggested higher mortality rate as compared to data compiled from the civil registration system. Conclusion: Official COVID-19 deaths have entirely failed to capture the scale of pandemic excess mortality in India. The under-ascertainment of COVID-19 deaths has been high, with around 8-10 excess deaths for every been high for every recorded COVID-19 death.

Assessing Provider Utilization of COVID-19 Inflammatory Marker Trends in Hospitalized Patients and Implications in Optimizing Value-Based Care during a Pandemic

Background. Numerous inflammatory markers may serve a role in prognostication of patients hospitalized with COVID-19. Early in the pandemic, our health system created an admission order set which included daily d-dimer, c-reactive protein (CRP), lactate dehydrogenase (LDH), and ferritin. Given more available outcomes data, limiting standing order of studies that do not affect daily management could result in significant cost savings to the health system without adverse patient outcomes. The purpose of this study was to determine ordering and utilization patterns of inflammatory markers by physicians caring for patients hospitalized with COVID-19 infections. Methods. An anonymous 10-question survey was distributed to 125 physicians (Infectious Diseases, Hospitalist, Pulmonary and Critical Care faculty). Responses were tallied and values greater than 50% were identified as the majority of the surveyed group. Results. Of the 125 physicians surveyed, 77 (62%) responded. A total of 57.1% (44/77) of physicians reported ordering daily inflammatory markers for 3-10 days from admission. Another 31.2% (24/77) ordered markers until clinical improvement or hospital discharge. D-dimer was used for care decisions by 83.1% (64/77) of respondents;93.8% (60/64) of those reported utilizing it in determining anticoagulation dose. CRP was used by 61% (47/77) of physicians to help identify a secondary infection or determine steroid dose or duration. LDH and ferritin were not used for management decisions by the majority of physicians. Inflammatory markers were not used routinely after isolation precautions had been discontinued, even when ongoing care required mechanical ventilation. Conclusion. Of the markers studied, both d-dimer and CRP were considered useful by most respondents. LDH and ferritin were used less frequently and were not considered as useful in guiding medical decision making. Discontinuation of standing daily LDH and ferritin orders is believed to have potential to result in cost savings to the health care system with no adverse patient outcomes.

Clinical characteristics, laboratory parameters and outcomes of COVID-19 in cancer and non-cancer patients from a tertiary Cancer Centre in India.

BACKGROUND: There is paucity of data regarding clinical characteristics, laboratory parameters and outcomes of coronavirus disease (COVID-19) in cancer versus non-cancer patients, particularly from India. MATERIALS AND METHODS: This was an observational, single-centre, retrospective analysis of patients with laboratory-confirmed COVID-19 hospitalised in our institution between 22 May 2020 and 1 December 2020. We compared baseline clinical characteristics, laboratory parameters and outcomes of COVID-19 (overall mortality, time to discharge) between cancer and non-cancer patients. RESULTS: A total of 200 COVID-19 infection episodes were analysed of which 109 (54.5%) were patients with cancer and 91 (45.5%) were patients without cancer. The median age was 43 (interquartile range [IQR]:32-57), 51 (IQR: 33-62) and 38 (IQR: 31.5-49.3) years; of whole cohort, cancer and non-cancer patients, respectively. Comparison of outcomes showed that oxygen requirement (31.2% [95% CI: 22.6-40.7] vs. 17.6% [95% CI: 10.4-26.9]; p = 0.03), median time to discharge (11 days [IQR: 6.75-16] vs. 6 days [IQR: 3-9.75]; p < 0.001) and mortality (10.0% [95% CI: 5.2-17.3] vs. 1.1% [95% CI: 0.03-5.9]; p = 0.017) were significantly higher in patients with cancer. In univariable analysis, factors associated with higher mortality in the whole cohort included diagnosis of cancer (10.1% vs. 1.1%; p = 0.027; odds ratio [OR]: 7.04), age ≥60 (17.4% vs. 2.6%; p = 0.001; OR: 7.38), oxygen requirement (22% vs. 0.6%; p < 0.001; OR: 29.01), chest infiltrates (19.2% vs. 1.4%; p < 0.001; OR: 22.65), baseline absolute lymphocyte count <1 × 109 /L (10.8% vs. 1.9%; p = 0.023; OR:5.1), C-reactive protein >1 mg% (12.8% vs. 0%; p = 0.027; OR: 24.69), serum procalcitonin >0.05 ng/ml (22.65% vs. 0%; p = 0.004; OR: 4.49) and interleukin-6 >6 pg/ml (10.8% vs. 1.3%; p = 0.036; OR: 3.08). In multivariable logistic regression, factors significantly associated with mortality were oxygen requirement (p = 0.005; OR: 13.11) and high baseline procalcitonin level (p = 0.014; OR: 37.6). CONCLUSION: Cancer patients with COVID-19 have higher mortality and require longer hospital stay. High procalcitonin levels and oxygen requirement during admission are other factors that affect outcomes adversely.

A comparison of clotting rate during hemodialysis in COVID-19 Patients Receiving Anticoagulant vs. No Anticoagulant in an Inpatient Setting

Background: Anticoagulant use during hemodialysis is a standard practice in both outpatients and inpatients setting. In an inpatient setting with heightened acuity of illness, the potential for bleeding attributable to anticoagulant is concerning. Hospitals have started applying an anticoagulant free HD protocol with success. COVID-19 patients showed a degree of systemic hypercoagulability with unique features, including a consumptive disseminated intravascular coagulation coexisting with hyperfibrinolysis and increased bleeding risk. Maintaining circuit patency and avoiding bleeding risk has been challenging. Data regarding anticoagulant in COVID-19 patients who received hemodialysis is limited. This study's primary objective is to compare hemodialysis clotting rate in COVID-19 patients who received anticoagulant versus those without anticoagulant. Methods: Retrospective chart review for all COVID-19 patients who received hemodialysis at Banner Medical Center Tucson Campus Between November 2020 and January 2021. Primary outcome was clotting rate during hemodialysis. CRRT was excluded. Results: 330 total patients observed, 56% sessions in the ICU unit and 44% in the medicine unit. 57% were AKI and 43% were ESRD. Anticoagulant use was 38.5% (heparin IVP during hemodialysis was 12%, continuous systemic heparin was 16% and others (warfarin, DOAC, Argatroban, etc) was 11%). Clotting rate was 12%. Other characteristics can be seen on the table 1. There was no difference in the clotting rate between group with anticoagulant versus without anticoagulant (8% vs.15%, p value 0.06). Multivariable logistic regression for clotting outcome showed that compared to no-anticoagulation, systemic heparin continuous infusion decreased clotting by 83% (OR 0.17, 95% CI 0.04-0.77, p-value=0.02) and others anticoagulant decreased clotting by 91% (OR=0.09, 95% CI 0.01-0.85);compared to AV fistula, temporary dialysis catheter increased clotting by 2.9x (OR 2.9, 95% CI 1.10-7.44, p-value=0.03);and every 10 increase in platelet count increased clotting by 4% (OR 1.04, 95% CI 1.01-1.07, p value =0.01) Conclusions: No anticoagulation and temporary catheters carry high risk for clotting in patients with COVID undergoing iHD. Continuous heparin should be considered.

Using telehealth to support expectant and breastfeeding momsduring the COVID-19 pandemic

Program Goals: Since the COVID-19 pandemic began in March 2020, an increased number of healthy, full-termnewborns are being discharged 24 hours after delivery. No study has demonstrated the presence of SARS-CoV-2 in breast milk, so breastfeeding promotion and education are still of the utmost importance. Withshelter-at-home recommendations in place, mothers face challenges with finding lactation guidance.Telehealth allows this gap to be filled by providing breastfeeding support virtually when in-person contact islimited. Telehealth breastfeeding support initiatives were piloted for expectant and new mothers (andfamilies). The objective is to provide breastfeeding education by establishing interactive, support groupsfacilitated by lactation professionals using telehealth services. Evaluation: Two models were established basedon experiences with the prior in-person sessions, as well as those of local and national colleagues. Model A:Small group teaching Several 1-hour IBCLC-led sessions (one in Spanish) were offered weekly online on aHIPAA-compliant videoconferencing platform through a consistent link. A toll-free number was provided if no internet access was available. English and Spanish flyers with link, instructions for joining, and email to answertechnology questions were distributed to 150+ partners electronically. Each session was structured aroundopportunity for individualized questions on video chat or chatbox, with additional resources provided onslides. A separate team member managed technology, slides, attendance and the chatbox, which freed theIBCLC to serve solely as subject matter expert. Challenges addressed are listed in Table. This model'sattendance was initially limited but increased each week with additional promotional efforts. Ultimately 29expectant and breastfeeding mothers joined across 10 sessions, including several repeaters. Mothers foundthe sessions helpful and informative, and offered to spread the word. Model B: Traditional didactic teaching A1-hour webinar, led by IBCLCs (including Spanish), was offered weekly with unique themes on a differentHIPAA-compliant videoconferencing platform. The weekly theme was sent to a listerv with a registration linkfor attendance tracking and for distribution of the attendee link to address security concerns. A formal slidepresentation (45 minutes) was given, followed by Q+A (15 minutes) via chatbox. Presentation slides and videorecording were sent to registrants with an access code for security. This model had consistently highattendance -- 110 mothers across 4 sessions, including several repeaters. Each session had a different theme,which allowed for women to select a session specific to their needs. Discussion: Establishing virtual lactationsupport groups is realistic and important. Our 5-week pilot initiative successfully created telelactation sessionsfacilitated by IBCLCs and CLCs. Notable challenges faced in transitioning to a virtual support environment were able to be quickly met, resulting in increased attendance and engagement. Using telehealth servicesallowed vital accessibility to essential breastfeeding support for mothers during this public health crisis.

Resuming elective hip and knee arthroplasty in the COVID-19 era: a unique insight into patient risk aversion and sentiment.

INTRODUCTION: There has been guidance from the government and orthopaedic community on how best to ensure the safety of our patients and colleagues as we recommence elective surgery in the UK. The primary aim was to determine what proportion of patients feel they should proceed with their elective hip and knee arthroplasty surgery during the COVID-19 climate. The secondary aim was to investigate what variables affected this decision. METHODS: Patient information from a single surgeon's waiting list in a district general hospital were recorded. A standardised telephone discussion was had with all the patients noting the severity of pain and the potential reasons for not wanting to proceed with surgery. RESULTS: A total of 70.6% (96/136) of patients wished to proceed with surgery; 29.4% (40/136) did not wish to proceed. The decision to proceed with surgery was not correlated with sex, American Society of Anesthesiologists grade or COVID-19 risk. Those who wished to proceed with surgery had a mean age of 68.5 years while those who did not had a mean age of 72.4 years (P = 0.03). Within the matched subgroups, patients under the age of 70 years were more willing to proceed with primary hip arthroplasty surgery (87.9%) compared with primary knee arthroplasty surgery (57.1%; P = 0.007); 75% of the patients who did not wish to proceed with surgery expressed concerns about perioperative COVID-19 infection. CONCLUSION: There is a significant proportion of arthroplasty patients on waiting lists who would be willing to accept the increased risks associated with COVID-19 to undergo surgery on an urgent basis. The subgroup of younger patients awaiting hip arthroplasty is more willing than those awaiting knee arthroplasty to proceed with surgery.

Clinical course of severe COVID19 treated with tocilizumab and antivirals post-allogeneic stem cell transplant with extensive chronic GVHD.

Recipients of allogeneic hematopoietic stem cell transplantation (allo-HSCT) are an immunocompromised group who are likely to develop severe complications and mortality because of coronavirus disease 2019 (COVID-19). We report here a 61-year-old male patient of primary myelofibrosis who underwent an allo-HSCT 6 years earlier, had chronic graft-versus-host disease (cGVHD) involving the liver, lung, eyes, and skin, (with recurrent episodes of pulmonary infections) who developed severe COVID-19. The patient was treated with tocilizumab, and a combination of lopinavir/ritonavir, ribavirin, interferon-ß1b. He was discharged after 31 days with full recovery. Tocilizumab, a humanized monoclonal antibody against IL6, has been shown to benefit respiratory manifestations in severe COVID19. However, this is first report, to our knowledge, of its use and benefit in a post HSCT recipient.