Fulminant onset COVID-19: predictors and outcome.

PURPOSE: During COVID-19 infection, organ dysfunction such as respiratory failure tends to occur towards the second week of illness; however, in a subset, there may be rapid onset of organ dysfunction as early as symptom onset. We define fulminant onset COVID-19 as rapid onset of organ dysfunction such as acute respiratory failure, acute kidney injury, acute encephalopathy or shock within 4 days of symptom onset. Fulminant onset COVID-19 has not yet been systematically studied. We aimed to identify predictors and prognosis of fulminant onset COVID-19. METHODS: This retrospective study was carried out on patients admitted to a single referral hospital in South India between June 2020 and January 2022. Patients were categorised into fulminant and non-fulminant onset COVID-19. Candidate predictors for fulminant onset were chosen by an intuitive approach and analysed using logistic regression. Then, the outcome of fulminant onset COVID-19 at 30 days was studied. RESULTS: Out of 2016 patients with confirmed COVID-19, 653 (32.4%) had fulminant onset COVID-19. Age>60 years (a-OR 1.57, 95% CI 1.30 to 1.90, p<0.001), hypertension (a-OR 1.29, 95% CI 1.03 to 1.61, p=0.03) and immune-suppressed state (a-OR 5.62, 95% CI 1.7 to 18.7, p=0.005) were significant predictors of fulminant onset COVID-19. Complete vaccination lowered the odds of fulminant onset COVID-19 significantly (a-OR 0.61, 95% CI 0.43 to 0.85, p=0.004). At 30 days, the fulminant onset COVID-19 group had higher odds of mortality and need for organ support. CONCLUSION: Fulminant onset COVID-19 is not uncommon and it carries poor prognosis and deserves recognition as a distinct phenotype of COVID-19.

Lockdown and its impact on food and exercise study

Introduction: The COVID-19 pandemic had enforced several restrictions which were necessary to abate the spread of the virus, however, the blow of these limitations on health behaviors and lifestyles remains vague. Therefore, this study was carried out to assess the behavioral and lifestyle consequences of complete lockdown during the pandemic. Materials and Methods: The Lockdown and its Impact on Food and Exercise study was a pilot study conducted in the form of a questionnaire which was handed out to the public and circulated electronically. The questions regarding exercise were adapted from the International physical activity questionnaire and those regarding food habits were taken from the Public Library of Science and the Self-regulation of Eating Behavior Questionnaire. This survey was conducted from March 28 to April 14, 2020, during which a complete lockdown prevailed. Results: The COVID-19 complete lockdown had a negative impact on all intensity exercise levels, vigorous exercise (64.34% vs. 41.20%, P ≤ 0.00001), moderate exercise (95.67% vs. 84.57%, P ≤ 0.00001), and walking (55.42% vs. 42.89%, P = 0.0003). Food consumption and meal patterns (58.55% vs. 47.95%, P = 0.0022) were also more unhealthy (78.60% vs. 87.94%, P = 0.0096) during complete lockdown with only the consumption of late night snack decreasing significantly. Conclusion: The results of this analysis indicate that physical activity had decreased significantly and eating behaviors were unhealthy. Hence, our survey will help to develop interventions which would potentially alleviate these negative lifestyle and nutrition behaviors.

Whole lung irradiation as a novel treatment for COVID-19: Final results of the prospective randomized trial (WINCOVID trial).

BACKGROUND AND PURPOSE: The ability of low dose radiotherapy (LDRT) to control the unprecedented cytokine release associated with COVID-19 pathogenesis has been an area of widespread research since the COVID pandemic. It has not been studied adequately whether the anti-inflammatory effect of LDRT provides additional benefit when used concurrently with steroids amongst other standard pharmacologic therapy. MATERIAL AND METHODS: 51 RT-PCR positive COVID-19 patients were recruited between November 2020 and July 2021. 34 patients were allotted to receive 0.5 Gy single session LDRT along with standard pharmacologic therapy while 17 patients received standard pharmacologic therapy alone. All had SpO2 <94% on room air, respiratory frequency >24/min and SpO2/FiO2 (SF) ratio between >89 but <357. All patients underwent a baseline CT scan. They were followed up for 28 days during when serial SF ratio, blood biomarkers (CRP, Serum ferritin, IL-6), Absolute lymphocyte count (ALC), repeat CT scan were performed at pre-defined time points. RESULTS: LDRT showed a statistically significant early improvement in oxygenation, an early time to clinical recovery, early hospital discharge and better radiological resolution compared to control group. There was no statistically significant difference between the two groups with respect to ALC or blood biomarkers at any of the measured time points. The 28-day mortality rate did not show statistically significant difference between the two groups. CONCLUSION: LDRT can be considered for selected oxygen-dependent moderate to severe COVID-19 patients for rapid relief of respiratory distress. It can be safely combined with standard pharmacologic treatment in such patients for added clinical benefit.

Whole lung irradiation as a novel treatment for COVID-19: Interim results of an ongoing phase 2 trial in India.

BACKGROUND AND PURPOSE: The main cause of death in COVID-19 pneumonia is acute respiratory distress syndrome which is preceded by massive cytokine release. Low-dose radiation therapy (LDRT) has anti-inflammatory and immunomodulatory effects that can interfere with the inflammatory cascade, reducing the severity of associated cytokine release. MATERIAL & METHODS: 25 patients with RT-PCR proven COVID-19 pneumonia were enrolled between November 2020 and May 2021. All patients had SpO2 < 94 % on room air, respiratory frequency > 24/min and SpO2/FiO2 ratio (SF ratio) of >89 but <357. Patients were treated according to standard COVID-19 management guidelines along with single fraction LDRT of 0.5 Gy to bilateral whole lungs within 10 days of symptom onset and 5 days of hospital admission. RESULTS: LDRT was well tolerated by all patients. There was a statistically significant improvement in oxygenation as given by the SF ratio between pre-RT and day 2 (p < 0.05), day 3 (p < 0.001) and day 7 (p < 0.001) post RT. Demand for supplemental oxygen showed statistically significant reduction between pre-RT and day 2 (p < 0.05), day 3 (p < 0.001), day 7 (p < 0.001) post RT. 88 % patients attained clinical recovery within 10 days post LDRT and median time to hospital discharge from day of LDRT was 6 days. Three patients deteriorated and died. CONCLUSION: As per our initial experience, LDRT appears to be a promising modality of treatment with rapid relief of respiratory distress in selected patients with moderate to severe COVID-19 pneumonia. This translates to early clinical recovery and hospital discharge in the selected patient group.

Pattern recognition of high-resolution computer tomography (HRCT) chest to guide clinical management in patients with mild to moderate COVID-19.

AIM: To describe the distribution of lung patterns determined by High Resolution Computed Tomography (HRCT) in COVID patients with mild and moderate lung involvement and outcomes after early identification and management with steroids and anticoagulants. MATERIAL AND METHODS: A cross sectional study of COVID-19 patients with mild and moderate lung involvement presenting at 5 healthcare centres in Trichy district of South TamilNadu in India. Patients underwent HRCT to assess patterns and severity of lung involvement, Inflammatory markers (LDH/Ferritin) and D-Dimer assay and clinical correlation with signs and symptoms. Patients were assessed for oxygen, steroid and anticoagulant therapy, clinical recovery or progression on follow up and details on mortality were collected. The RSNA, Fleischer Society guidelines and CORADS score was used for radiological reporting. New potential classification of patterns of percentage of lung parenchyma involvement in Covid patients is being suggested. RESULTS: The study included 7,340 patients with suspected COVID and 3,963 (53.9%) patients had lung involvement based on HRCT. RT PCR was positive in 74.1% of the CT Positive cases. Crazy Pavement pattern was predominant (n = 2022, 51.0%) and Ground Glass Opacity (GGO) was found in 1,941 (49.0%) patients in the study. Severe lung involvement was more common in the Crazy Pavement pattern. Patients with GGO in moderate lung involvement were significantly more likely to recover faster compared to Crazy Pavement pattern (P value <0.001). CONCLUSION: HRCT chest and assessment of lung patterns can help triage patients to home quarantine and hospital admission. Early initiation of steroids and anticoagulants based on lung patterns can prevent progression to more severe stages and aid early recovery. HRCT can play a major role to triage and guide management especially as RT PCR testing and results are delayed for the benefit of patients and in a social cause to decrease the spread of the virus.