Pneumomediastinum as a complication of SARS-CoV-2 pneumonia

The incidence of pneumomediastinum in hospitalised patients diagnosed with SARS-CoV-2 pneumonia is by no means negligible, much higher compared to the general population. The pathophysiology of pneumomediastinum in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia is explained by the increase in alveolar-interstitial pressure gradient (dry coughing spells, respiratory work, barotrauma from ventilatory support) in the context of particularly "fragile" lungs due to diffuse alveolar-interstitial damage from infectious-inflammatory origin, all of which significantly increases the risk of alveolar wall rupture. The more severe the SARS-CoV-2 pneumonia, the more likely it is that pneumomediastinum will occur. The development of pneumomediastinum in patients with SARS-CoV-2 pneumonia is associated with higher frequencies of death, intensive care unit (ICU) admission and tracheostomy and longer hospital and ICU lengths of stay. In most cases, pneumomediastinum in SARS-CoV-2 pneumonia is a benign and self-limiting process that resolves with conservative treatment. © 2022 Sociedad Madrinela de Neumologia y Cirugia Toracica. All rights reserved.

Impact of Covid-19 Pandemic on Pharmacologic Treatment of Patients Newly Diagnosed with Osteoporosis

Purpose of Study: The COVID-19 pandemic has presented considerable challenges in the care of patients with chronic diseases, including osteoporosis. In this study, we determined whether initiation of pharmacologic treatment was delayed for patients who were newly diagnosed with osteoporosis during the pandemic. Methods Used: Patients >= 50 years who were newly diagnosed with osteoporosis using dual-energy x-ray absorptiometry (DXA) screening at a single academic institution were included. Patients with osteoporosis diagnosed between March 1, 2018 to January 31, 2020 (pre-pandemic cohort) were compared to patients diagnosed between March 1, 2020 to January 31, 2022 (pandemic cohort). Basic demographics including age, gender, race, and ethnicity were evaluated. Primary outcomes included the proportion of patients who were initiated on pharmacologic therapy at 3-months and 6-months of diagnosis, as well as the mean time from osteoporosis diagnosis to initiation of pharmacologic treatment. Ordering providers (primary care vs specialty care providers) and types of pharmacologic agents were also compared. Summary of Results: In total, 1,189 were newly diagnosed with osteoporosis on DXA during the study period, with 576 patients in the pre-pandemic cohort and 613 in the pandemic cohort. There was no significant difference between cohorts with regard to age (69.3 vs 68.8 years, p=0.33), gender (87.0 vs 86.1% female, p=0.67), or ethnicity (88.2 vs 86.0% Non-Hispanic, p=0.25). However, there was a higher proportion of Whites in the pre-pandemic cohort (74.1 vs 68.4%, p=.028). Overall, only 40.5% of patients (n=481) newly diagnosed with osteoporosis were started on pharmacologic therapy within 6 months of diagnosis. Proportions of patients treated at 3-months (31.8 vs 35.4%, p=0.19) and at 6-months (37.8 vs 42.9, p=0.08) were comparable between cohorts (47.2 vs 50.2% p=0.30). Mean time from osteoporosis diagnosis to initiation of pharmacologic treatment was similar (46 vs 45 days, p=0.72). Ordering providers did not differ between cohorts (65.1 vs 57.4% primary care providers, p=0.08). Bisphosphonates were the most often prescribed in pre-pandemic (90%) and pandemic cohorts (82.1%). Conclusion(s): This is the first study to compare the impact of the COVID-19 pandemic on the pharmacologic treatment of patients who were newly diagnosed with osteoporosis. In our retrospective comparative study, we found only 40.5% of patients with newly diagnosed osteoporosis were treated pharmacologically within 6 months of diagnosis, and the COVID-19 pandemic did not significantly affect treatment rates. Bisphosphonates were the most often prescribed medication group. Further studies are needed to better understand patient-, provider-, and system-specific factors contributing to the low treatment rates of patients newly diagnosed with osteoporosis.

Impact of COVID-19 Pandemic on Osteoporosis Screening Using Dual-Energy X-ray Absorptiometry

Purpose of Study: Several survey studies have expressed concerns regarding a general decline in osteoporosis screening as a result of the COVID-19 pandemic. We compared our institution's experience on osteoporosis screening using dual-energy x-ray absorptiometry (DXA) before and during the COVID-19 pandemic. Methods Used: Patients >=50 years who received DXA screening at our academic institution were included. Patients with DXA completed between March 1, 2018 to January 31, 2020 (pre-pandemic cohort) were compared to patients with DXA completed between March 1, 2020 to January 31, 2022 (pandemic cohort). Basic demographics including age, gender, race, and ethnicity were evaluated. DXA utilization was calculated as the number of DXA studies completed monthly. The ordering providers (primary care vs specialty care providers) and mean time from initial order to DXA completion were compared between cohorts. Chi square tests were performed for categorical data, while independent t-tests were performed for continuous data, with significance set at 0.05. Summary of Results: In total, 10,680 DXA studies were completed at our institution over the study period. From March 1, 2018 to January 31, 2020, 5,375 DXA studies were completed (pre-pandemic cohort). From March 1, 2020 to January 31, 2022, 5,305 DXA studies were completed (pandemic cohort). Mean monthly DXA utilization did not differ between cohorts (233.7+/-28.5 vs 230.7+/-59.9 studies, p=0.83). There were also no statistically significant differences when comparing total DXA procedures per quarter per year between cohorts. Patients were older in the pandemic cohort at the time of DXA completion (69.3+/-8.2 vs 68.6+/-8.3 years, p<0.001). The distributions for gender (89.6% vs 89.2% female, p=0.5), ethnicity (90.3% vs 89.3% Non-Hispanic, p=0.09), and race (74.4% vs 73.3% White, p=0.21) did not differ between cohorts. The mean time from initial order to DXA completion was shorter for the pre-pandemic cohort (79.1+/-104.4 vs 88.8+/-107.6 days, p<0.001). The ordering providers (67.2% vs 62.7% primary care providers, p<0.001) also differed. Conclusion(s): This is the first study to quantitatively compare the rates of osteoporosis screening before and during the COVID-19 pandemic. In our retrospective study, we found that DXA utilization to screen for osteoporosis was not affected by the COVID-19 pandemic. However, DXA completion was more delayed, and the ordering providers were more likely to be non-primary care providers.

ZINC ADJUVANT TREATMENT IN SARS-CoV-2: A RANDOMIZED CLINICAL TRIAL

Background: The immune system is highly susceptible to changes of zinc levels and this might imply a different response against infection. Prior evidence suggests some benefit on viral infection prognosis after zinc supplementation. We aim to study the efficacy of zinc supplementation in SARS-CoV-2 infection outcomes. Method(s): This is an unicenter prospective, randomized cliinical trial where unvaccinated individuals with moderate SARS-CoV-2 infection without endorgan failure were randomized to standard of care+oral zinc for 15 days (three times per day a tablet of 83mg of Zn acetate equals to 75 mg of Zn element) (zSoC) (n =37) or standard of care alone (SoC) (n = 34). The primary combined outcome was death due to SARS-CoV-2 or intensive care unit (ICU) admission. Secondary outcomes included length of hospital stay (LoS) and time to clinical stability (defined as: oxygen saturation >94% [FiO2 21%], normalized level of consciousness [baseline], HR < 100rpm, systolic BP >90mm Hg,Temperature < 37.2degreeC). Wilcoxon-Mann-Whitney test generalized Odds ratio (ORs) and 95% confidence intervals (CIs) for differences in outcomes between SoC and zSoC. A logistic regression model was fitted adjusted by age, sex, severity and comorbidity to compare the primary outcome between SoC and zSoC. Result(s): Seventy-one participants were recruited. No significant differences in terms of age, gender and comorbidities nor in SoC were found between groups (Table 1). 14-day Mortality was 2.90 % (2 participants) in the SoC group and none in zSoC. ICU admission rates were, respectively, 8 (23%) and 1 (2.7%) (OR: .098;95% CI .013-.766). The principal combined outcome occurred in 8 participants (23%) in SoC and in 2 (5.4%) in zSoC (OR: 0.18;95% CI .03-.946). In a logistic regression model adjusting by age, sex, comorbidity and severity the OR for the combined outcome in those in zSoC was 0.091 (95% CI: 0.007-0.913;p=0.045). LoS was shorter in zSoC (6.9 days (SD 6.1) vs 12.7 (SD 11.6);p=0.013) respectively. Time to clinical stability was significantly shorter in zSoC (5 days (SD 6.1)) compared to SoC (11.9(SD 9.1));p=0.005. No significant differences in changes in inflammatory markers were found among groups. No severe adverse events were observed during the study. Conclusion(s): Daily zinc supplementation with 240 mg of zinc acetate for 14 days during the acute phase of SARS-CoV-2 infection resulted in lower rates of severity (less death and ICU admission) and faster clinical recovery along with shorter hospital stay.

Severe SARS-CoV-2 pneumonia and pneumomediastinum and/or pneumothorax: a prospective observational study in an intermediate respiratory care unit

Introduction: The occurrence of pneumomediastinum (PNMMD) or pneumothorax (PNMTX) was evaluated in patients with severe SARS-CoV-2 pneumonia. Method(s): This is a prospective observational descriptive study that was carried out on patients admitted to the IRCU of a COVID-19 monographic hospital in Madrid from 14/01/2021 to 27/09/2021. All of them had a diagnosis of severe SARS-CoV-2 pneumonia and required NIRS (HFNC, CPAP, BPAP). The incidences of PNMMD and PNMTX, total and according to NIRS, and their impact on the probability of IMV and death were studied. Result(s): (tables 1 and 2) 4.3% (56/1306) developed PNMMD or PNMTX, 3.8% (50) PNMMD, 1.6% (21) PNMTX, and 1.1% (15) PNMMD+PNMTX. 16.1% of patients with PNMMD or PNMTX had HFNC alone (vs 41.7% without PNMMD or PNMTX;p<0.001) and 83.9% CPAP (vs 57.5%;p<0.001). There was a probability of needing IMV of 64.3% among patients with PNMMD or PNMTX (vs 21.0%;p<0.001), and a mortality of 33.9% (vs 10.5%;p<0.001). Conclusion(s): In patients admitted to the IRCU for severe SARS-CoV-2 pneumonia who required NIRS, incidences of 3.8% for PNMMD and 1.6% for PNMTX were observed. LDH was a risk factor for developing PNMMD or PNMTX (median 438 vs 395;p=0.013), and PNMMD (median 438 vs 395;p=0.014). The majority of patients with PNMMD or PNMTX had CPAP as the NIRS device, much more frequently than patients without PNMTX or PNMMD. However, the pressures used in CPAP were even lower in patients with PNMMD or PNMTX (median 8 vs 10;p=0.031). The probabilities of IMV and mortality among patients with PNMMD or PNMTX were 64.3% and 33.9%, respectively, higher than in patients without PNMMD or PNMTX, 21.0% and 10.5%.

Clinical Findings and Outcomes from 1306 Patients with Covid-19 Pneumonia in an Intermediate Respiratory Care Unit: A Prospective, Observational Study

Background: An intermediate respiratory care unit (IRCU) may be a valuable tool for optimizing patient care, allowing to implement standardized algorithm management to decrease clinical failure and mortality. We aimed to describe the practice of noninvasive respiratory strategies (NRS) in a novel facility fully dedicated to COVID-19 and to establish outcomes of these patients Methods: Prospective, observational study performed at one hospital in Spain. We included consecutive patients admitted to IRCU due to COVID-19 requiring NRS between December 2020 and September 2021. Data collected included mode and usage of NRS, endotracheal intubation and mortality to day 30. A multivariable Cox proportional hazards method was used to assess risk factors associated with clinical failure and mortality Findings: 1306 patients with COVID-19 were included. Of them, 64.6% were men and mean age was 54.7 years. During IRCU stay, 345 patients presented a clinical failure, (89.6% intubated;14.5% died). Cox model showed a higher clinical failure in IRCU when time between symptoms onset and hospitalization < 10 days (HR 1.59;95% CI 1.24-2.03;p<0.001) and PaO2/FiO2 <100 (HR 1.59;95% CI 1.27-1.98;p<0.001). Conversely, these variables were not associated with an increased mortality to day 30 Interpretation: IRCU may be a useful option for the multidisciplinary management of COVID-19 patients requiring NRS;thus, reducing ICU overcharge. Men gender, gas-exchange and blood chemistry at admission are associated with worse clinical outcomes, while older age, gas-exchange and blood chemistry are associated with 30-day mortality.

Usefulness of the early combination of non-invasive respiratory therapies in patients with COVID-19

Aim: To determine the effect of the early combination of high flow nasal cannula (HFNC) plus continuous positive airway pressure (CPAP) regarding endotracheal intubation (ETI) and 30-day mortality in patients with SARS-CoV-2 pneumonia. Method(s): Observational study of patients admitted to the intermediate respiratory care unit (IRCU) who received HFNC+CPAP. Two groups were formed according to the time of starting the combined therapy: Early HFNC+CPAP (first 24 h - EHC) and Late HFNC+CPAP (after 24 h - LHC). A multivariate analysis was performed to establish the strength of the association with ETI and 30-day mortality. Result(s): 780 patients were included (502 male, mean age 56.5 +/- 12.9 years). Table 1 shows the baseline characteristics. 273 patients were subjected to ETI, 32.9% in the EHC group vs 38.9% in the LHC group (p 0.05). 30day mortality was 8.2% in the EHC vs 15.5% LHC (p 0.02). Table 2 shows the multivariate analysis. Conclusion(s): The combination of HFNC+CPAP, especially in the first 24 hours after IRCU admission, is a useful tool in the management of SARS-CoV-2 pneumonia.

Clinical characteristics and respiratory care of hospitalized patients according to vaccination status of COVID 19

Although protection of vaccines against COVID-19 has been reported, very little is known about the clinical characteristics of hospitalized vaccinated patients. Method(s): This single-center cohort study of 1888 COVID-19 patients hospitalized at the "Enfermera Isabel Zendal" Emergencies Hospital, Madrid (Spain) was performed between July and September, 2021. It compared the results of 1327 unvaccinated patients to 209 fully vaccinated and 352 partially vaccinated. Vaccines administered were: BNT162b2, ChAdOx1 nCoV-19, mRNA-1273, Ad26.COV2.S. Finding(s): Hospitalized patients' median age was 41 years (IQR 33.0-50.0) for the unvaccinated and 61.0 years (IQR 53.0-67.0) for the fully vaccinated ones. The main comorbidities were obesity, hypertension and diabetes mellitus. The fully vaccinated patients obtained higher C-reactive protein values (median 48.9 mg/l [IQR 21.7-102.9]) and significantly lower for ferritin (median 367.0 ng/ml [IQR 182.0-731.0]) and lactate dehydrogenase (median 269.0 units/l [IQR 218.5-330.5]) values. 266 unvaccinated patients required noninvasive respiratory care, as did 51 partially vaccinated and 30 fully vaccinated patients;78 of the unvaccinated patients also needed invasive respiratory care, as did 16 partially vaccinated and 11 fully vaccinated patients. The fully vaccinated patients were 84% less likely to be admitted to hospital, and protection for those aged <50 years. Interpretation(s): Once hospitalized, the vaccinated patients displayed more protection against requiring respiratory care than the unvaccinated ones, despite being older and having more comorbidities. No differences appeared for the four studied vaccine types.

From Pre-crises to Global Recoveries and Why We Can Build Sustainable Futures for the World

The coronavirus disease of 2019 (COVID-19) generated a crisis;however, it also gave us an opportunity to imagine the future and build a better world. Moreover, as we are convinced of the importance of understanding the lessons of history when facing both current and future challenges, this chapter seeks to present a concise overview of global crises since the end of the nineteenth century and to show crises for which we ignored the warning signs and wakeup calls, the consequences of said crises and how we managed to recover and thrive in several cases. Ultimately, we seek to justify the capacity of humanity to build a sustainable future-ideally, a regenerative future. © 2022 Emerald Publishing Limited.

Controversies in neuroimmunology: multiple sclerosis, vaccination, SARSCoV-2 and other dilemas

Neuroimmunology is a discipline that increasingly broadens its horizons in the understanding of neurological diseases. At the same time and in front of the pathophysiological links of neurological diseases and immunology, specific diagnostic and therapeutic approaches have been proposed. Despite the important advances in this discipline, there are multiple dilemmas that concern and filter into clinical practice. This article presents 15 controversies and a discussion about them, which are built with the most up-to-date evidence available. The topics included in this review are: steroid decline in relapses of multiple sclerosis (MS), therapeutic recommendations in MS in light of the SARS-CoV2 pandemic, evidence of vaccination in MS and other demyelinating diseases, overview current situation of isolated clinical and radiological syndrome, therapeutic failure in MS as well as criteria for suspension of disease-modifying therapies, evidence of the management of mild relapses in MS, recommendations for prophylaxis against strongyloides stercolaris, usefulness of a second course of immunoglobulin in the syndrome Guillain-Barre (GBS), criteria to differentiate an acute-onset inflammatory demyelinating chronic polyneuropathy versus GBS and the utility of angiotensin-converting enzyme in neurosarcoidosis. In each of the controversies, the general problem is presented and specific recommendations are offered that can be adopted in daily clinical practice.

Centralized management of Intensive and Intermediate Care Unit beds by the Emergency Care Regulation Center of Bogotá facing the COVID-19

Introduction. In the context of the health emergency, there has been an increase in the number of critical cases of COVID-19 in the Intensive and Intermediate Care Units (ICU, IMCU), indicating the need to develop strategies for coordination. Objective. To describe the approach implemented in Bogotá for the bed occupancy coordination on the ICU and IMCU, facing an increase in critical COVID-19 cases. Methods. We conducted a descriptive study using Emergency Division databoards and SaluData indicators. Additionally, we made a comparison between the essential points of the Capital's strategy and the bed occupancy rate in ICU and IMCU services at 12-hour intervals. Results. We described the design and implementation of the strategy, the bed occupancy rate indicators for COVID-19 cases, the hospitalization indicators for COVID-19 and non-COVID-19 cases, and the parameters of high demand (adult ICU beds occupancy percentage 50% or highest) for more than 24 hours. Taking into account these percentages we determined the alerts levels. Procedures, instruments, and channels of communication necessaries for supplying beds were considered as well. Conclusion. Centralized management of ICU beds by the Regulation Center has been favorable for the health services provided to patients in a critical state. © 2021 Pontificia Universidad Javeriana. All rights reserved.

COVID-19 impact on elderly hemodialysis population: Results from the Spanish COVID-19 CKD working group registry

BACKGROUND AND AIMS: Age and chronic kidney disease have been described as mortality risk factors for coronavirus disease 2019 (COVID-19). Currently, an important percentage of patients in hemodialysis are elderly. This study aimed to investigate the impact of COVID-19 in this population and to determine risk factors associated with mortality. METHOD: Data was obtained from the Spanish COVID-19 CKD Working Group Registry, that included patients in renal replacement therapy (dialysis and kidney transplantation) infected by COVID-19. From March 18, 2020, to August 27, 2020, 1165 patients on hemodialysis affected by COVID-19 were included in the Registry. A total of 328 patients were under 65 years-old and 837 were 65 years old or older (elderly group). RESULTS: Mortality was 18.6% higher (95% confidence interval (CI): 13.8%-23.4%) in the elderly hemodialysis patients compared to the non-elderly group (see figure). Death from COVID-19 infection was increased 5.5-fold in hemodialysis patients compared to mortality in the general population for a similar period, and there was an age-associated mortality increase in both populations (see figure 1). In multivariate Cox regression analysis, age (hazard ratio (HR) 1.58, 95% CI: 1.31-1.92), dyspnea at presentation (HR 1.61, 95% CI: 1.20-2.16), pneumonia (HR 1.76, 95% CI: 1.12-2.75) and admission to hospital (HR 4.13, 95% CI: 1.92-8.88) were identified as independent mortality risk factors in the elderly hemodialysis population. Treatment with glucocorticoids reduced the risk of death (HR 0.71, 95% CI: 0.51-0.98) in aged patients on hemodialysis. CONCLUSION: Mortality is dramatically increased in elderly hemodialysis patients affected by COVID-19. Age, dyspnea at presentation, pneumonia or hospitalization are factors associated with a worse prognosis, after adjusting dialysis population to other confounding factors. Treatment with glucocorticoids could be a therapeutic option for this specific population. (Table Presented).

Kidney transplant patients infected by SARSCoV-2 pneumonia treated with remdesivir: Cases reports

BACKGROUND AND AIMS: Remdesivir is the only treatment that has been shown to be useful against SARS-CoV-2 infection. It shorts hospitalization time compared to placebo. Kidney transplant (KT) patients were not included in these studies, therefore, its effects in this population is limited to some published cases. METHOD: We performed a retrospective observational study that included all KT patients admitted between August 01, 2020 and November 17, 2020 with SARS-CoV-2 pneumonia who received treatment with remdesivir. Patients received a 200mg loading dose followed by 100 mg/day maintenance dose for 5 days. The objective of this study was to describe the experience of a cohort of KT patients treated with remdesivir. RESULTS: A total of 36 KT patients developed SARS-CoV-2 infection, 6 of them received treatment with remdesivir. The rest of the patients did not receive the drug due to either CKD-EPI less than 30 mL/min or they did not present clinical criteria. In addition to remdesivir, all pacients received dexamethasone and anticoagulation therapy. Immunosuppression was suspended in all patients, maintaining only dexamethasone. 50% were men, the median age was 58.5 (52.75-68) years. 67% had unknown underlying kidney disease, 83% were hypertensive and 33% had diabetes. All patients received KT from deceased brain donor and 50% received thymoglobulin as induction treatment. Median time from transplantation was 49 (20.5-135.5) months, with median glomerular filtration at admission of 47.5 (42.25-63.25) mL/min. The most frequent clinical manifestation was dry cough and dyspnea (83%), followed by tachypnea and fever (67%). Chest X-rays of all patients showed pulmonary infiltrates and required low oxygen flow therapy upon admission, requiring high flow nasal therapy in 33% of cases during admission. Only 17% of the cases presented deterioration of the graft function, not requiring hemodialysis in any case, and all recovered renal function at hospital discharge. No patient died or required admission to the critical care unit. Median days of admission was 12 (10-18) days. CONCLUSION: KT patients with SARS-CoV-2 pneumonia under treatment with remdesivir have a good clinical course, with few cases of renal function deterioration and a low mortality rate. Additional studies are necessary with a larger number of patients to improve the knowledge of remdesivir in KT with SARS-CoV-2 infection.

Colombian consensus for the prevention, diagnosis and treatment of thrombotic conditions in adults with COVID-19: applying GRADE Evidence to Decision (EtD) Frameworks

Introduction: recent studies have reported the occurrence of thrombotic phenomena or coagulopathy in patients with COVID-19. There are divergent positions regarding the prevention, diagnosis, and treatment of these phenomena, and current clinical practice is based solely on deductions by extension from retrospective studies, case series, observational studies, and international guidelines developed prior to the pandemic. Objective: to generate a group of recommendations on the prevention, diagnosis and management of thrombotic complications associated with COVID-19. Methods: a rapid guidance was carried out applying the GRADE Evidence to Decision (EtD) frameworks and an iterative participation system, with statistical and qualitative analysis. Results: 31 clinical recommendations were generated focused on: a) Coagulation tests in symptomatic adults with suspected infection or confirmed SARS CoV-2 infection;b) Thromboprophylaxis in adults diagnosed with COVID-19 (Risk scales, thromboprophylaxis for outpatient, in-hospital management, and duration of thromboprophylaxis after discharge from hospitalization), c) Diagnosis and treatment of thrombotic complications, and d) Management of people with previous indication of anticoagulant agents. Conclusions: recommendations of this consensus guide clinical decision-making regarding the prevention, diagnosis, and treatment of thrombotic phenomena in patients with COVID-19, and represent an agreement that will help decrease the dispersion in clinical practices according to the challenge imposed by the pandemic.