ABSTRACT
Background. Environmental factors such as infections and vaccines are known to trigger dermatomyositis (DM), and during the recent SARS-CoV-2 pandemic this has become even clearer. SARS-CoV-2 infection may share features with anti-MDA5 DM, such as rapidly progressive lung involvement, cutaneous lesions and cytokine release syndrome. A few case reports of DM following SARSCoV-2 vaccination have been published, suggesting the onset of an aberrant immune response leading to DM with specific autoantibody signatures and severe organ impairment. Methods. Clinical and laboratory data of the 2 case reports were obtained from electronic clinical charts in Humanitas Research Hospital (Rozzano, Milan, Italy). Autoantibody analysis was performed by protein-immunoprecipitation for anti-MDA5 and immunoblot for anti-Ro52 and TIF1gamma antibodies as per protocol. Results. Case report 1 is a 71-year-old woman who developed fever, cough, and anosmia, which resolved spontaneously in two weeks, but did not undergo a nasopharyngeal swab, while her relatives were diagnosed with SARS-CoV-2 infection. When symptoms improved, she developed arthralgia and skin lesions on her face, chest, and hands for which she started topical treatment, with negative SARSCoV-2 nasopharyngeal swab and positive serum test for IgG against SARS-CoV-2 spike protein. For the persistence of the skin rash and arthralgia, she was admitted to our Department in March 2021. Blood tests showed mild elevation of C reactive protein (2.1 mg/L -normal value NV<5), aspartate (84 UI/L) and alanine aminotransferase (133 UI/L -NV<35), ferritin (595 ng/ml -NV<306), troponin I (19 ng/L -NV<14), and BNP (251 pg/ml -NV<100) with normal complete blood cell count, creatine kinase, C3 and C4. IgG antibodies for SARS-CoV-2 spike protein were confirmed to be elevated (96 AU/ml -NV<15). Autoantibodies associated with connective tissue diseases were tested and only anti-MDA5 antibodies were positive at immunoprecipitation. A punch biopsy of a Gottron-like lesion on the left hand showed leukocytoclastic vasculitis. We observed reduced capillary density with neoangiogenesis and ectasic capillaries at the nailfold capillaroscopy. EKG and ecocardiography were normal, while cardiac magnetic resonance detected abnormalities in the parametric sequences, consistent with signs of previous myocarditis. A lung CT scan revealed pulmonary emphysema while respiratory function tests demonstrated reduced volumes (FVC 82%, FEV1 64%, inadequate compliance CO diffusion test). Based on the biochemical and clinical findings, a diagnosis of anti-MDA5-associated DM with skin and heart involvement was made and treatment with low-dose methylprednisolone (0.25 mg/kg daily) and azathioprine 100 mg was started, then switched to mycophenolate because not effective on skin lesions. Case report 2 is an 84-year-old woman with history of colon cancer (surgical treatment) and oral lichen treated with low doses steroids in the last 2 years. After the 2nd dose of SARS-CoV-2 mRNA vaccination, in March 2021 she developed skin rash with V-sign, Gottron's papules, periungueal ulcers, muscle weakness and fatigue, thus she performed a rheumatologic evaluation. Blood tests showed mild elevation of creatine kinase (484 UI/L, NV <167), CK-MB (9.6ng/ml, NV <3.4), BNP (215 pg/ml -NV<100) with normal values of complete blood cell count, C3 and C4. Anti-Ro52kDa and TIF1gamma were positive at immunoblot, thus we confirmed a diagnosis of DM. The clinical evaluation also showed active scleroderma pattern at nailfold capillaroscopy, normal echocardiography, bronchiectasia but not interstitial lung disease at lung CT, and normal respiratory function tests (FVC 99%, FEV1 99%, DLCO 63%, DLCO/VA 81%). A PET-CT scan was performed to exclude paraneoplastic DM, and treatment with steroids and mycophenolate was started. Conclusions. SARS-CoV-2 may induce mechanisms for escaping the innate immunity surveillance and causing autoimmune diseases, but more clinical and functional studies are needed to demonstrate this possible association.
ABSTRACT
Faced with the need for isolation of most people to reduce the transmission of COVID-19, a great concern for the well-being of the population has resurfaced. Considering the numerous benefits of outdoor activities to human health and well-being, we assessed whether the quality of the experience of recreational divers in a marine protected area (MPA) was impacted during the pandemic. We applied a semi-structured questionnaire to divers, collected their socioeconomic profile, preferences, motivations, experiences, and compared the results with those obtained in the previous season. We found that the quality of the recreational diver's experience remained high even during one of the world's biggest health crises. This suggests that the combination of contact with a preserved environment and the adaptation of regulations in favor of visitor safety was enough to stimulate positive experiences. Therefore, we highlight the importance of investing in adaptive management so that MPAs continue to promote ecosystem services such as human health and subjective well-being.
ABSTRACT
"There`s only beauty if there is an interlocutor. The beauty of the lagoon is always someone” (Mãe, 2017, p.40). Valter Hugo Mãe expresses our desire in the making of this paper to share our experience of meeting refugee children, as part of an ongoing research project dedicated to exploring the conditions in which they live in Baixada Fluminense, Rio de Janeiro, Brazil, and the influences they bring with them from their birth countries. In the process of conducting this research, we were surprised by a group of children who belong to the Warao ethnic group, and who have been welcomed by the municipality of Nova Iguaçu, which is part of Baixada Fluminense. The Warao are indigenous peoples from the North of Venezuela and their name means "canoe,” given their close relationship with water. A group of displaced Warao children and their families arrived in Nova Iguaçu after having "camped” out in the surroundings of Novo Rio bus station for a few weeks, followed by a sojourn in a public shelter, where the differences between them and the existing members of the institution led to conflict. Through a religious institution's initiative, the families then found shelter in a small farm in the city of Japeri. They stayed there for six months, but once again were threatened by the prospect of eviction, after which they were finally welcomed in the city of Nova Iguaçu. The families–five interconnected units–expressed the wish to remain together and a social service institution found them a closed school building, which was modified to accommodate the group. When the Covid pandemic struck, the research and study group GEPELID began following the daily routine of these children at the shelter school and at the Marambaia welfare center. In their meetings with the Warao, the researchers were struck by their references to the Buriti tree as the "tree of life,” and the depths of its implications for their identity. In exploring this concept, the research group's experience of radical cultural difference revealed the extent to which research in the human sciences is always a meeting with the other, and the relation between researcher and subjects an occasion for dialogue. © 2022 State Univ of Rio de Janeiro - Center of Childhood and Philosophy Studies. All rights reserved.
ABSTRACT
Background. The objective of this study was to characterize frailty and resilience in people evaluated for Post-Acute COVID-19 Syndrome (PACS), in relation to quality of life (QoL) and Intrinsic Capacity (IC). Methods. This cross-sectional, observational, study included consecutive people previously hospitalized for severe COVID-19 pneumonia attending Modena (Italy) PACS Clinic from July 2020 to April 2021. Four frailty-resilience phenotypes were built: 'fit/resilient', 'fit/non-resilient', 'frail/resilient' and 'frail/non-resilient'. Frailty and resilience were defined according to frailty phenotype and Connor Davidson resilience scale (CD-RISC-25) respectively. Study outcomes were: QoL assessed by means of Symptoms Short form health survey (SF-36) and health-related quality of life (EQ-5D-5L) and IC by means of a dedicated questionnaire. Their predictors including frailty-resilience phenotypes were explored in logistic regressions. Results. 232 patients were evaluated, median age was 58.0 years. PACS was diagnosed in 173 (74.6%) patients. Scarce resilience was documented in 114 (49.1%) and frailty in 72 (31.0%) individuals. Table 1 shows demographic, anthropometric and clinical characteristics, comorbidities and patient-reported outcomes according to four frailty-resilience phenotypes. With regards to study outcomes, Figure 1 depicts in radar graphs, mean scores of each domain of SF-36 (1A), EQ-5D5L (1B) and IC (1C). Figures shows polygon areas for each frailty/resilience phenotypes. Progressive increase of mean scores of each domain are plotted in the vertices of polygons, from the lowest (near the center) in frail and non-resilient, to highest (towards periphery) in fit and resilient. Multivariate logistic analyses were used to identify predictors of the total scores of SF-36 (Figure 2A), EQ-5D5L (Figure 2B) and IC (Figure 2C). Conclusion. Resilience is complementary to frailty in the identification of clinical phenotypes with different impact on wellness and QoL. Frailty and resilience should be evaluated in hospitalized COVID-19 patients to identify vulnerable individuals to prioritize urgent health interventions in people with PACS. Funding. This study is supported by a Gilead Sciences Inc. unrestricted grant.
ABSTRACT
Coronavirus disease-19 (COVID-19) is caused by a severe acute respiratory syndrome coronavirus-2 and was declared a pandemic in March 2020. It mainly causes upper respiratory symptoms, but an interstitial viral pneumonia may occur, in severe cases complicated by acute respiratory distress syndrome. Neurological involvement has been reported but has not been well investigated. A 75-year old man presenting with severe COVID-19 related pneumonia developed a severe cognitive impairment and a right temporal hemianopsia, with focal microangiopathy and subacute ischemic alterations detected on brain imaging, interpreted as vasculitic-inflammatory injury. The neurological disorder was diagnosed only after he was extubated. A rehabilitation program was set up, so the patient had a complete cognitive recovery. Our case underlines how COVID-19 can lead to severe neurological sequelae, so neurological examination should be promptly performed when patients display signs of nervous system involvement, in order to prevent further damages.
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COVID-19-related pneumonia requires different modalities of Intensive Care Unit (ICU) interventions at different times to facilitate breathing, depending on severity progression. The ability for clinical staff to predict how patients admitted to hospital will require more or less ICU treatment on a daily basis is critical to ICU management. For real datasets that are sparse and incomplete and where the most important state transitions (dismissal, death) are rare, a standard Hidden Markov Model (HMM) approach is insufficient, as it is prone to overfitting. In this paper we propose a more sophisticated ensemble-based approach that involves training multiple HMMs, each specialized in a subset of the state transitions, and then selecting the more plausible predictions either by selecting or combining the models. We have validated the approach on a live dataset of about 1, 000 patients from a partner hospital. Our results show that rare events, as well as the transitions to the most severe treatments outperform state of the art approaches. © 2021 IEEE.
ABSTRACT
Background: Antimalarials are off-label for COVID-19. While the efficacy still is inconclusive, safety is a major concern for using these drugs. We aimed to review the safety of antimalarials in patients with malaria and rheumatologic diseases (RD), and then, we attempted to translate these findings to COVID-19. Methods: a systematic review (PROSPERO CRD42020176659), was performed in order to identify clinical trials and observational studies in Pubmed/MEDLINE, Scopus, Cochrane and LILACS, evaluating the safety profile of chloroquine (CQ) and hydroxychloroquine (HCQ),. Random-effects proportion meta-analyses were conducted for cardiovascular, hepatic, hematologic, ocular and dermatological outcomes. Results: 77 studies were included (malaria=33, RD=44). Patients with malaria received CQ, 25mg/kg or 1500mg divided in three days of therapy, whilst RD patients received HCQ, 400mg od, for at least 6 months. QTc interval prolongation occurred in 4% (95%CI 2;11%) of chloroquine-exposed patients, but no deaths or ventricular arrhythmias were observed. Elevation of transaminases (CQ 7%, 95%CI 3;16%;and HCQ 6%,95%CI 3;12%) and bilirubin (CQ 3%, 95%CI 1;14%) were common, but only one patient evolved to CQ-induced hepatitis. Through 1-3% of patients developed anemia, none of them needed transfusion. Dermatological events were presented, and were clinically manageable. Retinopathy was reported only with HCQ and was associated with prolonged treatment duration. Discussion: When efficacy of antimalarials is still inconclusive, safety is the major driver for using them in COVID-19. Therefore, QTc prolongation and liver injury were common adverse events, but their clinical significance remains uncertain as patient-related factors, such as underlying diseases and concomitant treatments are determinant for developing such adverse reactions.