COVID-19 Viral Infection Presenting With Diabetic Ketoacidosis, Hyperosmolar Hyperglycemic Syndrome, or Mixed Hyperglycemic Crisis: A Case Series.

Cardiovascular disease, COPD, and diabetes (DM) are associated with increased complications with COVID-19. A correlation between COVID-19 and diabetic ketoacidosis (DKA) or Hyperosmolar Hyperglycemic Syndrome (HHS) has been suggested; however, the precise mechanism remains unclear. We present a case series of six patients with COVID-19 infections who were found to have DKA, HHS, or mixed picture. Wedescribe an association between COVID-19 and hyperglycemic emergencies. Six patients (50% male, 50% female, mean age 47.667 ± 18.747) were identified from November 2021 to February 2022. Comorbidities included DM (83.3%), HTN (50%), as well as ESRD, A-Fib, ISLD, HIV, and dementia (each 16.7%). Common review of systems included nausea and vomiting (50%), abdominal pain (33.3%), dyspnea (33.3%), and decreased appetite (33.3%). Additional findings were dysarthria, facial droop, generalized weakness, productive cough, myalgias, and increased urinary frequency (16.7%). Patients were diagnosed with DKA (50%), mixed process (33.3%), andHHS(16.7%). In terms of COVID-19 symptoms, most patients were asymptomatic (83.3%), with one patient developing hypoxia. The survival rate was 100%. Infections can incite DKA/HHS; yet, COVID-19 may have factors that amplify this process, in the setting of pancreatic beta-cell dysfunction from the virus itself. This may contribute to why diabetic patients have a ten times higher risk of death if they develop COVID-19. This virus binds to ACE2 receptors in the pancreas and damages the islets, ultimately decreasing insulin release. Here, we introduce cases of DKA/HHS in the setting of COVID-19, to understand the relationship between how COVID-19 infections may exacerbate diabetic complications.

Effect of the COVID-19 Pandemic on the Rate of Interventional Pain Management Therapies. Could the Application of Personal Protective Equipment Help?

BACKGROUND: Chronic pain symptoms are distressing conditions that necessitate regular visits to  pain therapists and may require interventions, however, the COVID-19 pandemic has caused patients and their therapists to limit both visits and interventions with the transition to telehealth, with little or no preparation or training. This has resulted in the extensive use of over-the counter analgesia and corticosteroids. OBJECTIVES: Our study aimed to evaluate the effect of the COVID-19 pandemic on the rates of counseling and interventional pain management therapies (IPMT), and determine the effects of implementing an infection control program (ICP) and mandating personal protective equipment (PPE) on these rates. STUDY DESIGN: Prospective multicenter survey, based on an online self-assessed questionnaire. SETTING: Departments of Anesthesia, Pain, Intensive Care Unit, Physical Medicine, Rheumatology, and  Rehabilitation at Egyptian University hospitals. METHODS: A self-assessed questionnaire was uploaded on Google forms and links were sent to enrolled therapists with an identification number to allow self-administration and privacy. Feedback was analyzed by 2 authors who were blinded to the identity of the responders. RESULTS: A total of 57.9% of responders increased their patients' contact by phone and video conference. Within 1-4 months after the outbreak began, 59% stopped in-person contact and 38.2% stopped their IPM practice. Prescriptions of analgesics and oral steroids increased by about 50%. The majority of responders complained of a shortage of ventilation appliances in their workplaces. About 50% of them always use ICP, 85% use surgical masks, 61% use gloves, and 45% wear gowns when meeting with patients. After the application of PPE, 45.5% of responders increased their consultation rate and 40% increased their rate of IPMT. LIMITATIONS: This study is limited to being a national study, and so lacked comparative data. CONCLUSION: The COVID-19 outbreak seriously affected the rates of in-person consultations and IPMT for patients with chronic pain and increased the rates of consumption of analgesia and oral steroids. Most responders reported a shortage of PPE especially ventilation appliances in workplaces. A high percentage of responders lack interest in ICP and PPE, despite the positive effects of its application on consultation and IPMT rates.

A validated LC-MS/MS method for determination of antiviral prodrug molnupiravir in human plasma and its application for a pharmacokinetic modeling study in healthy Egyptian volunteers.

A fully validated, simple, rapid and reproducible liquid chromatography-tandem mass spectrometry method was developed to determine NHC (N-hydroxycytidine), the active metabolite of Molnupiravir (MOL) in human plasma; one of the limited treatment options for SARS-CoV-2 in plasma of healthy volunteers. The internal standard (IS) used was ribavirin. The extraction of analyte and IS from plasma was performed using acetonitrile as a solvent for protein precipitation. Agilent Zorbax Eclipse plus C18, 4.6 × 150 mm, (5 µm) was used for chromatographic separation using a mixture of methanol0.2 % acetic acid (5:95, v/v) as a mobile phase that was pumped at a flow rate of 0.9 mL/min. Detection was performed on a triple quadrupole mass spectrometer operating in multiple reaction monitoring (MRM) employing positive ESI interface using API4500 triple quadrupole tandem mass spectrometer system, with the transitions set at m/z 260.10 â†’ 128.10 and 245.10 â†’ 113.20 for NHC and IS respectively. Method validation was performed in accordance with United States FDA bioanalytical guidance. The concentration range of 20.0-10000.0 ng/mL was used to establish linearity via weighted linear regression approach (1/x2). Moreover, the analyzed pharmacokinetic data from twelve Egyptian healthy volunteers were used to develop a population pharmacokinetic model for NHC. The developed model was used to perform simulations and evaluate the current MOL dosing recommendations through calculating the maximum concentration (Cmax) "the safety metric" and area under the curve (AUC0-12 h) "the efficacy metric" for 1000 virtual subjects. Geometric mean ratios (GMR) with their associated 90% confidence intervals (CI) compared to literature values were computed. Geometric means of simulation-based Cmax and AUC0-12 were 3827 ng/mL (GMR = 1.05; 90% CI = 0.96-1.15) and 9320 ng.h/mL (GMR = 1.04; 90% CI = 0.97-1.11), respectively indicating that current MOL dosage can achieve the therapeutic targets and dose adjustment may not be required for the Egyptian population. The developed model could be used in the future to refine MOL dosage once further therapeutic targets are identified.

Modeled impact of the COVID-19 pandemic and associated reduction in adult vaccinations on herpes zoster in the United States.

Due to COVID-19, vaccinations dropped in 2020 and 2021. We estimated the impact of reduced recombinant zoster vaccine (RZV) use on herpes zoster (HZ) cases, complications, and quality-adjusted life-year (QALY) losses among older adults. Various scenarios were compared with Markov models using data from national sources, clinical trials, and literature. Missed series initiations were calculated based on RZV distributed doses. In 2020, 3.9 million RZV series initiations were missed, resulting in 31,945 HZ cases, 2,714 postherpetic neuralgia cases, and 610 lost QALYs. Scenarios further projected disease burden increases if individuals remain unvaccinated in 2021 or the same number of initiations are missed in 2021. Health professionals should emphasize the importance of vaccination against all preventable diseases during the COVID-19 era.

Impact of COVID-19 on neurosurgical service: A one-year experience from a provincial countryside hospital in a rural area in north Egypt.

BACKGROUND: Globally, there is a shooting pandemic that affected many healthcare systems. Healthcare facilities had to set up strategies to avoid exhaustion while facing a catastrophic health problem. Vaccines or perfect therapies were not available over a long pandemic time and also no certified immunity against that disease is guaranteed. Therefore, it is probable that healthcare systems will face it for an exceptionally long period. That already had a grave effect on the strategy of daily practice of different specialties' services at healthcare centers. METHODS: We tried simply to share a countryside hospital's expertise in managing neurosurgical cases amid a dreadful health crisis. Healthcare workers' safety and patient safety were typical priorities for neurosurgical service at Damietta Specialized Hospital. We expose the lines of management, triaging cases, the methods of handling confirmed and suspected neurosurgical patients, and strategies for discharging and following up patients. We identified hospital admission and discharge records starting from February 2020 till February 2021 to track the neurosurgical case burden, the state of service offered and the rate of infection among healthcare workers who participated in surgeries. RESULTS: At the peak time of the COVID­19 pandemic in Egypt starting from February 2020 till February 2021, we have admitted about 500 neurosurgical patients. About 400 (80%) of them did surgeries according to the triaging protocol of the hospital. About 150 (30%) of those who did surgeries were urgent and the rest were borderline or semi­urgent. About 20 (4%) were tested COVID-19 positive and six of them died due to acute respiratory distress syndrome. Only two mortality cases were reported due to post-operative complications and not related to SARS­CoV­2 infection. The rest of the cases (97.6%) were discharged for follow­up without complications. No neurosurgeons but three anesthesia staff were infected with SARS­CoV­2. A successful undisturbed neurosurgical care was available for patients during COVID-19 time. CONCLUSIONS: Following the suggested strategies, a rural area-serving hospital managed to provide uninterrupted neurosurgical care amid COVID-19 pandemic in Egypt. Rural areas in developing countries are in need of strategies to deal with pandemics in the future without dismantling the normal health system, especially for life­saving cases in a critical specialty as neurosurgery.

Neurological problems in the context of COVID-19 infection in Egypt. A multicenter retrospective analysis.

BACKGROUND: COVID-19 infection has spread so fast in both low- and high-income countries. In December 2019, an outbreak of a respiratory disease occurred in China, and later, it involved different countries. Acute neurological insults are more likely to occur in severely infected patients. METHODS: We tried to evaluate patients with selective criteria including, the age of participants 18 and older with a confirmed diagnosis of SARS-CoV-2, and developed neurological complications post COVID-19 infection. An overall data of 1500 patients were collected from neurological and primary health care departments. About 970 of them had neurological problems. Patients-related data were gathered and assembled from the patients' records at participating hospitals from the Ministry of Health and university hospitals. RESULTS: We presented the results according to several variables including, regional distribution, reasons of presentation, neurological complications, follow-ups, and survival outcome. CONCLUSIONS: To our knowledge, we conducted the first retrospective analysis for neurological problems related to COVID-19 infection in Egypt. COVID-19 patients present with a variety of central and peripheral neurological symptoms, the pathogenic mechanisms of which have not been explained. Robust investigations of the neurological presentations of COVID-19 infection should be recruited for better understanding of the possible association. Moreover, further explaining the pathophysiologic mechanisms will help in designing proper treatment plans.

Improving management of hospitalised patients with COVID-19: algorithms and tools for implementation and measurement.

BACKGROUND: The COVID-19 pandemic represents an unprecedented challenge to healthcare systems and nations across the world. Particularly challenging are the lack of agreed-upon management guidelines and variations in practice. Our hospital is a large, secondary-care government hospital in Kuwait, which has increased its capacity by approximately 28% to manage the care of patients with COVID-19. The surge in capacity has necessitated the redeployment of staff who are not well-trained to manage such conditions. There was a great need to develop a tool to help redeployed staff in decision-making for patients with COVID-19, a tool which could also be used for training. METHODS: Based on the best available clinical knowledge and best practices, an eight member multidisciplinary group of clinical and quality experts undertook the development of a clinical algorithm-based toolkit to guide training and practice for the management of patients with COVID-19. The team followed Horabin and Lewis' seven-step approach in developing the algorithms and a five-step method in writing them. Moreover, we applied Rosenfeld et al's five points to each algorithm. RESULTS: A set of seven clinical algorithms and one illustrative layout diagram were developed. The algorithms were augmented with documentation forms, data-collection online forms and spreadsheets and an indicators' reference sheet to guide implementation and performance measurement. The final version underwent several revisions and amendments prior to approval. CONCLUSIONS: A large volume of published literature on the topic of COVID-19 pandemic was translated into a user-friendly, algorithm-based toolkit for the management of patients with COVID-19. This toolkit can be used for training and decision-making to improve the quality of care provided to patients with COVID-19.

COVID-19 pneumonia identified by CT of the abdomen: A report of three emergency patients presenting with abdominal pain.

Patients with COVID-19 infection may present to the Emergency Department (ED) with gastrointestinal complaints and no respiratory symptoms. We are presenting 3 patients who came to the ED with abdominal pain; and the computed tomography [CT] of the abdomen showed findings suggestive of COVID-19 pneumonia. A 65-year-old male patient presented with symptoms of urinary tract infection and left renal angle tenderness. A 42-year-old male patient presented with right flank pain postextracorporeal shock wave lithotripsy. A 71-year-old male known to have type 2 diabetes mellitus and who had had whipple surgery for a neoplasm of the head of the pancreas presented with a painful epigasteric swelling. The 3 patients had positive COVID-19 polymerase chain reaction (PCR) tests and mild-to-moderate illness, and were discharged home after 2 weeks with a good recovery. The first patient had a false negative early PCR test, which turned positive on 2 repetitions of the test. A systematic review of CT abdomen, including inspection of the lung bases using the lung window in all CT abdomen, is essential to detect findings suggestive of COVID-19 pneumonia in patients requiring a CT abdomen study. As proven in the literature, CT findings of COVID-19 pneumonia have a higher sensitivity than the PCR test.

Optimizing lung cancer radiation treatment worldwide in COVID-19 outbreak.

COVID-19 has spread around the planet, sending billions of people into lockdown as health services struggle to cope. Meanwhile in Asia, where the disease began, the spread continues, in China it seems for now to have passed its peak. Italy, Spain, France, UK, and the US have been the countries more affected in terms of deaths. The coronavirus is more dangerous to the elderly and those with certain pre-existing medical conditions which is precisely the profile of lung cancer patients. Essential cancer services should be delivered but all steps should be taken to protect patients and the health workforce from infection with COVID-19. This presents a major challenge to radiotherapy (RT) departments worldwide. An international panel with expertise in the management of lung cancer in high-volume comprehensive centres has come together to share its experience on COVID-19 preparedness to deliver optimal care in such exceptional circumstances. A comprehensive systematic review of the literature through a PubMed search was undertaken. Twelve recommendations including, among others, the consideration of shorter courses, delays, and the omission of RT for lung cancer are proposed by the panel. In summary, we recommend the screening of every single person accessing the treatment room, the consideration of hypofractionation and to delay postoperative RT for non-small cell lung cancer, to avoid twice-daily treatments and delay or deliver prophylactic cranial irradiation during radio(chemo)therapy for limited-stage small cell lung cancer, review image guided RT images for suspicious image findings, and the use of single-fraction RT for the palliative treatment of stage IV lung cancer patients. Given that lung cancer is one of the most common and severe pathologies in radiation oncology departments, the following recommendations require particularly urgent consideration. The decision-making paths strongly depend on locally available resources, and a tailored approach should be used to attend lung cancer patients during this pandemic.