Case report: Spontaneous pneumomediastinum (SPM) and intestinal perforation secondary to COVID-19 in the same patient

Case History:A 73-year old male patient with Hypertensive Cardiomyopathy, pulmonary emphysema, dyslipidemia,presented to our Pulmonary Department for COVID-19 pneumonia associated with respiratory failure. He was started on medical therapy and high flow oxygen reduced during hospitalization,he was not treated with noninvasive ventilation. During hospitalization,he developed before SPM,showed chest CT scan,and we achieved good results with conservative management, consisting of bed rest with oxygen inhalation or supportive pain control. After ten days,as the patient complained of continued abdominal pain, computed tomography(CT)abdomen was ordered and revealed sigmoid colonic diverticular and intestinal perforation. He underwent to resected sigmoid colon but few days after surgery the patient died. Spontaneous pneumomediastinum (SPM),unrelated to positive pressure ventilation and intestinal perforation (IP)have been recently reported as an unusual complications in cases of COVID19 pneumonia. For SPM, the presumed pathophysiological mechanism is diffuse alveolar injury leading to alveolar rupture and air leak, for GP is unclear,the perforation could result from altered colonic motility due to neuronal damage in addition to local ischemia resulting from hypercoagulable state caused by the virus. We present a case of COVID-19 pneumonia complicated both SPM and IP in the same patient,not yet described in literature. On this basis,we believe it is vital to institute SARS-CoV-2 precautions in patients who present with either respiratory or gastrointestinal symptoms,therefore high index of suspicion is needed to further manage those patients and,thus,improve their outcome.

Deep Venous Thrombosis in Elderly Inpatients with Pneumonia

Background: The occurrence of deep vein thrombosis (DVT) in COVID-19 pneumonia has raised wide concern recently, but few studies have reported the incidence of DVT in other types of pneumonia. We evaluate the prevalence, risk factors and treatment of DVT in the elderly inpatients with pneumonia. Method(s): A cohort of 550 elderly inpatients (>= 75 years old) with pneumonia between 2017 and 2021 were reviewed. They were divided into DVT group and non-DVT groups on the basis of whether pneumonia was combined with new-found DVT. Clinical data were collected retrospectively. Patients with DVT were divided into anticoagulant group and non-anticoagulant groups on the basis of whether they received anticoagulant therapy. Result(s): Ninety-seven patients were included in the DVT group;453 in the non-DVT group. The incidence of DVT was 17.64%. Hospital stays were significantly longer for DVT patients than for non-DVT counterparts (p = 0.005). Coronary heart disease, heart failure, hyperlipidemia, bed rest, and elevated D-dimer were independent risk factors for DVT (p < 0.05). The rate of anticoagulant therapy in DVT group was 63.92% (62/97 cases). Follow-up showed that the continuous anticoagulant treatment rate was 48.39% (30/62 cases) at 3 months and 30.65% (19/62 cases) at 6 months. Conclusion(s): Elderly inpatients with pneumonia are at high risk of DVT. The combination of DVT and pneumonia may lead to prolonged hospitalization. Coronary heart disease, heart failure, hyperlipidemia, bed rest and elevated D-dimer are independent risk factors for DVT in these patients. The rate of regular anticoagulant treatment is low because of the high risk of bleeding.Copyright © 2022, Taiwan Society of Geriatric Emergency & Critical Care Medicine.

The Treatment of Postural Orthostatic Tachycardia Syndrome, Post-Covid-19 Using Aerobic and Resistance Training

BACKGROUND AND PURPOSE: Twenty-five to 50% of individuals who contract COVID-19 develop postural orthostatic tachycardia syndrome (POTS).3 The underlying etiology remains undetermined, yet there is research to support several root causes. Mechanisms such as dysautonomia, hypovolemia and prolonged bed rest leading to cardiac atrophy provide some indications.2,3,4 Recent research suggests that a structured and supervised training program that includes both aerobic and resistance components, was found to improve oxygen uptake, increase cardiac size, and increase blood volume.1,5 The purpose of this case study is to describe the successful treatment of a 13-year-old female diagnosed with POTS following COVID-19 using aerobic and resistance training. CASE DESCRIPTION: A 13-year-old female student who was being treated for hypermobility, contracted COVID-19 during her plan of care. During this time, she developed symptoms of lightheadedness, headaches, fainting episodes, dizziness and heart palpitations. Her rheumatologist performed an active head up tilt test that was negative for orthostatic hypotension but positive for tachycardia, which indicated a diagnosis of POTS. She was prescribed fluidicortisone with a dose of 1mg twice per day and returned to physical therapy. The interventions included 40 minutes of zone 2 aerobic training with a heart rate range of 151 to 171 beats per minute (BPM) on a recumbent bike and 20 minutes of resistance training of the lower extremities at rate of perceived exertion (RPE) of 7 to 8. The intensity of the aerobic training progressed to zone 3 and greater aerobic training with a heart rate of at least 171 BPM when the resting heart rate was stabilized. OUTCOME(S): The patient completed 26 visits over 4 months. Following the completion of the program, the resting heart rate of the patient returned to 76 BPM from a starting rate of 127 BPM. Heart rate response to exercise was congruent with the subjective RPE reported by the patient without any reoccurring symptoms previously experienced. An active head up tilt test was performed in the clinic without a tachycardic response indicating she was no longer positive for POTS. The patient was able to resume her previous extracurricular activities, including soccer, without symptom provocation. DISCUSSION: The physiological rationale supporting this conclusion consists of a decreased compensatory tachycardic response to upright positions, improved oxygen uptake, increased blood volume and increased cardiac size. Although there was a successful outcome to this case, there are some limitations. Psychological components should be monitored as well as a greater importance of RPE due to due to the inability to accurately detect heart intensity in the diagnosis of POTS.4,1.

Acute Sarcopenia in Elderly with COVID-19: An Overlooked Problem

The coronavirus Disease-19 (COVID-19) pandemic was announced in March 2020 by World Health Organization (WHO). Studies showed that the elderly had higher morbidity and mortality rates. Acute sarcopenia in the elderly with COVID-19 is an overlooked problem. Inflammation, malnutrition, immobilization, a side effect of COVID-19 treatment, depression, and hormonal dysregulation contributed to acute sarcopenia in COVID-19, especially in the elderly. Muscle quantity can be assessed with different techniques such as imaging or anthropometric measurements in diagnosing sarcopenia. Imaging such as CT scan was widely used in multiple studies. Still, anthropometric measurements are more fit in developing countries because they are widely available, safe, do not require special skills, and fit in low-resources facilities. Muscle strength can be assessed with grip strength. Acute sarcopenia was associated with immune dysregulation and cytokine storm, length of stay and readmission, and ICU admission and mechanical ventilation. These will contribute to high mortality in sarcopenic elderly with COVID-19.

Research progress of thrombosis in patients with COVID-19

The COVID-19 pandemic poses a huge challenge to the global economy and healthcare.Coagulation dysfunction and thrombosis are the main clinical features of severe COVID-19 patients, and closely related to the risk of death.Several mechanisms of thrombosis in COVID-19 have been proposed, such as immune inflammation, hypoxia, imbalance of angiotensin system, endothelial injury etc, and other high-risk factors such as combined with basic diseases, bed rest braking and intravenous catheterization.In this review, we summarize the mechanisms that may increase the risk of thrombosis in patients with severe COVID-19, in order to improve people′s understanding of coagulation abnormalities and thrombosis complications in patients with severe COVID-19, and further explore effective methods to prevent and treat COVID-19 related thrombosis.

Viral exanthems Unravelling viral rashes

Common causes of viral exanthems in Australia include herpesviruses, enteroviruses, parvovirus B19, varicella, measles and rubella viruses and mosquito-borne alphaviruses. The cause can often be diagnosed clinically from the rash distribution and morphology, confirmed only when necessary with serological or PCR tests. Most viral exanthems are self-limiting, requiring supportive care alone.

Systematic Investigation of Vital Signs, Cardiovascular Problems and Level of Consciousness in Patients with Infectious and Non-Infectious Diseases

This study systematically investigated vital signs, cardiovascular problems and level of consciousness in patients with infectious and non-infectious diseases. Respiratory viruses are a serious threat to the health security of people internationally and can lead to global epidemics with high mortality and financial burden for treatment. An example of these viruses that have always brought many challenges are coronaviruses. There are several reasons for this. Heart cells have angiotensin-converting-2 (ACE-2) receptors at the point where the coronavirus attaches to cells. Heart damage can also be caused by too much inflammation in the body. As the immune system fights the virus, the inflammatory process can damage some healthy tissues, including the heart. The coronavirus also affects the inner surfaces of blood vessels, which can cause inflammation of blood vessels, damage to very small vessels, and blood clots. All of these can compromise blood flow to the heart or other parts of the body. Severe covid-19 is a disease that affects endothelial cells, which form the inner lining of blood vessels. Many symptoms have been reported in the post-Covid-19 period and there are several reasons for these symptoms. Severe fatigue after infection with the corona virus is common like other serious diseases. Many people experience shortness of breath, chest pain or palpitations. Any of these problems can be related to the heart. But it can also be due to other factors, including the consequences of a long-term illness, prolonged inactivity, and weeks of bed rest for recovery. People who recover from the coronavirus sometimes show symptoms of a condition known as standing orthostatic tachycardia syndrome. Researchers are discovering whether or not there is a connection between this disease and the corona virus. Standing orthostatic tachycardia syndrome is not a heart problem per se, but a neurological problem that affects the part of the nervous system that regulates heart rate and blood flow. This syndrome can cause a rapid heartbeat when standing which can lead to fatigue, palpitations, lightheadedness and other symptoms.

Post COVID-19 syndrome

Dyspnea and fatigue are the most frequent symptoms that can remain for a long time in the post-COVID-19 phase, especially in patients returning from prolonged bed rest in intensive care or in acute care wards. In all these patients, pulmonary rehabilitation (PR) plays an important role in promoting their recovery, improving their autonomy and quality of life, and should be started early. The programs must be tailored to the needs and clinical conditions of the patient, also taking advantage of the possibilities offered by tele-rehabilitation.

HETEROTOPIC OSSIFICATION AFTER COVID-19 INFECTION - CASE REPORT

Background/Aims Heterotopic ossification (HO) is the abnormal formation and deposition of mature lamellar bone within soft tissue, associated with trauma, surgery, neurologic injury and prolonged immobilisation. Several recent case reports have demonstrated this condition in COVID-19 patients requiring mechanical ventilation. Methods We present a case of heterotopic ossification in the shoulder after a long stay in intensive care unit (ICU) due to COVID-19 infection. Results A 55-year-old man with stable psoriatic arthritis on sulfasalazine was admitted to ICU for mechanical ventilation after contracting COVID-19 infection. After discharge from ICU, he began noticing increasing right shoulder pain with restricted movements of abduction, internal and external rotation. His serum alkaline phosphatase was moderately elevated. Despite physiotherapy and NSAIDs, there was slow improvement. Shoulder x-ray showed significant bony overgrowth around proximal humerus which was initially thought to be part of his psoriatic arthritis. It was confirmed at Rheumatology/Radiology MDT to be heterotopic ossification. A computed tomography of the right shoulder was requested to evaluate the extent of the condition and orthopaedic advice was sought. Conclusion There are many factors contributing to the development of heterotopic ossification including trauma, spinal cord injury, brain injury, hypoxia, prolonged immobilisation with limitation of joint movement and prolonged bed rest which cause alterations in calcium homeostasis, male sex and over 60 years of age. New onset joint pain and stiffness in patients who have recovered from COVID-19 especially those who had long ICU stay should be further investigated for this condition. Treatment includes analgesia and physiotherapy with potential surgical intervention.

AP-519-01 A MULTIDISCIPLINARY APPROACH TO SAME DAY DISCHARGE OF PATIENTS POST ATRIAL FIBRILLATION ABLATION

Background: The COVID-19 pandemic created an increased need for inpatient hospital beds. This need along with advances in AF ablation technology led us to develop a program to discharge patients the same day as their AF ablation. Objective: To develop and implement a protocol to allow safe Same Day Discharge (SDD) of eligible patients after AF ablation. Methods: A multi-disciplinary team of providers and nurses developed an institutional-wide protocol to identify patients for safe SDD. Eligibility was based on comorbidities, home support, and distance from hospital. Adjusted procedural workflow included use of vascular closure devices to decrease bedrest time, avoidance of urinary catheters, and careful monitoring of volume status. A post discharge automated call system was developed to trigger nurse-level outreach to identify and treat potential post-operative complications. A retrospective analysis was performed to review enrollment and complications to ensure safety of the program. Results: SDD for AF ablation was performed in 113 patients in 2020. There was 1 complication in the immediate post-op period due to traumatic foley insertion, 1 visit to urgent care for pericarditis, and 1 hospital readmission within 30 days due to volume overload;a total complication rate of 2.7%. There was no mortality observed and no major complications. Average general anesthesia time was 168.7 +/- 58.5min and average procedural time (vascular access to reversal) was 105.6 +/- 53.1 min. Conclusion: A safe and effective same day discharge program was developed for patients undergoing AF ablation by a multidisciplinary team. This program resulted in improved patient satisfaction and had favorable impacts on healthcare utilization. [Formula presented]

SAFETY AND CRITERIA FOR PERCUTANEOUS LEFT ATRIAL APPENDAGE OCCLUSION SAME DAY DISCHARGE

Background: Left Atrial Appendage Occlusion (LAAO) with the Watchman device is considered an elective procedure, and thus often deferred during outbreak peaks associated with the COVID-19 pandemic. Patients with bleeding issues on anticoagulation may require additional hospitalization for bleeding episodes or suffering increased risk of stroke by postponing occlusion while anticoagulation is discontinued. We chose to develop a protocol for screening, same day discharge, and follow up of selected LAAO patients and continuing to provide quality clinical outcomes while accounting for decreased bed and staff capacity due to the pandemic. Methods: Utilizing Knowledge to Action (KTA) nursing framework, a protocol was developed and reviewed with key stakeholders. Criteria for Same Day Discharge (SDD) includes: support at home, stable vitals and access site hemostasis prior to DC, agreeable to SDD, tolerant of oral intake, ability to urinate and safely ambulate prior to DC. Exclusion for SDD includes: Liver disease, Plt count <70,000, ESRD or CKD IV or any site or procedure complications. With Perclose usage patients must have 3 hours of bedrest, with manual pressure closure must have bedrest for 6 hours and purse string suture removed. This is followed by a next day phone call to ensure the patient is taking appropriate medicines and have no medical issues. Results: 38 out of 113 patients were screened as SDD candidates from January 2021-October 2021. Average patient age was 76, 31% female, with average CHA2DS2-VASc of 5. One patient required overnight hospitalization due to underlying asthma and need for nebulizer. One patient presented to an outpatient ED on a weekend with chest pain and underwent heart catheterization due to elevated troponin and did not require intervention. There were no access site complications. No patients contracted SARS-Cov-2 within 6 weeks post procedurally, compared with 2 of the overnight stays during the same period (75 patients). Conclusion: SDD in a carefully selected patient population is a feasible and safe strategy for LAAO patients. These patients had a clinically significant, though underpowered decrease in incidence of COVID-19 diagnosis within 6 weeks post implant.

Consequence of acute lack of exercise: detraining and overall decrease in functional capacity

Almost everyone will experience a short-term lack of physical activity during their lifetime. In athletes who train regularly, the rea-son is most often an acute illness or injury. In the untrained population, restrictions on physical activity at any age are most often linked to health problems, but may also be related to anti-pandemic measures, as we have recently seen in the global fight against the COVID-19 pandemic. As "detraining" we mean a condition that occurs with such an extraordinary reducing of physical activity. It is manifested mainly by a decrease or loss of adaptive abilities, achieved by previous training or previous normal daily physical activity. In athletes there is a decrease in performance, in average fit people there is a weakening of the state of health, which requi-res convalescence. For people who have previously suffered from health problems, "detraining" can lead to loss of independence and deepening of their frailty to complete dependence on the environment. In the prevention of these negative consequences, it is necessary to reduce the period of restriction of movement to a minimum, ensure sufficient protein in the diet, minimize time spent in bed or sedentary and use online instruction on how to exercise at home. Otherwise, only a few weeks without optimal movement leads to a very significant reduction in physical condition, manifested in particular by a very significant decrease of adaptations earned from training especialy of cardiorespiratory capacity. © 2021, Czech Medical Association J.E. Purkyne. All rights reserved.

Acute-phase bed-rest duration was associated with lower grip strength in a post-covid-19 cohort

Background: Though age-related muscle loss is traditionally associated with older cohorts, strong evidence suggests a life-spanning precipitation of decreasing muscle mass and strength beginning as early as the fourth decade of life, with established deleterious consequences for later-life morbidity and mortality. Periods of low activity and bed rest (LA/BR) can further compound this depletion of muscle strength. Our aim was to examine such associations in a post-COVID-19 cohort. Methods: Participants reporting ongoing symptomatology and fatigue post COVID-19 underwent assessments of grip strength via hand-held dynamometry (2 measures on each hand). Demographics of COVID-19 illness, including time since diagnosis, duration of LA/BR during acute illness, and levels of fatigue were captured via self-reported questionnaires. Independent predictors of mean grip strength were investigated using a linear regression model. Results: Forty-nine participants underwent assessments (69% female, mean age 44(12) years). At the time of assessment, days post COVID-19 diagnosis ranged from 39-522 (mean 262(140)). The mean self-reported period of LA/BR during the acute illness was 15(18) days. In general, participants reported significant levels of fatigue (median Chalder Fatigue Scale score 22(8)). Mean grip strength was 41.3(6.3) Kg for men and 22.8(6.7) Kg for women. When predictors of grip strength were investigated, an increased duration of LA/BR was found to be associated with lower grip strength, independently of age, gender, time since COVID-19 diagnosis, and self-reported fatigue (Beta=-0.158, 95% Confidence Interval-0.242 to -0.074, p=0.001). Conclusion: In this cohort, every day of LA/BR during acute COVID-19 illness was independently associated with subsequent lower grip strength of approximately 150 g. These results underscore the importance of early mobilization and discouraging bed rest in the acute phase of COVID-19. Patients who are isolating should be encouraged to maintain physical activity and muscle strength as part of a modified isolation-friendly rehabilitation programme.

Identification of patients who can safely undergo same day discharge following atrial fibrillation ablation: Lessons learned in the COVID-19 era

Background: Historically, pts have been admitted for overnight observation following atrial fibrillation (AF) ablation. The COVID-19 pandemic ushered the need to consider same day discharge (SDD). It remains unclear how to identify pts who can safely undergo SDD. Objective: To evaluate acute (within 4 hrs) and subacute (within 24 hrs) safety of SDD post AF ablation;we also sought to identify predictors of safe discharge. Methods: All pts undergoing AF ablation at our center following the end of the COVID imposed lockdown were enrolled. In each pt, ICE guided single transseptal puncture using the VersaCross® (Baylis) system was performed. Following ablation, protamine was not administered;all femoral venous access sites were closed with Vascade™ (Cardiva Medical) closure devices. Pts ambulated after 2 hrs of bedrest. Pts who had SDD were compared to those who stayed for overnight observation. Results: The cohort included 226 pts (65 ± 10 yrs, 157 [69%] male, 118 [52%] PAF, CHA2DS2 -VASc 2.4 ± 1.7). Cryo PVI was performed in 193 (85%) pts;34 (15%) pts had a redo procedure. SDD was attempted in 126 pts and successfully accomplished in 115 (91%) pts at 251 + 72 minutes from procedure end. The most common reason for failed SDD attempt was access site oozing necessitating additional bedrest. No SDD pt had a major complication. Overnight observation was performed in 100 (44%) pts, most commonly due to physician/pt preference. Compared to pts who had SDD, these pts were older and more likely to have heart failure and history of TIA/stroke. Oozing within the first 4 hrs was observed at a similar rate to SDD pts. A minor complication was seen in 1 pt each in SDD and overnight stay group between 4 and 24 hrs of ablation (Figure). Conclusions: Our study shows that when attempted, SDD after AF ablation can be accomplished in >90% of pts. Venous access site oozing was the greatest hinderance to pts going home. However, if pts had no issue 4 hrs after AF ablation, they had an uneventful course over the next 24 hrs. (Figure Presented).

Heterogeneity of Hematological Response to Hypoxia and Short-Term or Medium-Term Bed Rest.

Hematological changes are commonly observed following prolonged exposure to hypoxia and bed rest. Typically, such responses have been reported as means and standard deviations, however, investigation into the responses of individuals is insufficient. Therefore, the present study retrospectively assessed individual variation in the hematological responses to severe inactivity (bed rest) and hypoxia. The data were derived from three-bed rest projects: two 10-d (LunHab project: 8 males; FemHab project: 12 females), and one 21-d (PlanHab project: 11 males). Each project comprised a normoxic bed rest (NBR; PIO2=133mmHg) and hypoxic bed rest (HBR; PIO2=91mmHg) intervention, where the subjects were confined in the Planica facility (Ratece, Slovenia). During the HBR intervention, subjects were exposed to normobaric hypoxia equivalent to an altitude of 4,000m. NBR and HBR interventions were conducted in a random order and separated by a washout period. Blood was drawn prior to (Pre), during, and post bed rest (R1, R2, R4) to analyze the individual variation in the responses of red blood cells (RBC), erythropoietin (EPO), and reticulocytes (Rct) to bed rest and hypoxia. No significant differences were found in the mean ∆(Pre-Post) values of EPO across projects (LunHab, FemHab, and PlanHab; p>0.05), however, female EPO responses to NBR (Range - 17.39, IQR - 12.97 mIU.ml-1) and HBR (Range - 49.00, IQR - 10.91 mIU.ml-1) were larger than males (LunHab NBR Range - 4.60, IQR - 2.03; HBR Range - 7.10, IQR - 2.78; PlanHab NBR Range - 7.23, IQR - 1.37; HBR Range - 9.72, IQR - 4.91 mIU.ml-1). Bed rest duration had no impact on the heterogeneity of EPO, Rct, and RBC responses (10-d v 21-d). The resultant hematological changes that occur during NBR and HBR are not proportional to the acute EPO response. The following cascade of hematological responses to NBR and HBR suggests that the source of variability in the present data is due to mechanisms related to hypoxia as opposed to inactivity alone. Studies investigating hematological changes should structure their study design to explore these mechanistic responses and elucidate the discord between the EPO response and hematological cascade to fully assess heterogeneity.

COVID-19: Short and Long-Term Effects of Hospitalization on Muscular Weakness in the Elderly.

The COVID-19 pandemic has recently been the cause of a global public health emergency. Frequently, elderly patients experience a marked loss of muscle mass and strength during hospitalization, resulting in a significant functional decline. This paper describes the impact of prolonged immobilization and current pharmacological treatments on muscular metabolism. In addition, the scientific evidence for an early strength intervention, neuromuscular electrical stimulation or the application of heat therapy during hospitalization to help prevent COVID-19 functional sequels is analyzed. This review remarks the need to: (1) determine which potential pharmacological interventions have a negative impact on muscle quality and quantity; (2) define a feasible and reliable pharmacological protocol to achieve a balance between desired and undesired medication effects in the treatment of this novel disease; (3) implement practical strategies to reduce muscle weakness during bed rest hospitalization and (4) develop a specific, early and safe protocol-based care of functional interventions for older adults affected by COVID-19 during and after hospitalization.