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'You do not know what you will find, you may set out to find one thing and end up discovering something entirely different'-Alexander Fleming As the pace at which medicine is advancing continues to accelerate, haematologists will increasingly find themselves practising unfamiliar medicine and using novel treatments. Whilst most scientific breakthroughs hopefully lead to an overall improvement in quality of life and prognosis, it is imperative that enough attention is paid to the shortcomings of new treatments and adverse events. The recent COVID-19 pandemic is a stark reminder of the cyclical nature of history and the need for healthcare professionals to utilise lessons learnt by our predecessors. Fleming and the discovery of penicillin highlights how mistakes in practice can sometimes lead to unexpected but useful revelations. The use of thalidomide as a treatment for hyperemesis gravidarum in the 1960s devastatingly lead to birth defects in thousands of people. Today, the repurposing of thalidomide, through lateral thinking and further study, has contributed to significant improvements in the prognosis of patients with Multiple Myeloma.1 Mortality following allogenic stem cell transplant continues to decrease overtime as knowledge surrounding complications and how to manage these improves, despite the fact that patients receiving stem cell transplants are becoming increasingly complex.2 These examples from history demonstrate the merit in studying adverse events and undesired outcomes. National reviews of patient health records indicate that errors currently occur in 10% of hospital admissions.3 With new treatments and more complex patients this will likely increase. It is estimated that voluntary reporting by healthcare professionals of such events only occurs 70% of the time.3 History should be used to guide essential changes in attitudes towards error reporting and help to create an ethos where 'failings' are more willingly recognised as a tool to guide improvement and innovation.
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Background: The US Food and Drug Administration under an Emergency Use Authorization approved use of Paxlovid (nirmatrelavir and ritonavir) for the treatment of mild-to-moderate COVID-19 in adults and children with a positive test for SARS-Co-2 and who are at high risk for progression to severe COVID-19. Pregnant women are at increased risk of severe complications resulting from COVID-19 infection;however, minimal data on the safety of Paxlovid in human pregnancy are available. Objective(s): The objectives of this study are to assess risks of major congenital malformations, spontaneous abortion, elective termination, stillbirth, preterm delivery, small for gestational age infants at birth, or infants who were small for age at one year in pregnancies/infants prenatally exposed to Paxlovid in pregnancy compared to individuals who did not receive this treatment. Design(s): This study involves prospective data from the Organization of Teratology Information Specialists (OTIS) Pregnancy Registry which enrolls pregnant women residing in the US or Canada and captures data through maternal interviews and ion of medical records. Result(s): Among pregnant women participating in the OTIS Pregnancy Registry as of February 1, 2023, 59 reported exposure to Paxlovid in pregnancy;25.4% exposed within 30 days prior to the last menstrual period and through the first trimester, 42.4% exposed in second trimester, and 32.2% exposed in the third trimester. As of January 2023, 17 of those enrolled have completed pregnancy outcomes. One was lost to follow-up. Of the remainder, there were no adverse pregnancy outcomes reported. Conclusion(s): Very limited data are available on this potentially beneficial treatment in pregnancy. To date, no serious signals for this exposure have been detected.
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The proceedings contain 90 papers. The topics discussed include: characterization of nonalcoholic fatty liver disease in children with psoriasis: a pilot study;management of pediatric psoriasis: a representative US survey;severity and patient-related outcomes in atopic dermatitis do not correlate with deprivation index as an indicator of socioeconomic setting in a US metropolitan area;pediatric atopic dermatitis: assessment of burden based on lesional morphology;metered dose applicators: a potential solution for improving topical medication adherence in atopic dermatitis patients;serial staged punch excision technique for linear epidermal nevus and nevus sebaceous;the molecular basis of superficial vascular lesions of the skin: genotype-phenotype correlation of capillary malformations;utilization and effect of telehealth for the treatment of hemangioma before and after COVID;image analysis of port wine birthmarks using optical coherence tomography;image analysis of port wine birthmarks using optical coherence tomography;and responsiveness to change of the morphea activity measure.
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Background: Increasing availability of highly effective cystic fibrosis (CF) transmembrane conductance regulator (CFTR) modulator therapy (HEMT) has improved the quality of life and long-term prognosis for many people with CF. Thus, more people with CF are considering parenthood. Almost all menwith CF (MwCF) are infertile because of congenital bilateral absence of the vas deferens (CBAVD). Based on CF animal models, CBAVD occurs early in gestation and is unlikely to be reversible using HEMT, but assisted reproductive techniques (ARTs) can enable MwCF to father children using the sperm in their testes. Animal reproductive models suggest no HEMT teratogenicity, and the amount of exposure of the fetus to HEMT via absorption of seminal fluid through the vaginal wall is predicted to be negligible, although to ensure no sperm exposure to HEMT, the life span of sperm would require MwCF to discontinue CFTR modulators for approximately 3 months before ART. Because abrupt discontinuation of CFTR modulators may result in health decline, MwCF and their providers must consider all potential risks. There are no published data in MwCF regarding use of HEMT during conception and partner pregnancy. Method(s): Beginning in August 2021, CF center staff in the United States, United Kingdom, and Australia completed a two-page anonymous questionnaire regarding MwCF who used CFTR modulators during ART (sperm retrieval and in vitro fertilization) or natural conception with subsequent partner pregnancy. Result(s): Providers have submitted 34 surveys for MwCF on CFTR modulators whose partner became pregnant after use of ART (n = 32) or natural conception (n = 2). The median age of the samplewas 32 (range 24- 43). Fifteen were homozygous for F508del, median percentage predicted forced expiratory volume in 1 second was 76% (range (22-111%), and median body mass index was 24 kg/m2 (range 18.5-32.1). Twenty-three were taking elexacaftor/tezacaftor/ivacaftor. The median time that MwCF were taking CFTR modulators before partner conception was 18 months (range 0-82). One newly diagnosed man initiated HEMT after sperm retrieval. Four MwCF stopped CFTR modulators before sperm retrieval, one of whom experienced pulmonary decline. None of the 19 MwCF whose condom use during pregnancy was known used condoms. Fetal complications in partners of MwCF included three first-trimester miscarriages, two* COVID, two breech presentation, two* vaginal bleeding, and one vasa previa. None of the complications were deemed definitively related to use of CFTR modulators. One MwCF experienced testicular infection after sperm retrieval#. Postpartum complications included three# infants with hypoxemia requiring neonatal intensive care unit stay, three maternal blood loss, one forceps delivery, and one caesarean section. No congenital anomalies were reported for any infant. (*/# overlap). Conclusion(s): Use of CFTR modulator therapy during partner conception and pregnancy in 34 MwCF has not resulted in higher-than-expected miscarriage rates or congenital anomalies. Providers should consider the risk to the health of MwCF combined with the lack of teratogenicity in animal reproductive models and limited safety data in the human fetus before discontinuing CFTR modulators before ART or natural partner conception. Survey collection is ongoing;results will be updated for presentationCopyright © 2022, European Cystic Fibrosis Society. All rights reserved
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Background: We aimed to measure COVID-19 vaccine uptake among women giving birth in Melbourne and to compare perinatal outcomes by vaccination status. Method(s): Routinely-collected data from all 12 public maternity hospitals in Melbourne were extracted on births >=20 weeks' from 01.07.21 to 31.03.22. Sociodemographic characteristics and perinatal outcomes were compared between COVID-19 vaccinated and unvaccinated women. The primary outcomes were stillbirth and preterm birth in singletons >24 weeks. We calculated the adjusted odds ratio of perinatal outcomes among vaccinated versus unvaccinated women using inverse propensity score weighting regression adjustment with multiple covariates;P < 0.05 was considered significant. Result(s): Births from 32 536 women were analysed: 17 365 (53.4%) were vaccinated and 15 171 (47.6%) were unvaccinated. Vaccination status was significantly associated with multiple sociodemographic factors. Vaccinated women had a significantly lower rate of stillbirth compared with unvaccinated women (0.2% vs. 0.8%, aOR 0.18, 95% CI 0.09- 0.37, P < 0.001). Vaccination was associated with a significant reduction in total preterm births <37 weeks (5.1% vs. 9.2%, aOR 0.60, 95% CI 0.51-0.71, P < 0.001), spontaneous preterm birth (2.4% vs. 4.0%, aOR 0.73 95% CI 0.56-0.96, P = 0.02) and iatrogenic preterm birth (2.7% vs. 5.2%, aOR 0.52, 95% CI 0.41-0.65, P < 0.001). There was no significant increase in congenital anomalies or foetal growth restriction among vaccinated women. Conclusion(s): COVID-19 vaccination during pregnancy was associated with a reduction in stillbirth and preterm birth, and not associated with any adverse impacts on foetal growth or development. Vaccine coverage was significantly influenced by known social determinants of health.
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Background: As a quality service improvement response since elexacaftor/ tezacaftor/ivacaftor (ELX/TEZ/IVA) became available and the yearly average number of cystic fibrosis (CF) pregnancies (n = 7 pre-2020, n = 33 in 2021) increased significantly at an adult CF center (~600 people with CF), a monthly multidisciplinary CF-maternal health virtual clinic was established with antenatal virtual CF exercise classes dedicated to providing adaptive, specialist support to this cohort, aswell as outreach guidance and education to local obstetric teams. Method(s): This was a single-center retrospective reviewof Royal Brompton Hospital CF-Maternal Health multidisciplinary team clinic records and a patient survey from March 2020 to March 2022. Result(s): Of 47 pregnancies in 41 women (median age 30;) eligible for ELX/ TEZ/IVA at start of pregnancy, 40% (n = 19) were unplanned, and 19% (n = 9) used assisted conception. Three women with a history of infertility conceived naturally, having required assisted conception for previous pregnancies, and five women had multiple pregnancies during the study period. ELX/TEZ/IVA was continued in 60% (n = 28), delayed in 28% (n = 13), and stopped in 13% (n = 6) of pregnancies through maternal choice and careful clinical counselling. Pre-pregnancy pulmonary status was poorer in women who continued than in those who delayed or stopped (Table 1). Of those who stopped, 85% (n = 5) restarted because of pulmonary deterioration by the third trimester. Prenatal CF complications included at least one episode of minor hemoptysis in 21% (n = 9/41) of women, at least one infective exacerbation in 55% of pregnancies (n = 26/47), and noninvasive ventilation in one woman. Other pregnancy-associated complications included one case of ovarian hyperstimulation syndrome, one case of sub-segmental pulmonary embolism, and two cases of pregnancy-induced hypertension. Excluding 10 first trimester terminations, 10 current pregnancies, and one patient relocation, obstetric outcomes available for 26 pregnancies confirmed a live birth rate of 85% (n = 22/26) and a 15% first-trimester miscarriage rate (n = 4). Obstetric complications included preterm delivery rate of 23% (n = 6/26), including two cases of COVID infection resulting in two neonatal intensive care unit admissions, one case of endometritis after cesarean section, and a fourthdegree perineal tear. There were no ectopic pregnancies, maternal or neonatal deaths, or reports of infant cataracts or congenital malformations. Median gestational age was 37/40 weeks (range 29-40). Mode of delivery was via cesarean section in 45% (n = 10/22, of which twowere emergency) and vaginal in 55% (n = 12/22), of which 83% (n = 10/12) were via induction of labor for diabetes (CF or gestational) indication. Deliveries were supported and occurred equally at local obstetric units and in tertiarycare obstetric hospital settings (50%, n = 11/22). Patient-experience survey responses cited high levels of confidence in health optimization and prioritization during pregnancy and praised excellent inter-health care provider communication and peer-to-peer emotional support provided among expectant mothers in the virtual prenatal exercise groups. Table 1. Baseline demographic and clinical characteristics of elexacaftor/tezacaftor/ivacaftoreligible expectant mothers according to therapeutic decision (Table Presented) Conclusion(s): In the absence of clinical trial safety data, the novel approach of a dedicated CF-maternal health multidisciplinary team clinic with local obstetric outreach support has ensured regular specialist clinical and emotional peer-to-peer support for this cohort of women eligible for ELX/ TEZ/IVA to ensure optimal outcomes and experiences of their pregnancies, where appropriate, close to home.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved
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INTRODUCTION AND OBJECTIVE: Various diversion techniques exist for the management of neurogenic bladders. In pediatrics, the appendicovesicostomy is a successful approach but may not be applicable for all patients. An alternative is the Yang-Monti ("Monti") catheterizable conduit, created using a section of small bowel. Although commonly used in pediatrics, there are very few series evaluating adults. This study aims to evaluate "Monti" outcomes in an adult population. METHOD(S): Between 1999 and 2022, "Monti" procedures at a single institution were identified using CPT codes, and the list was reviewed to select for adult patients with neurogenic bladder dysfunction. Preoperative data included indications for surgery and patient demographics. Perioperative (day 0 to end of hospital stay) data included time to return of bowel function, length of stay, and perioperative complications. Long-term complications included infections, hospital admissions, and reoperations. Data are presented as means or percentages. RESULT(S): 21 adult patients (male n=8;female n=13) with neurogenic bladder dysfunction were identified. 14 patients developed neurogenic bladder secondary to trauma, while other indications for surgery included idiopathic urinary retention (n=1), tumors (n=2), congenital abnormalities (n=2), multiple sclerosis (n=1), and autoimmune neuropathy (n=1). The mean follow-up time was 3.13 years and mean age at surgery was 35.5 years. The mean time to return of bowel function was 2.7 days (n=14) and postoperative hospital stay was 4.3 days (n=16). Perioperative complications occurred in 10 patients (47.6%) in the first 30 days including UTIs (n=3), surgical site infection (n=3), ileus (n=1), small bowel obstruction (n=1), and suprapubic tube related complications (n=3). Five emergency room admissions for urologic concerns occurred within this period with a total of 28 visits overall. At six month follow-up, a total of six (28.6%) patients had longer-term complications. These included a takedown, a scheduled revision, a hospitalization for complicated UTI, and three patients who were unable to catheterize. Overall, nine patients (42.9%) required reoperation, including three revisions and one cystectomy with conversion to ileal conduit. Two patients expired during the course of this study due to COVID pneumonia and suspected sepsis. CONCLUSION(S): "Monti" procedures are useful for adult patients with neurogenic bladder dysfunction. However, these procedures are associated with significant complications. This information should be used to aid in presurgical counseling.
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A 5-month-old, intact male, yellow Labrador retriever was presented with a 24-hour history of anorexia and vomiting. Abdominal imaging revealed the presence of a mechanical obstruction in the jejunum and peritoneal effusion. Cytologic evaluation and culture of the effusion prior to surgery identified a suppurative exudate with bacteria consistent with septic peritonitis and suspected to be related to the intestinal lesion. An exploratory laparotomy was performed, and a segment of jejunum was circumferentially severely constricted by an off-white, fibrous band of tissue. Resection and anastomosis of the strangulated segment of jejunum and excision of the constricting band provided resolution of the clinical signs. The dog made a complete recovery. Histologic evaluation revealed the band to be composed of fibrovascular and smooth muscle tissue, consistent with an idiopathic anomalous congenital band. No other gastrointestinal lesions were observed, either grossly at surgery or histologically in the resected segment of intestine. To our knowledge, a similar structure has not been reported in the veterinary literature.Copyright © 2022 Canadian Veterinary Medical Association. All rights reserved.
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Advances in neonatal medicine have progressively increased the survival of premature infants. Increased survival has however come at the cost of increased number of infants with prematurity-related complications. This is represented by high rates of respiratory distress syndrome, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), sepsis, periventricular leukomalacia (PVL), intraventricular haemorrhage (IVH), cerebral palsy, hypoxic ischaemic encephalopathy (HIE) and visual and hearing problems in survivors. In addition to prolonged hospital stay after birth, readmission to hospital in the first year of life is common if chronic lung disease exists. Around 3% of newborns have a congenital physical anomaly with 60% of congenital anomalies affecting the brain or heart and around 1% having multiple anomalies. Individual congenital conditions requiring surgical intervention in the neonatal period are rare. Neonates have a higher perioperative mortality risk largely due to the degree of prior illness, the complexity of their surgeries, and infant physiology. The maintenance of oxygenation and perfusion in the perioperative phase is critical as both affect cerebral perfusion and neurocognitive outcome but the triggers for intervention and the thresholds of physiological parameters during neonatal anaesthesia are not well described. After even minor surgical procedures, ex-premature infants are at higher risk for postoperative complications than infants born at term.Copyright © 2022
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Objective: To describe the burden of COVID-19 in a children's multidisciplinary hospital for two years of the pandemic, taking into account of age, severity of the disease, the spectrum of underlying conditions and the intensive care need. Method(s): An assessment of 6048 cases of COVID-19 in patients under 18 years of age hospitalized from March 26, 2020 to December 31, 2021 was carried out. The diagnosis was confirmed by PCR on an outpatient basis or after hospitalization with the help of diagnostic kits registered in the Russian Federation. The features of the work of a children's multidisciplinary hospital in new conditions, the dynamics of hospitalization, age characteristics and new coronavirus (CV) infection severity in the pandemic development process are presented. The analysis of the underlying condition's structure depending on the severity of the disease, as well as the need and volume of therapy in the intensive care unit. The frequency and main characteristics of children's multisystem inflammatory syndrome (MIS-C) in hospital conditions, long-term PCR positivity and its effect on the duration of inpatient treatment of children have been established. Result(s): The spread of SARS-COV-2 in St. Petersburg required a radical change in the work of the children's multidisciplinary hospital. During the two years of the pandemic, four waves of hospitalization of children with new CV were revealed, differing in duration, intensity, and frequency of lung damage, but having no significant differences in the proportion of severe forms of the disease (1.7-2.8% of cases). Intensive therapy was required in 3.6% of cases, of which only 1/3 was due to the severe course of COVID-19 with a lung lesion volume of up to 100%. In 1/3 of cases, patients had risks of developing severe forms and in 1/3 - other pathology. Severe course of new CV was significantly more often accompanied by the need for respiratory support, anticoagulants and anti-inflammatory therapy. Contributing factors of severe forms and unfavorable outcomes were: pathology of the central nervous system, genetic diseases and malformations, obesity, as well as chronic bronchopulmonary pathology. Mortality in the hospital was recorded only among children with severe underlying conditions (0.1% of cases). D-MVS was registered significantly more often in boys (7 out of every 10 patients), accounting for 1.2% of cases of hospitalization of children with new CV over the entire period. Convalescent PCR-positivity in the outcome of COVID-19 was detected in 1/3 of children, significantly more often during the autumn-winter waves of the pandemic and among patients of high school age. Conclusion(s): New CV is gradually strengthening its position in the structure of acute respiratory pathology in children. Some of SARS-COV-2 infection cases is accompanied by extensive lung damage, as well as severe systemic inflammation independently or in the other infectious diseases structure, induction of the debut of various somatic pathology is not excluded. The presented data confirm the need for increased attention at high risk of adverse respiratory diseases outcomes children. All severe cases of COVID-19 in children require a personalized approach, taking into account the existing background diseases and possible options for the progression of the process. MIS-C should be considered as a systemic inflammatory response syndrome within the framework of an infectious disease of various etiologies, differentiated with Kawasaki disease and the debut of systemic diseases. The long-term PCR-positivity in the outcome of COVID-19 requires further study to address the need and nature of therapy in order to prevent further spread of infection in the population.Copyright © 2022 Interregional public organization Association of infectious disease specialists of Saint-Petersburg and Leningrad region (IPO AIDSSPbR). All rights reserved.
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Aplasia cutis congenita (ACC) is often sporadic, but familial cases have been reported. We report a case of a dichorionic diamniotic twin pregnancy in which both the male and female twins had matching areas of aplasia cutis on their scalps. An Irish couple sought fertility treatment using a donor egg and paternal sperm. Successful in vitro fertilization (IVF) and the transfer of two embryos resulted in a diamniotic dichorionic twin pregnancy. Two fetal poles were noted at the 12-week ultrasound (US) scans. The mother suffered from a minor urinary tract infection during the first trimester but had no other history of infection, including herpes simplex virus or COVID- 19. She was known to be varicella immune prior to pregnancy. The twins were born by elective caesarean section owing to breech presentation. Twin one was female and twin two was male. Both infants were born with scarring on the crown of their head, which was consistent with ACC. Cranial US showed no underlying bony abnormality. The rest of the cutaneous examination was normal and there were no other congenital anomalies. ACC is a rare, heterogeneous group of disorders characterized by the congenital absence of skin, which can be focal or widespread. It is thought to affect 1-3 per 10 000 live births. The exact cause of ACC is unclear. Various hypotheses have been suggested, including defective closure of the neural tube or embryonic fusion lines, intrauterine trauma, placental insufficiency, fetus papyraceus, amniotic membrane adhesions, intrauterine infections, teratogens and genetic mutations. The classification of ACC is based on the area affected, type of skin irregularity, associated congenital defects and mode of inheritance. Scalp ACC without multiple anomalies (category 1) is generally associated with an autosomal dominant or sporadic pattern of inheritance. These twins may have an autosomal dominant mutation that led to this phenotype. ACC can also be associated with fetus papyraceus or placental infarct. This is less likely in this case as only two embryos were transferred, and the pregnancy was dichorionic. Most cases of ACC associated with fetus papyraceus occur in monozygotic pregnancies. ACC lesions often heal spontaneously by re-epithelialization resulting in a hairless superficial scar. Twin one had a slightly smaller area affected by ACC and overlying eschar resolved several weeks after birth. Twin two has had no hair growth in the area. This case highlights the difficulties in ascertaining the aetiology of this rare condition in twin pregnancies.
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Aim: In this study, it was aimed to share the clinical experiences of mothers and their babies (perinatal, natal) who encountered severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during pregnancy. Material(s) and Method(s): The study was carried out retrospectively, 62 pregnant individuals were diagnosed with the 2019 coronavirus disease (COVID-19). Demographic characteristics, clinical course, laboratory and radiological findings and clinical results of the baby were evaluated by examining electronic and file records. Result(s): The average age of the 62 pregnant women included in the study was 29.8+/-4.7 (19-42) years, and the average gestational week at the time of admission was 28.5+/-10.4 (5-40) weeks. More than half of the patients (80,6%) on admission were in their third trimester. The most common initial symptoms were cough (45.2%), myalgia (43.5%),) fever (21%). In total, 15 of the pregnant women had evidence of COVID-19 pneumonia in lung involvement. The PCR test results of all pregnant women were positive. There were three cases admitted to the intensive care unit, one of whom was due to gestational diabetes. No maternal mortality was recorded. One gestation ended in a miscarriage and two women gave birth prematurely. One stillbirth occurred at the 33h week of gestation. Among 22 neonates, two were admitted to the neonatal intensive care unit. Neonatal mortality, congenital malformation, and mother-to-child transmission were not observed in newborns. Discussion(s): The results of our study suggest that the clinical course of COVID-19 infection in pregnant women was mostly asymptomatic/mild.Copyright © 2022, Derman Medical Publishing. All rights reserved.
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Background: Data are limited regarding the safety of and antibody response to the BNT162b2 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) messenger ribonucleic acid vaccine in adolescents and young adults with underlying disease. Methods: This prospective observational study enrolled patients age 12–25 years with chronic underlying disease who received 2 doses of BNT162b2. A 18-item questionnaire was used to assess adverse events within 7 days post-vaccination, and data regarding severe adverse events were collected from electronic medical records. An antibody titer for the receptor-binding domain of the spike protein in SARS-CoV-2 was used to assess antibody response after the second vaccine dose. Results: Study participants were 429 patients (241 [56.2%] age 12–15 years;188 [43.8%] age 16–25 years). The most common underlying diseases were genetic or chromosomal abnormalities and/or congenital anomalies, followed by endocrine or metabolic diseases;32% of participants were immunocompromised. Severe adverse events were observed after the second dose in 1 (0.4%) patient age 12–15 years and in 2 (1.1%) patients age 16–25 years;all patients recovered. Seropositivity after the second vaccine dose was 99.0%. The geometric mean antibody titer was higher in patients age 12–15 years versus 16–25 years (1603.3 [1321.8–1944.7] U/mL vs. 949.4 [744.2–1211.0] U/mL). Compared with immunocompetent patients, immunocompromised patients had a lower antibody titer (2106.8 [1917.5–2314.7] U/mL vs. 467.9 [324.4–674.8] U/mL). Conclusions: Vaccination with BNT162b2 was acceptably safe and immunogenic for adolescents and young adults with underlying disease. © 2022 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases
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Objective: To determine relationship of SARS-CoV-2 infection to the risk and severity of preeclampsia, as well as its impact on newborns. Design and method: We performed a systematic search in databases (PubMed, ScienceDirect, ProQuest, and Cochrane Library) for studies examining impact of SARS-CoV-2 infection on pregnancy. Included studies were evaluated for risk of bias based on the Newcastle Ottawa Score. A meta-analysis was conducted using the data extracted from each study. Review Manager (RevMan) 5.4 was utilized to compute the summary of odds ratios (OR), mean differences (MD), and 95% confidence intervals (CI) for the outcomes. Our outcomes of interest are preeclampsia, preeclampsia with severe features, eclampsia, fetal distress and still birth. The other outcomes are preterm birth (< 37 week), instrumental labor, sectio caesaria and birth defect. Results: We identified twenty two observational studies involving 1,025,048 pregnancy patients. Based on the analysis, SARS-CoV-2 infection in pregnancy significantly increased the risk of preeclampsia [OR 2.01(95% CI 1.59-2.53;p < 0.00001;I2 = 82%)], and the severity was based on the high prevalence of preeclampsia with severe features [OR 3.04(95% CI 1.19-7.78;p = 0.02;I2 = 91%)] and eclampsia [OR 17.73(95% CI 13.83-22.72;p < 0.00001;I2 = 0%)]. Poor outcome in newborns in terms of incidence of preterm birth [OR 1.65(95% CI 1.54- 1.76;p < 0.00001;I2 = 86%)], fetal distress [OR 19.18(95% CI 17.14-21.45;p < 0.00001;I2 = 99%)] and still birth [OR 2.12(95% CI 1.74-2.59;p < 0.00001;I2 = 0%)], were also significantly associated with SARS-CoV-2 infection. Conclusions: SARS-CoV-2 infection during pregnancy increases the risk and severity of preeclampsia and gives a poor outcome in newborn.
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Case Report: A 25-year-old woman with history of Diamond-Blackfan anemia (DBA) presented with a 3- week history of weakness and fatigue. The patient was in her usual state of health until 3 weeks prior when she was diagnosed with COVID-19, at which time she experienced cough, congestion, weakness, and fatigue. She reported that the cough and congestion improved after a few days, but the fatigue and weakness progressively worsened. Admission labs were notable for a hemoglobin of 5.5 g/dL with a MCV of 119.3 fL. She received 2 units of packed RBCs with improvement in hemoglobin to 8.9 g/dL. The patient was diagnosed with DBA at birth via bone marrow biopsy and had been stable on chronic prednisone with a baseline hemoglobin around 8 g/dL. Prior to this admission, she has only required one transfusion at 3 months old. Her outpatient management involved close monitoring of her hemoglobin and increasing/decreasing prednisone based on her trending hemoglobin. She had been stable on 15 mg/day of prednisone for the past few years. Her hematologist was consulted, and the decision was made to increase her dose of prednisone to 20 mg/day resulting in resolution of symptoms and stabilization of her hemoglobin level. Discussion(s): We present a rare case of DBA with worsening anemia in the setting of a recent COVID-19 infection. The literature regarding the risk and complications of COVID-19 in these patients is severely limited, with no current data on disease management, outcomes, or predictors of morbidity. DBA is a rare, congenital erythroid red cell aplasia that typically presents in infancy with an estimated incidence of 5 cases per 1 million births. DBA is characterized by progressive macrocytic anemia, congenital malformations, and increased risk of endocrine dysfunction and malignancies. Glucocorticoids are the first-line therapy for DBA, although the exact mechanism of how they stimulate erythropoiesis in DBA remains unknown. In terms of patient prognosis, approximately 40% are steroid-dependent, 40% are transfusiondependent, and 20% go into remission by age 25 years. Copyright © 2023 Southern Society for Clinical Investigation.
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Background. This study was inspired by the sudden unexplained increase in pediatric amputations during the SARSCoV- 2 pandemic. Method(s): With appropriate IRB approval, pathology files were searched for all amputations from Jan 2017 to May 2022. All available slides on thrombotic amputations of 2020 and 2021 were reviewed. Additional immunohistochemical stains for CD3, CD20 and CD163 were performed. Medical records were reviewed. Result(s): Total yearly amputations from 2017 to 2020 ranged from 17 to 19;they increased to 26 in 2021. They remained stable in etiologies such as oncologic, diabetic, traumatic, congenital anomalies, and infectious, but rose for thrombotic/ischemic etiology. Between Jan 2020 and Oct 2021, 10 children (M:F 1:1), ranging from 36 days to 19 years in age underwent lower extremity amputations secondary to large vessel thrombosis (compared to 2 in 2017 and 0 for 2018-2019). All except 3 were previously healthy. Five were African American, 3 Caucasian, and 2 Hispanic. At admission, 4 were SARS-CoV-2 positive (RT-PCR), 2 showed elevated SARS-CoV-2 IgM antibody suggestive of recent exposure/infection, and 4 were negative or non-tested. One was vaccinated 6 months prior (2 doses) with reported recent COVID-19 exposure. Four had co-existing viral positivity including Influenza B, parainfluenza virus type 3, Parvovirus B19, and HSV-1. Six had secondary bacterial sepsis during the course of illness. At presentation, 8/10 had cardiac, renal and/or respiratory failure;6/10 showed all three. Seven were started on ECMO at or immediately after presentation. Elevation in BNP was seen in 7, CRP in 9, and ferritin in 7. All were diagnosed with compartment syndrome and underwent multiple fasciotomies before amputations. Tissue was available as thrombectomy, amputation specimens, and autopsy. Admission to amputation interval ranged from 2 days to 3.5 months. Three patients died of multiorgan failure. Histopathology review showed microthrombi (10/10), medium/large vessel thrombi (10/10), intravascular macrophages (9/10), extravascular macrophages (9/10), vasculitis (6/10), and myositis (5/10). Histologic lympho- and hemophagocytosis was seen in 7/10 cases. Immunostains showed scant T and B cells with abundance of CD163 positive foamy macrophages. No such cases have been seen since Oct 2021 to May 2022. Conclusion(s): Sudden unexplained rise in pediatric amputations was noted during the SARS-CoV-2 pandemic. Histopathology showed large, medium and small vessel thrombosis. Clinical elevation of inflammatory markers in conjunction with histologic abundance of macrophages and occurrence of lympho- and hemophagocytosis suggests macrophage activation syndrome as a likely thrombotic etiology.
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An 86-year-old woman with a recent hospitalization for severe coronavirus disease 2019 (COVID-19) infection presented to the emergency department with abdominal discomfort and bilateral leg swelling. She was mildly tachycardic on physical exam, with superficial abdominal vessel dilation and bilateral lower extremity edema. Her laboratory results were significant for a mildly elevated lipase of 260 U/L (normal range: 0-160 U/L) and a positive COVID-19 PCR test. CT of the abdomen and pelvis did not show any pancreatic abnormality but revealed a duplicated inferior vena cava (IVC) with a thrombus located in the right IVC. The patient was subsequently placed on full-dose anticoagulation with the eventual achievement of clot lysis. It appears that the incidence of thrombosis, including IVC thrombosis, has been on the rise due to COVID-19-associated coagulopathy; therefore, a high index of clinical suspicion in these cases may prove to be lifesaving.
ABSTRACT
Birth chest circumference(CC) shows often, like birth gestational age(GA), tight direct relations to birth body weight(BW). However distinct connections of hypoxia/undernutrition with different body structures might be suspected based on brain-, heartand adrenal-sparing following intrauterine growth restriction and, postnatally, on higher chest size for body mass observed at high altitude. Growth retarded fetuses gestated by hypoxic rats may present increments of blood serum Insulin-like Growth Factor Binding Protein(IB) 2, but not of IB3. Relevance of human newborn(NWB) CC/BW ratio(i.e., CC through BW, CC/BWR) to relationships between BW<=10.th centile for GA(SGA), and IB2/ IB3 ratio(IB2/IB3R) was evaluated. NWBs with any among total parenteral nutrition, parenteral nutrition other than dextrose, blood component transfusion, postnatal corticosteroid-, catecholamine- or methylxantine-based treatments, life-threatening disease, diabetes mellitus(DM) or other endocrine diagnosis, malformation, and mother with DM were excluded. 78 included NWBs, all studied before covid-19 pandemic and from conception to study end near sea-level, had complete data for 1) same-day records at one of the first 5 postnatal days(x), 5 days after x(y) and 10 days after x(z) of postnatal age(PNA, unit:day), IB2 and IB3 radioimmunoassay(unit=uM/dl), and for 2) gender(SEX), GA(unit: complete week;extremes=28-42), GA<=36 present(PTB, n=46), CC(25th-75th centiles=27-32cm), BW(25th-75th centiles=1926-2942g), and SGA(n=20)(computations;male SEX(n=43), SGA;condition absent=0, condition present=1). SPSS-27 software was used to generate GA-unrelated CC/BWR standardized residuals(CC/BWRsr)(i.e., Linear regression procedure- Save pushbutton/ Standardized residual checkbox-Continue pushbutton/ regress CC/BWR on only GA). IB2/IB3R(i.e., IB2 through IB3) calculated at x-y-z time-poins, was averaged(i.e., (x+y+z)/3;IB2/IB3RM). IB2/IB3RM normal scores according to Van der Waerden(IB2/IB3RM-NS) were normally distributed. SGA evidenced significantly higher CC/BWR, CC/BWRsr and IB2/IB3RM than non-SGA(Mann-Whitney Test). Spearman rank correlations between the following variable pairs are reported(Rho;significance): GA vs CC/BWR(-.706, p<.0001), GA vs CC/BWRsr (-.024;p=.8315), GA vs IB2/IB3R(-,409;p=.0002), CC/BWRsr vs IB2/IB3R(.346;p=.0019). Partial correlation(pc) coefficient(pcc) of SGA pc with outcome IB2/IB3RM-NS in multiple linear regression(MLR) was significant (t=4.194, p<.0001, pcc=.565) with SEX-GA-SGA-PNAx as predictors, but non-significant with SEX-GA-SGA-CC/BWRsr-PNAx as predictors(MLR R2, .447- .492, always significant). CC/BWRsr could be involved in direct relationships between SGA and IB2/IB3RM-NS after controls including GA in not-life-threatened NWBs.
ABSTRACT
Birth chest circumference(CC) shows often, like birth gestational age(GA), tight direct relations to birth body weight(BW). However distinct connections of hypoxia/undernutrition with different body structures might be suspected based on brain-, heartand adrenal-sparing following intrauterine growth restriction and, postnatally, on higher chest size for body mass observed at high altitude. Low BW and hypoxia may be associated with circulating Insulin-like Growth Factor-I(IG1) lower levels. Relevance of human newborn(NWB) CC/BW ratio(i.e., CC through BW, CC/ BWR) to relationships between BW<=10.th centile for GA(SGA), and blood serum IG1(IG1s) was evaluated. NWBs with any among total parenteral nutrition, parenteral nutrition other than dextrose, blood component transfusion, postnatal corticosteroid-, catecholamine- or methylxantine-based treatments, life-threatening disease, diabetes mellitus(DM) or other endocrine diagnosis, malformation, and mother with DM were excluded. 78 included NWBs, all studied before covid-19 pandemic and from conception to study end near sea-level, had complete data for 1) same-day records at one of the first 5 postnatal days(x), 5 days after x(y) and 10 days after x(z) of postnatal age(PNA, unit:day) and IG1s radioimmunoassay(unit=uM/dl), and for 2) gender (SEX), GA(unit:complete week;extremes=28-42), GA<=36 present(PTB, n=46), CC(25th-75th centiles=27-32cm), BW(25th-75th centiles=1926-2942g), BW standard deviation scores(BW-SDS), and SGA(n=20)(computations;male SEX(n=43), SGA;condition absent=0, condition present=1). SPSS-27 software was used to generate GA-unrelated CC/BWR standardized residuals(CC/ BWRsr)(i.e., Linear regression procedure-Save pushbutton/ Standardized residual checkbox-Continue pushbutton/ regress CC/BWR on only GA). IG1s at x-y-z time-points was averaged (i.e., (x+y+z)/3;IG1sM). IG1sM normal score according to Van der Waerden(IG1sM-NS) resulted normally distributed. Mann- Whitney Test: PTB did not differ significantly from non-PTB for CC/BWRsr;SGA showed significantly lower IG1sM than non- SGA. Spearman rank correlations between the following variable pairs are reported(Rho;significance): BW-SDS vs CC/BWR(-.361;p=.0012), BW-SDS vs CC/BWRsr(-.766;p<.0001), CC/BWR vs IG1sM(-.659, p<.0001), CC/BWRsr vs IG1sM(-.271, p=.0166). Partial correlation(pc) coefficient(pcc) of SGA pc with outcome IG1sM-NS in Multiple linear regression (MLR) was significant(t=-3.349, p<.0013, pcc=-.365) with SEX-GA-SGAPNAx as predictors, but was non-significant with SEX-GASGA- CC/BWRsr-PNAx as predictors (MLR R2, .486-.513, always significant). CC/BWRsr could be involved in inverse relationships between SGA and IG1sM-NS after controls including GA in NWBs free of life-threatenig disease.