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CD4+ T Cells from Preeclamptic patients with or without a history of COVID-19 during pregnancy cause hypertension, autoantibodies and cognitive dysfunction in a pregnant rat model Objective: Preeclampsia (PE) new onset hypertension (HTN) during pregnancy, is associated with increased autoantibodies, cerebral blood flow (CBF) impaired cognitive function and memory loss. We have shown adoptive transfer of placentalCD4+T cells from PE women into athymic nude pregnant rats causesHTNand autoantibodies associated with PE.COVID-19 (CV) during pregnancy is associated with increased diagnosis of PE. However, we do not know the role of CD4+ T cells stimulated in response to CV in contributing to the PE phenotype seen patients with a Hx of CV during pregnancy. Therefore, we hypothesize that adoptive transfer of placental CD4+ T cells from patients with a CV History (Hx) during pregnancy with PE causes HTN, increased CBF and cognitive dysfunction in pregnant athymic nude recipient rats. Study Design: Placental CD4+ T cells isolated from normotensive (NP), PE, Hx of CV normotensive (CV Hx NT), and Hx of CV with PE (CV Hx+PE) at delivery. One million CD4+ T cells were injected i.p. into nude athymic rats on gestational day (GD) 12. The Barnes maze and the novel object recognition behavioral assays were used to assess cognitive function on GDs 15-19. Blood pressure (MAP) and CBF were measured by carotid catheter and laser Doppler flowmetry on GD19, respectively. A two-way ANOVA was used for statistical analysis. Result(s):MAPincreased inCVHx+PE (111 +/- 4, n = 4) and PE recipient rats (115 +/- 2 mmHg, n = 5) compared to CV Hx NT (100 +/- 4, n = 5) and NP (99 +/- 3 mmHg, n = 4, P < .05). CV Hx+PE and PE exhibited latency with errors navigating in the Barnes maze compared to CV Hx NT and NP groups. Locomotor activity was decreased in CV Hx+PE (P < .05) compared to PE, CV Hx NT, and NP groups. CV Hx+PE and PE spent more time exploring identical objects compared to CV Hx NT and NP groups. PE and CV Hx+ PE had increased CBF compared to CV Hx NT and NP rats. Conclusion(s): Our findings indicate that pregnant recipients of CD4+ T cells from PE with or without a Hx CV during pregnancy cause HTN, increased CBF and cognitive dysfunction compared to recipients of NP or NT Hx COVID-19 CD4+ T cells.
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INTRODUCTION AND OBJECTIVE: We performed a shamcontrolled, randomized prospective trial in men with ED using an electrohydraulic shockwave device FDA cleared for connective tissue activation and improved blood flow. METHOD(S): This single-blind study was performed in men with ED naive to acoustic wave and shockwave therapy. Patients were randomized to treatment and assigned to active low intensity shockwave therapy (LiSWT) (4 Hz, 0.12 mJ/mm2) or sham treatment, 2:1. Arm 1 consisted of 3 treatments of 5000 shocks every 3 weeks. Arm 2 consisted of 5000, 3000, and 3000 shocks during weeks 1, 2, and 3, respectively, followed by an identical cycle of treatment 3 weeks later. Doppler ultrasound and grayscale imaging with a 15.4 MHz probe were performed under pharmacologic erection at weeks 20 and 32. Subjects completing sham treatment were unblinded and crossed over to the opposite arm for active treatment. Post-treatment end diastolic velocity (EDV) and peak systolic velocity (PSV) were measured, and visual grading scores were used to assess extent of hypoechoic regions in the corpora cavernosa. Data were analyzed by 2-way repeated measures ANOVA with Geisser-Greenhouse correction. Pairwise comparisons were performed to baseline used Dunnett's multiple comparison test. Missing data were imputed by "last observation carried forward". RESULT(S): Although powered for 60, recruitment was limited due to COVID and 36 subjects (22 active, 14 sham) were randomized. Sham treatments showed no significant changes in outcome measures. The number of subjects with improved visual grading scores in the proximal region was consistently higher in active LiSWT vs sham (Arm 1=88.9% vs. 11.1%;Arm 2=40.0% vs. 20.0%, respectively) with statistical significance in Arm 1 at weeks 20 (p=0.005) and 32 (p=0.001). Sham subjects rolled over to active LiSWT also had improved grayscale ratings (Arm 1=33.3% vs. 11.1%;Arm 2=40.0% vs. 20.0%). After LiSWT, greater numbers of patients had higher PSV, lower EDV, or no worsening of blood flow parameters relative to baseline. Decrease in EDV was statistically significant in active treatment Arm 2 at Week 32 (p=0.003). Mean IIEF-EF scores were nominally higher in subjects in active treatment who had improved visual grading scores vs those with no improvement. Adverse events were transient. CONCLUSION(S): Flaccid penile LiSWT appears to be safe and efficacious for treating ED based on statistically significant changes from baseline between sham and active treatments in primary outcome measures.
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Protein S is a multifunctional plasma protein, whose deficiency, results in a rare congenital thrombophilia, inherited in an autosomal dominant pattern. It can aggravate the hypercoagulable state of pregnancy, when it presents in parallel with the condition, leading to adverse maternal outcomes and foetal loss. A 35-year-old female third gravida having previous 2 deliveries by Lower Segment Caesarean Section (LSCS) presented to emergency at 10 weeks pregnancy with chief complaints of pain and swelling in left thigh since 4-5 days. After thorough investigations and work-up, the patient was diagnosed with Protein S deficiency. She was managed conservatively and was delivered by elective LSCS with bilateral tubal ligation at 38 weeks of gestation with good foetal and maternal outcomes.The rarity of Protein S deficiency along with the successful outcome of the pregnancy makes this a unique case.Copyright © 2023 Journal of Clinical and Diagnostic Research. All rights reserved.
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Background: Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder that occurs in a sporadic, nonhereditary pattern. It is caused by circulating autoantibodies against clotting factor VIII that are triggered by several conditions. Moreover, AHA is clinically distinct from the inherited form of hemophilia A, with a different natural history and management approach, necessitating a high-index of suspicion in at-risk patients. Coronavirus disease 2019 (COVID-19) has emerged as a multisystemic disease whose manifestations are continuously being evaluated. There are few case reports of AHA associated with COVID-19 infection, while one case of AHA has been associated with COVID-19 vaccination. Similarly, deep venous thrombosis (DVT) frequently complicates COVID-19 infection, but two cases of DVT have been reported following COVID-19 vaccination. We report the occurrence of both AHA and DVT in a 63-year-old male patient within one week of receiving his first dose of the Pfizer-BioNTech SARS-CoV-2 mRNA vaccine. Case Description: Patient is a 63-year-old male who presented with a 3-day history of left lower extremity (LLE) swelling and pain. He was hemodynamically stable, but examination showed exquisite tenderness, ecchymosis, and pitting edema at the calf of the LLE. He had normal platelet counts at presentation but had mild anemia (11.9 g/dL) and elevated activated partial thromboplastin time (APTT) of 68.0 seconds. Venous Doppler ultrasound showed acute DVT in the left popliteal vein, necessitating commencement on heparin drip. He developed progressively worsening hematomas, symptomatic anemia that required red cell transfusions, and persistently elevated APTT despite stopping the heparin drip. Work up for pulmonary embolism, malignancy, and disseminated intravascular coagulopathy (DIC) were negative. Antiphospholipid antibodies and lupus anticoagulant were also negative. He had low factor VIII levels, tested positive for factor VIII inhibitor, and PTT mixing studies were consistent with acquired factor inhibitor. Treatment involved administration of Factor Eight Inhibitor Bypassing Activity (FEIBA) as well as intravenous methylprednisolone and cyclophosphamide. Following resolution of active bleeding with evidence of stable hemoglobin concentration, he was discharged home on oral prednisone and cyclophosphamide. Conclusion(s): This case report highlights the possibility of AHA and DVT as rare, potentially life-threatening adverse events that could occur following COVID-19 vaccination, which is currently the most effective tool employed in controlling the COVID-19 pandemic.Copyright © Annals of Blood. All rights reserved.
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Introduction: SARS-CoV-2 is the cause of the recent pandemic. Although children are less affected by the virus, they can present with various presentations ranging from asymptomatic or fatigue and fever to multisystem inflammatory syndrome in children (MIS-C). Case Presentation: In this case report, we presented a case of a 9-year-old boy who presented with bilateral deep vein thromboses (DVTs) of the femoral and iliac veins as his main presentation of MIS-C, which occurred following a COVID-19 infection. A complete history was taken from the patient, and then a series of tests, including complete blood counts (CBCs), liver function tests (LFTs), and D-dimer, were performed. Bilateral doppler sonography to confirm the event and its location, as well as a decent follow-up method, were performed. Levels of anti-Xa assays followed the toxic levels of enoxaparin. The child was treated with a regimen of enoxaparin and corticosteroids, with a dosage of 1 mg/kg/12 h for both. The child was in the hospital for two weeks, after which he got better and was managed as an out-patient with a regularly scheduled appointment. Finally, once the radiologic evidence of DVTs was cleared, the patient tapered off his enoxaparin over the course of three weeks. Conclusion(s): Thrombotic events following COVID-19-associated MIS-C are an unlikely yet deadly event, especially in children. Prompt treatment with anticoagulants and corticosteroids alongside monitoring the patients are strongly advised.Copyright © 2022, Author(s).
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Introduction: Hughes-Stovin syndrome (HSS) is a systemic vasculitis characterized by pulmonary artery aneurysms (PAA) and widespread venous and arterial thrombosis. Fatalities in HSS resulted from unforeseeable fatal suffocating hemoptysis. It is critical to early detect pulmonary involvement to take timely measures against inevitable serious life-threatening complications. Case presentation: A 27 year old Filipino male patient presented to the emergency department with an acute attack of massive hemoptysis. The markers of inflammation were elevated with anemia and a normal coagulation profile. The patient had bilateral lower limb edema with tender calf muscles. Color Doppler ultrasound revealed bilateral deep vein thrombosis. Importantly, an urgent computerized tomography pulmonary angiography (CTPA) revealed bilateral large PAAs which matched the pattern of pseudoaneurysms described by the HSS international study group (HSSISG). There was no history of iridocyclitis, recurrent oral or genital ulcers. Accordingly, the patient was diagnosed with HSS. The patient received intravenous pulse methylprednisolone (1 g/3 days), then oral prednisone (1 mg/kg/d/3 months), and monthly pulse cyclophosphamide (1 g) for three months. The patient remained symptom-free, yet on the third pulse of cyclophosphamide;he patient contracted corona virus disease-2019 (COVID-19) infection and died three weeks later from a fatal episode of massive hemoptysis. The case was discussed and the recent literature was reviewed relative to fatal hemoptysis associated with pulmonary artery pseudoaneurysms (PAPs) pattern in HSS Conclusion(s): HSS presenting with massive hemoptysis could be lifethreatening and the PAPs are considered a double edged sword. Detailed description of such rare cases is warranted for optimum future management.Copyright © 2023
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The present work is focused on the study of changes in microcirculation parameters in patients who have undergone COVID-19 by means of wearable laser Doppler flowmetry (LDF) devices. The microcirculatory system is known to play a key role in the pathogenesis of COVID-19, and its disorders manifest themselves long after the patient has recovered. In the present work, microcirculatory changes were studied in dynamics on one patient for 10 days before his disease and 26 days after his recovery, and data from the group of patients undergoing rehabilitation after COVID-19 were compared with the data from a control group. A system consisting of several wearable laser Doppler flowmetry analysers was used for the studies. The patients were found to have reduced cutaneous perfusion and changes in the amplitude-frequency pattern of the LDF signal. The obtained data confirm that microcirculatory bed dysfunction is present in patients for a long period after the recovery from COVID-19.
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BACKGROUND: Endothelial dysfunction and microvascular disturbances are suggested to play a key role in higher morbidity and worse prognosis in patients with COVID-19 and cardiometabolic diseases. OBJECTIVE: Study was aimed to establish relationships between the skin microcirculation parameters and various clinical and laboratory indicators. METHODS: The study included 18 patients with moderate disease according to WHO criteria. Skin microcirculation measurements were performed by laser Doppler flowmetry using a heating test on the hairy skin of the right forearm. RESULTS: Baseline perfusion only correlated with C-reactive protein (Rsâ=â0.5, pâ=â0.034). Microcirculation indices characterising the development of hyperaemia during the first minute of heating (LTH1 and AUC60) showed significant correlations (Rs from 0.48 to 0.67, pâ< â0.05) with indices of general blood analysis and blood coagulation (fibrinogen, D-dimer, haemoglobin, erythrocyte count and haematocrit). Indexes characterising the dynamics of hyperaemia development over longer time intervals showed correlation with the glomerular filtration rate (Rsâ=â0.6, pâ=â0.009). CONCLUSION: Known COVID-19 risk factors (haemorheological parameters, age) are correlated with the microvascular reactivity to heating in patients with COVID 19. We suggest that, prospectively, the method of laser Doppler flowmetry could be used for non-invasive instrumental assessment of microcirculatory disorders in patients with COVID-19.
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Aim/Introduction: The etiology of SAT (subacute thyroiditis) is presumed to be usually viral (most commonly associated viruses include enterovirus, coxsackievirus, mumps, measles, and adenovirus). In this pandemic era, prevalence of SAT associated with the COVID 19 seems to be increasing either during or after the course of disease, characterized by neck pain or discomfort, goiter and transient hyperthyroidism. However, this is usually missed due to the wide spectrum of COVID syndrome, and a simple thyroid scan can be instrumental in diagnosing related thyroiditis. Material(s) and Method(s): We report 3 (1 male, 2 females) cases of thyroiditis detected using Tc99m pertechnetate scan. Thyroid scan was done 20 minutes after injection of 5 milicuries (170 MBq) of Tc99m pertechnetate and planar images were acquired. Result(s): 3 (1 male, 2 females) cases of thyroiditis detected using Tc99m pertechnetate scan. Mean age was 36.3 years. Symptoms such as goiter (n=1), neck pain and tenderness (n=2), weakness and fatiguability (n=3), palpitations (n=2), heat intolerance (n=1), restlessness (n=2) were observed along with raised T3, T4 hormone levels and suppressed TSH, 3-4 months after COVID infection (mean duration 3.3 months). Other possible causes of thyroiditis and drug interference were ruled out. Thyroid scan images revealed faint or absent tracer uptake in thyroid gland. Conclusion(s): The affinity of SARS-Cov-2 to the thyroid gland has been presumed via the ACE2 receptors which are more prevalent in thyroid cells than lung cells. Inflammatory response and apoptosis is another proposed factor. Ultrasound will show a normal or enlarged thyroid but typically, diffusely, or focally hypoechogenic, and the color Doppler sonography will demonstrate low flow but thyroid scan is easier to perform, is less user dependent and carries more diagnostic value. COVID related thyroiditis can present months after infection and is a part of long COVID syndrome. Possibility of post immunization also exists. Thyroid scan can be widely used in these scenarios.
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Background: Treatment of deep venous system obstruction of the lower limb is a challenge. There are few cases described in the literature even less with long-term follow-up which justifies this presentation. The objective is to report the case of a patient who underwent the May-Husni procedure for the treatment of femoral vein obstruction secondary to a stab wound with a 24-year follow-up. Method(s): Case report. Result(s): A 37-year-old male was stabbed in the left groin causing major bleeding and was operated on immediately 8 years ago. Since then he complained of edema, pigmentation, dermatofibrosis and recurrent ulcers in the left lower limb. Phlebography revealed femoral vein occluded from Hunter's canal to the saphenofemoral junction, obstruction of femoral vein, insufficient leg perforators, collateral venous circulation;the great saphenous vein (GSV) and external iliac vein were patent. He was operated on in 1997 and the left GSV was anastomosed to the popliteal vein above the knee (May-Husni procedure). The ulcers healed after 3 months with the help of compression therapy. After 18 months ulcer recurred. Echo color-doppler (ECD) showed four dilated perforating veins and patent saphenopopliteal anastomosis. Endoscopic subfascial perforation surgery (SEPS) was performed: The ulcer healed after 15 days. In 2019, another ulcer recurrence. During these 20 years patient became obese, diabetic and hypertensive. The ECD showed the saphenopopliteal anastomosis patent and GSV dilatated (11.4 mm) and insufficient with an insufficient dilated tributary in the middle third of the thigh finding several leg varicose tributaries.Ultrasound-guided foam sclerotherapy (UGFS) was performed under pharmacological prophylaxis for deep vein thrombosis (DVT) followed by compression therapy. The ulcer healed after one month. Patient was followed up until 2021 when he died of COVID-19. Conclusion(s): The ligation of veins in the deep venous system (DVS) can trigger severe manifestation and segmental obstructions should be restored;these restorations may have a high success rate and are durable;the patient must be accompanied throughout his life and treated as soon as the first signs of chronic venous disease appear.
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Background: University Hospitals Plymouth, NHS trust, is a teaching hospital which has been a venous thromboembolism (VTE) exemplar centre since 2010. Data on VTE events, whether hospital acquired (HAT) and radiology scans performed, has been collected since 2010. Aim(s): To review whether COVID had an impact on number of VTE events diagnosed, number of HAT events and radiological investigations performed. Method(s): Collect VTE outcome data from computed tomography pulmonary angiography (CTPA), ventilation perfusion scans (V/Q) and Doppler ultrasounds of upper and lower limbs. Review positive VTE events as to whether they meet criteria for HAT and compare outcome data for 2021 with an average from 2010 -2020. Result(s): In 2021 number of VTE events was 944, an increase of 153 (19%) over previous 11 years. HAT events were 206, increased by 17 (9%) though as a percentage of total VTE fell from 24% to 22%. Total pulmonary embolism (PE) was 590, increase of 136 (30%), although deep vein thrombosis (DVT) events were 354, representing an increase of 18 (5%). CTPA scans rose by 891 (41%) to 7021 though DUS remained similar with 2714 scans against an average of 2704 and VQ scans reduced to 339 compared with 545. Of the positive VTE events, 72 (8%) were associated with a COVID diagnosis and a significant number 67 (93%) being PE compared to 5 (7%) DVT. Conclusion(s): There is likely to be an association between VTE increase and shielding as well as positive COVID events causing a decrease in usual physical activity. It is not entirely clear why PE increased significantly but as COVID is a respiratory virus and causes significant inflammation within the lungs, this may have impacted on these figures. Initial review of data confirms no significant changes to VTE risk factors. We will continue to collect and monitor this data in 2022. (Table Presented).
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Category: Ultrasound Purpose: Lower limb deep vein thrombosis (DVT) causes significant morbidity, posing a diagnostic challenge. The National Institute for Health and Care Excellence (NICE) advises repeat ultrasound evaluation six to eight days after an initial negative scan, if the Well’s Score is ≥2 and D-dimer >230 ng/ml. Occasionally, in our trust, patients in whom symptoms improved have returned for repeat scans. We question the value in rescanning without clinical reassessment, aiming to investigate: a) the frequency of positive repeat scans and b) factors increasing the likelihood of DVT on the second scan. Our aims evolved in the context of the coronavirus (COVID-19) pandemic. Methods and materials: We evaluated 13 months of data (January 2018 to January 2019). Patients with two scans within six weeks (no DVT on initial scan and arranged as per NICE guidance) were selected. We retrospectively analysed data from the trust’s ultrasound database, the CDN radiology information system (CRIS) and electronic patient records system (PPM+). We analysed five months of data following the first UK COVID-19 lockdown (23 March 2020) to evaluate how the positive yield was impacted. Results: Pre-pandemic, of 1,006 patients (412 male, 594 female;age range 18–101), 19 had repeat ultrasound scans that were positive (1.9%). Following the UK national lockdown, of 170 patients, 11 were positive (6.5%). Conclusion: In the pre-lockdown setting, positive yield after a negative ultrasound is low (<2%). We support a clinical reassessment before rescan, combining persistent clinical suspicion with positive D-dimer. In a pandemic context, this has improved diagnostic yield (6.5%, p<0.01);however, long-term safety data is required.
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SESSION TITLE: Rare Cases with Masquerading Pulmonary Symptoms SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Paget-Schroetter (PS) syndrome, also known as venous thoracic outlet syndrome, is a primary thromboembolic sequela of compression of the subclavian vein. CASE PRESENTATION: A previously healthy 24 year old male presented with shortness of breath and cough. He had recently been exposed to COVID. He denied fever, diarrhea, vomiting, leg swelling, and rashes. On physical exam he was tachycardic, had no murmurs or JVD, and was CTAB with no wheezing or rales. Labs were significant for a WBC of 17k, and troponin of 0.033. CTA of the chest showed multiple filling defects in the pulmonary arteries consistent with Pulmonary Embolism (PE). He was started on a heparin drip. All COVID testing was negative. Lower extremity venous doppler ultrasounds (US) were negative for DVT. His respiratory status improved, and he was discharged on apixaban with the diagnosis of PE provoked by possible COVID infection. He returned approximately 2 months later with exertional dyspnea and upper extremity swelling and was found to have recurrent PE despite having been compliant with his apixaban. Upper extremity venous doppler US was significant for DVT in his right subclavian vein. He was placed on warfarin. At this time his hypercoagulable workup was also negative. Symptoms persisted despite being on warfarin with outpatient monitored INR. A venogram was ordered to evaluate upper torso blood flow. The venogram was remarkable for high-grade stenosis of the right subclavian vein. This finding led to the consideration of thoracic outlet syndrome aka Paget-Schroetter (PS). DISCUSSION: PS is a rare clinical entity that results from stress placed on the endothelium of the subclavian vein as it passes between the junction of the first rib and the clavicle. It can predispose otherwise healthy patients to recurrent venous thromboembolisms that are refractory to anticoagulation. The clinical features usually include upper extremity swelling and pain which is exacerbated by repetitive or strenuous exercise. Venous collaterals can also be seen in some patients. Evaluation should include some form of upper extremity Doppler and a CT/MR venogram or venography to make the final diagnosis. Treatment may involve anticoagulation, thrombolysis, and/or surgical decompression. Best results are seen with early thrombolysis and surgical decompression. If caught early and treated appropriately, PS has a good outcome with few long-term sequela. CONCLUSIONS: Our goal was to describe a patient with an uncommon cause for recurrent venous thromboembolisms that were refractory to anticoagulation. Our patient's presentation of PS serves to describe many aspects of the disease process, evaluation, diagnosis, and management as seen in the case presentation. The patient's demographic fit the epidemiological profile age of 20s-30s with typical imaging findings and pertinent negative workup which would lead providers to this rarer diagnosis. Reference #1: Saleem T, Baril DT. Paget Schroetter Syndrome. [Updated 2022 Jan 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK482416/ Reference #2: Alla VM, Natarajan N, Kaushik M, Warrier R, Nair CK. Paget-schroetter syndrome: review of pathogenesis and treatment of effort thrombosis. West J Emerg Med. 2010;11(4):358-362. Reference #3: Karl A. Illig, Adam J. Doyle, A comprehensive review of Paget-Schroetter syndrome, Journal of Vascular Surgery, Volume 51, Issue 6, 2010,Pages 1538-1547,ISSN 0741-5214, https://doi.org/10.1016/j.jvs.2009.12.022. DISCLOSURES: No relevant relationships by Jonathan Marks No relevant relationships by Zachary Stachura
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Background: Blood pressure (BP) management is imperative in reducing risk of adverse events in continuous flow (CF) left ventricular assist device (LVAD) patients. The gold standard for non-invasive blood pressure (BP) measurement in these patients is Doppler ultrasound, which requires training and dexterity and is not routinely used in the outpatient setting. In the current COVID-19 pandemic era, telehealth assessment has become mandatory to assess and monitor patients. At our institution, we have issued all CF-LVAD patients with a Doppler ultrasound device and an oscillometric BP monitor, and provided training to correctly use these devices. Accuracy of BP measurements in this setting has not been confirmed. Aim: We examined whether Doppler BP obtained by CF-LVAD patients (pts) correlates to Doppler BP obtained by health care workers (HCWs). Methods: CF-LVAD pts were recruited between November 2020 and January 2022. During these routine outpatient follow-up visits, Doppler BP measurements were obtained simultaneously and independently by pts and HCW. BP was taken in a comfortable seating position following 5 minutes rest. Results: A total 223 pairs of simultaneous patient Doppler BP readings and HCW Doppler BP readings were obtained from 38 CF-LVAD patients (87% male, mean age at implant 52 + 14 years, 15 HeartMate3 and 23 HeartWare HVAD, with support duration range 28 - 3492 days). Patient Doppler BP (average 85.9 + 9.8 mmHg) correlated closely with HCW Doppler BP (average 86.1 + 9.6 mmHg), r2=0.90, p<0.0001. There was no significant difference between BP taken by the patient and HCW (p=0.4). The mean difference between the two methods was -0.17 mmHg and the standard deviation was 0.22 mmHg (figure) using Bland-Altman analysis. Conclusions: These results demonstrate that in our patient-population, Doppler-derived blood pressure measurements in CF-LVAD patients were accurate and reliable. This supports the routine use of home Doppler BP measurement and monitoring by CF-LVAD patients, especially in the telehealth era. (Figure Presented).
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Introduction. The availability of an objective assessment of the microcirculatory bed is possible when examining the vessels of the conjunctiva. This is especially true in individuals who have had COVID-19 and have diseases associated with endothelial dysfunction. Aim. To study the microcirculation in the conjunctiva after a new coronavirus infection caused by the SARS-CoV-2 virus. Materials and methods. 83 patients with a history of coronavirus infection were examined. Patients were divided into 2 groups depending on the presence or absence of comorbidities. Group 1 patients (n = 42) with post-COVID changes in the conjunctiva (severe injection of the eyeball, chemosis, microhemorrhagia, folliculosis of the tarsal and bulbar conjunctiva, the presence of a nodular formation (conflicts), slight edema of the corneal epithelium) and a history of concomitant diseases: arterial hypertension, diabetes, coronary heart disease, atherosclerosis. Group 2 patients (n = 41) with no history of concomitant diseases and similar post-COVID changes in the conjunctiva. The control group consisted of healthy volunteers without a history of coronavirus infection (n = 30). All subjects underwent laser Doppler flowmetry of the bulbar conjunctiva 3, 6, 12 months after the coronavirus infection. Results and discussion. In comparison with the control group of persons after 3 months, microcirculatory disorders were detected in both groups (group 1 – subcompensated, group 2 – decompensated). In group 1, after 6 months and 12 months, violations persisted in the subcompensation stage, which were accompanied by an increase in the intensity of the functioning of the regulatory systems of the microcirculation: the M index corresponded to normal values, and the values of σ and Kv were above the norm. After 6 months in group 2, compensation of microcirculatory disorders was noted (indicators M, σ, Kv were normal), which persisted even by 12 months of observation. Conclusion. The data obtained indicate that in patients with concomitant endothelial dysfunction, the processes of restoration of the microvasculature are slowed down. © 2022, Remedium Group Ltd. All rights reserved.
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Objectives: Worldwide, Pfizer/BioNTech (BTN162b2) mRNA vaccine is now under massive use to be protected from COVID-19, although it may cause thrombotic thrombocytopenia in rare cases. Budd-Chiari syndrome (BCS) is a rare condition and is defined as the obstruction of hepatic venous outflow. Materials and Methods: A 34-year-old woman who was vaccinated with first dose of BTN162b2 6 weeks ago newly developed ascites, liver dysfunction, and thrombocytopenia. Results: Contrast-enhanced CT scan, doppler ultrasound, and hepatic venography showed complete obstruction of three major hepatic veins without membranous structure and without any collaterals, causing portal hypertension and liver dysfunction. Percutaneous liver biopsy showed diffusion dilation of sinusoids with extensive hepatocyte dropout, although there was no portal inflammation or fibrosis. The patient was treated with anticoagulants and intravenous immunoglobulin. After 6 weeks of anticoagulation, hepatic venous outflow became well detectable by doppler ultrasonography and ascites disappeared. Conclusion: This is a rare case of acute BCS with thrombotic thrombocytopenia after BNT162b2 mRNA vaccination.
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Thrombosis of the umbilical cord vessels is a rare complication of pregnancy, combined with a high level of perinatal morbidity and mortality. Anomalies of vascular attachment (velamentous attachment), pathology of the umbilical cord (hyperspiralization, short or long umbilical cord), intrauterine infections, maternal diabetes mellitus and preeclampsia as well as meconium found in the amniotic fluid are among the risk factors of developing thrombosis in the umbilical cord vessels. Here we present two clinical observations of umbilical vein thrombosis at full-term pregnancy. In both cases, during pregnancy and childbirth, no signs of umbilical cord pathology were found according to cardiotocography and Doppler ultrasound;despite this, the children were born in hypoxic state. Both newborns were transferred to the second stage of treatment due to suspected intrauterine pneumonia. Velamentous attachment, intrauterine infections as well as meconium found in the amniotic fluid were the risk factors of developing umbilical vein thrombosis described in case 1 and case 2, respectively. During pregnancy, both female patients suffered from clinically confirmed novel coronavirus infection (COVID-19) and contacted patients with COVID-19 in the third trimester of gestation. It is likely that endothelial damage caused by the novel coronavirus SARS-CoV-2 was one of the risk factors for the development of umbilical vein thrombosis, but this issue requires to be further explored.
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Introduction Objective evaluation of treatment response is the gold standard in ulcerative colitis (UC). In this setting, intestinal ultrasound (IUS) is a non-invasive alternative to endoscopy. Recent studies showed change in IUS parameters after treatment initiation but studies with an endoscopic reference standard are scarce. The aim of this study was to evaluate early change of IUS parameters and determine cut-off values for endoscopic endpoints in UC patients starting anti-inflammatory treatment. Methods In this longitudinal prospective study consecutive patients with moderate-severe UC (baseline endoscopic Mayo score (EMS)≥2) starting an anti-inflammatory treatment were included. Clinical scores, biochemical parameters and IUS parameters were collected at baseline, after 2 (T1), 6 (T2) and 8-26 weeks (T3) around time of the second sigmoidoscopy/colonoscopy. Bowel wall thickness (BWT), Colour Doppler signal (CDS), haustrations, inflammatory fat and wall layer stratification were measured as previously established1. Endoscopic remission (ER) and mucosal healing (MH) were evaluated in the sigmoid and defined as EMS=0 and EMS≤1, respectively. The ultrasonographist and endoscopist were blinded for the outcomes of endoscopy and IUS, respectively. Results 51 consecutive patients were included (Table 1) of whom 31 underwent a second endoscopy. Two additional patients underwent colectomy and were considered non-responders. 18 patients did not undergo second endoscopy due to the COVID-19 pandemic (n=2), refusal (n=5), loss to follow-up (n=1) or treatment escalation because of clinical deterioration confirmed by IUS and biomarkers before second endoscopy was performed (n=10). BWT was significantly lower from T2 onwards in patients reaching MH (p=0.026) and ER (p=0.002) at T3 (Fig 1). A significant decrease in BWT was already visible at T1 in patients receiving infliximab (median DBWT T0-T1: -26% [-43% - -6%], p=0.001) or tofacitinib (median ∆BWT T0-T1: -33% [-46% - -5%], p=0.001) but not in patients treated with vedolizumab (median ∆BWT T0-T1: -14% [-43% - 5%], p=0.11). Most accurate BWT cut-off values at T3 to determine MH and ER were 3.52 mm (AUROC: 0.95, 95% CI: 0.86-1.00, p<0.0001, sens:91%, spec:91%) and 2.98 mm (AUROC: 0.94, 95% CI: 0.85-1.00, p=0.001, sens:87%, spec:100%), respectively. At T2, BWT per 1 mm increase and CDS were inversely associated with MH (BWT: OR: 0.48 (0.24-0.96, p=0.038);CDS: OR 0.16 (0.03-0.83), p=0.028) and ER (BWT: OR: 0.30 (0.11-0.76), p=0.01). Conclusion BWT and CDS 6 weeks after start of treatment could predict MH and ER. In addition, treatment response at IUS is drug-specific. Furthermore, we have provided accurate BWT cut-off values for endoscopic outcomes. In a point-of-care setting, (early) treatment evaluation with IUS could guide treatment decision in UC in order to optimize treatment response. 1. Bots et al. JCC 2021
ABSTRACT
RATIONALE The COVID-19 pandemic led to rapid changes in care-delivery for intensive care unit (ICU) patients, due to factors including high ICU strain, shifting team member roles, and changes in care locations. As these changes may have not only impacted patients with COVID-19 but also critically ill patients without COVID-19, we assessed changes in common ICU practices for mechanically ventilated patients without COVID before and after the start of the COVID-19 pandemic. METHODS We used the Premier Healthcare Database to identify mechanical ventilated ICU patients in the US from January 1, 2016 - December 31, 2020. Patients were excluded if they had an ICD-10 diagnosis of COVID-19 (U07.1) or if they were admitted to a hospital that did not contribute data for all five years. We assessed annual rates of common ICU imaging studies (chest CT scan, chest x-ray, lower extremity doppler ultrasound), bedside diagnostics (electrocardiogram, electroencephalogram), and bedside procedures (arterial line, central venous catheterization, bronchoscopy) and annual mortality rates. We used interrupted time series analysis, adjusted for seasonality and autocorrelation where present, to evaluate trends in ICU practices prior to the pandemic (March 2016 - February 2020), at the onset of the pandemic (April 2020) and as the pandemic progressed (April 2020 - December 2020). March 2020, as the US transitioned into the pandemic, was excluded from the analysis. RESULTS We identified 584,393 mechanically ventilated patients without COVID- 19 at 509 hospitals. Trends in ICU procedures and mortality are illustrated in Figure 1. At the onset of the pandemic, use of chest x-ray (-35.6% [-53.5 to -17.8%, p<0.001]), electrocardiogram (-14.8% [-21.9 to -7.6%, p<0.001]), and bronchoscopy (-1.2% [-1.8 to -0.6%, p<0.001]) decreased;rates of lower extremity doppler (-1.8% [-4.1 to -0.5%, p=0.12]), electroencephalogram (-0.8% [- 1.7 to 0.1%, p=0.09]), arterial lines (-0.09 [-1.0 to 0.9%, p=0.85]) and central venous catheters (+0.2 [-1.3 to 1.7%, p=0.77]) did not significantly change;use of chest CT increased 2.6% (0.9 to 4.3%, p=0.001). With the exception of chest CT, arterial lines, and central venous catheters, trends in all other measured procedures increased as the pandemic progressed, compared with pre-pandemic trends. There was no significant trend change in mortality at the onset of the pandemic or during the pandemic. CONCLUSIONS Multiple practice patterns changed among patients without COVID-19 early during the pandemic. However, no change in mortality was seen during this time. These findings warrant further investigation to determine their impact on patientcentered outcomes.