Isometric thumb extension exercise as part of a multimodal intervention for de Quervain's syndrome: A randomised feasibility trial

Introduction: de Quervain's syndrome is a painful condition commonly presented to hand therapists. Exercise is utilised as an intervention, but isometric exercise has not been investigated. We aimed to assess the feasibility and safety of isometric thumb extension exercise for de Quervain's syndrome and to explore differences between high-load and low-load isometric exercise. Method(s): This parallel-group randomised clinical feasibility trial included individuals with de Quervain's syndrome. All participants underwent a 2 week washout period where they received an orthosis, education, and range of motion exercises. Eligible participants were then randomised to receive high or low-load isometric thumb extension exercises, performed daily for 4 weeks. Feasibility and safety were assessed by recruitment and drop-out rates, adherence, adverse events, and participant feedback via semi-structured interviews. Secondary outcomes included patient-reported outcomes for pain and function, and blinded assessment of range of motion and strength. Result(s): Twenty-eight participants were randomised. There were no drop-outs after randomisation, and no serious adverse events. Adherence to exercise was 86.7%, with 84% of participants stating they would choose to participate again. There were clinically and statistically significant improvements in pain and function over time (p < 0.001) but not in range of motion or strength. There were no statistically significant between-group differences. Conclusion(s): Isometric thumb extension exercise within a multimodal approach appears a safe and feasible intervention for people with de Quervain's syndrome. A large multi-centre trial would be required to compare high- and low-load isometric exercises. Further research investigating exercise and multimodal interventions in this population is warranted.Copyright © The Author(s) 2023.

Awareness and Knowledge of Carpal Tunnel Syndrome among Adult Saudi Population

Introductions: The median nerve's occasional or persistent compression or entrapment in the carpal tunnel from the wrist to the hand causes carpal tunnel syndrome (CTS). The main symptoms are pain, tingling, swelling, and loss of grip strength and function in the thumb, index finger, middle finger, and thumb of thumb. This study examined Saudi adults' awareness and understanding of Carpal Tunnel Syndrome and its link with demographics and chronic conditions. Material(s) and Method(s): This cross-sectional study examined adults' knowledge, attitudes, and practices regarding carpal tunnel syndrome from 2021 to 2022 in different Saudi Arabian regions. This study used a researcher-created questionnaire. In the awareness category, general public questions included CTS clinical aspects, etiology, and effects on daily life. Practice questions covered CTS preventive and chronic diseases. Volunteers were selected following informed consent. Result(s): 420 participants aged 34.8 +/- 13.49 years. 280 (66.6%) were male, 140 (33.3%) females. 38 (9.04%) were non-Saudi workers, while 384 were Saudis. 235 (55.9%) individuals knew about wrist CTS and 161 (38.3%) about pain. 157 (37.3%) individuals experienced thumb tingling or numbness, while 117 and 142 agreed that CTS may produce thumb weakness (27.8%) and hand grip (35.2%). The older age group reported more thumb numbness or tingling than the other groups, although there was no statistical difference (p= 0.09). CTS was not associated with chronic disease;however, diabetes was the main comorbidity in all age groups (44;45.3%), especially in the middle age group (21;60%). 5.4% had CTS. CTS was rare during pregnancy (0.7%), however all age groups agreed that it could influence their employment and social life (p= 0.014 and < 0.00001). The average knowledge score was 43.3 +/- 40.5, whereas the awareness score was 50.1 +/- 44.2. These findings indicate that Saudis were aware of CTS clinical symptoms. Conclusion(s): The study examined Saudi adults' awareness and understanding of CTS and estimated the association between CTS and demographics and chronic conditions. The study found that adult CTS awareness and knowledge were sufficient and associated with age and quality of life. CTS awareness campaigns may lower risk and raise knowledge of prevention and treatment. People who work with discomfort or use computers for long periods of time without breaks are more prone to develop CTS. Larger research is needed to understand how physical exercise causes CTS.Copyright © 2023, Ibn Sina Trust. All rights reserved.

Chronic Chilblain Like Lesions Associated with the Covid-19 Pandemic

Background/Aims We report the features of chronic chilblain-like digital lesions newly presenting since the start of the covid-19 pandemic. Comparison with primary perniosis and acrocyanosis, reveals a unique phenotype which appears to be a long-covid phenomenon. Methods The case records of 26 patients with new onset persistent chilblain-like lesions presenting to the Rheumatology service of St George's University Hospital, London between Autumn 2020 and Spring 2022 were reviewed. Demographic and clinical features, serology, imaging, treatment response and outcome up to Summer 2022 were collated retrospectively. Results Chilblain-like lesions first occurred between September and March;2019/ 2020 6 cases, 2020/2021 18 cases and 2021/2022 2 cases. Mean age 35.4 (17-60) years, 88% female, 85% white, all non-smokers. Median body mass index (BMI) 20.2, range 17.0 - 33.2. BMI underweight (<18.5) in 27%. All cases reported new red-purple-blue colour changes of the fingers, some with pain, swelling and pruritis, affecting both hands in 12, one hand in 6, and both hands and feet in 8 cases. There was a past history of cold sensitivity or primary Raynaud's in 54%. Covid was confirmed in 3 cases, 2 - 8 months prior to onset of chilblain-like symptoms. Possible covid, unconfirmed, was suspected in 5 cases, 1 - 11 months earlier. Affected digits appeared diffusely erythro-cyanotic in 81%, with blotchy discrete maculo-papular erythematous lesions in 42%, some with both features. Involvement was asymmetric in 54%, thumbs spared in 69%. Complement was low in 50% (8/16), ANA positive in 26% (6/23). MRI of hands showed phalangeal bone marrow oedema in keeping with osteitis in 4 of 7 cases. More severe signs and symptoms were associated with low BMI, low C3/4 and a past history of cold sensitivity or Raynauds. Cold avoidance strategies were sufficient for 58%. Pain prompted a trial of NSAIDs, aspirin, nitrates, calcium channel blockers, hydroxychloroquine, oral or topical corticosteroid or topical tacrolimus in 42%. In general, these were minimally effective or not tolerated. 4 severe cases received sildenafil or tadalafil, effective in 2. In 27% complete remission occurred during the first summer season after symptoms commenced, median duration 6 (range 2 - 10) months. In the remaining 19 cases, chilblain-like symptoms returned or worsened in the subsequent second winter period, with 6 of 19 entering remission the following summer. For the remaining 13 persistent cases the total duration of symptoms spans more than a year, and in four cases more than 2 years. Conclusion This series illustrates a distinct chronic chilblain-like condition. Features similar to primary perniosis include female predominance, middle age, pruritic painful blotchy lesions, asymmetry and low BMI. Features in keeping with acrocyanosis include chronicity, extensive diffuse erythro-cyanotic discoloration, relative improvement in warm weather and lack of association with smoking.

Output force and ratio of laparoscopic graspers: an evaluation of operating room ergonomics.

BACKGROUND: "Laparoscopist's thumb," or thenar paresthesia, can result from prolonged or excessive grip force during laparoscopy, as can more general syndromes, such as carpal tunnel syndrome. This is particularly relevant in gynecology, where laparoscopic procedures are standard. Although this method of injury is well known, there is a paucity of data to guide surgeons in selecting more efficient, ergonomic instruments. OBJECTIVE: This study compared the ratio of applied tissue force and required surgeon input in a sample of common ratcheting laparoscopic graspers in a small-handed surgeon, to provide potential metrics applicable to surgical ergonomics and surgeon instrument choice. STUDY DESIGN: Laparoscopic graspers with varied ratcheting mechanisms and tip shapes were evaluated. Brands included Snowden-Pencer, Covidien, Aesculap, and Ethicon. A Kocher was used as an open instrument comparison. Flexiforce A401 thin-film force sensors were used to measure applied forces. Data were collected and calibrated using an Arduino Uno microcontroller board with Arduino and MATLAB software. Single-handed, complete closure of each device's ratcheting mechanism was performed 3 times. The maximum required input force in Newtons was recorded and averaged. The average output force was measured with a bare sensor and the same sensor between 2 different thicknesses of LifeLike BioTissue. RESULTS: The most ergonomic ratcheting grasper for a small-handed surgeon was identified by the output ratio: the highest output force relative to the required surgeon input (the most force for the least amount of effort). The Kocher required an average input force of 33.66 N, with its highest output ratio of 3.46 (112 N output). The Covidien Endo Grasp was the most ergonomic, with an output ratio of 0.96 on the bare force sensor (31.4 N output). The Snowden-Pencer Wavy grasper was the least ergonomic, with an output ratio of 0.06 when applied to the bare force sensor (5.9 N output). All graspers except for the Endo Grasp had improving output ratios as tissue thickness and subsequent grasper contact area increased. Input force above that provided by the ratcheting mechanisms did not increase output force in a clinically relevant amount for any of the instruments evaluated. CONCLUSION: Laparoscopic graspers vary widely in their ability to provide reliable tissue force without requiring excessive input by the surgeon, and a point of diminishing returns often exists with increased surgeon input over designed ratcheting mechanisms. Output force and output ratio are potential quantitative measures of the efficiency of laparoscopic instruments. Providing users with this type of data could assist in optimizing instrument ergonomics.

Single Use Flexible Bronchoscopy: An ex-vivo comparison of all commercially available scopes

The development of single use flexible bronchoscopes (SUFB) has proceeded with pace over the last 2 years. Concerns regarding infection related to standard bronchoscopes with subsequent COVID-19 pandemic accelerated global uptake with multiple companies releasing SUFB. There has been no ex-vivo comparison of SUFBs to date. We obtained samples of all commercially available SUFBs (TSC© , Boston Scientific©, Ambu©, Vathin© and Pentax © prototype SUFB). We compared technical metrics using a custom-built bench toolkit engineered to allow standardisation. Angulation was analysed by a force meter to ascertain the effort needed to fully flex the scopes while empty and while accessed by both a forceps and cytology brush. The Ambu aScope 4 has the best performance in measured thumb force (Mean 4.15Nm/100 ). The Pentax EB15- S01 has the smallest outer diameter and the largest working channel but has the greatest loss in angulation when its working channel is occupied (-33 / -67 , -100 ). The Pentax EB15-S01 deviated the most from its reported specifications. The Vathin H-SteriScope provided the most angulation overall, including with its working channel in use (180 / 186 , 366 ). This research helps to inform the practical usability of each bronchoscope when deciding which SUFB is best for the physicians intended end use. Further research should look at perceived qualitative assessment of SUFB by clinicians.

WashRing: An Energy-Efficient and Highly Accurate Handwashing Monitoring System Via Smart Ring

The outbreak of COVID-19 has greatly changed everyone's lifestyle all over the world. One of the best ways to prevent the spread of infections is by washing hands properly. Although a number of hand hygiene monitoring systems have been proposed, they either cannot achieve high accuracy in practice or work only in limited environments such as hospitals. Therefore, a ubiquitous, energy-efficient and highly accurate hand hygiene monitoring system is still lacking. In this paper, we present WashRing—the first smart ring-based handwashing monitoring system. In WashRing, we design a Partially Observable Markov Decision Process (POMDP) based adaptive sampling approach to achieve high energy efficiency. Then, we design an automatic feature extraction scheme based on wavelet scattering and a CNN-LSTM neural network to achieve fine-grained gesture recognition. Finally, we model the handwashing gesture classification as a few-shot learning problem to mitigate the burden of collecting extensive data from five fingers. We collect data from 25 subjects over 2 months and evaluate the system performance on both commercial OURA ring and customized ring. Evaluation results show that WashRing achieves 97.8%accuracy which is 10.2%–15.9%higher than state-of-the-arts. Our adaptive sampling approach reduces energy consumption by 64.2%compared to fixed duty cycle sampling strategies. IEEE

District-Coupled Epidemic Control via Deep Reinforcement Learning

The rapid spread of the Coronavirus (COVID-19) poses an unprecedented threat to the public health system and social economy, with approximately 500 million confirmed cases worldwide. Policymakers confront with high-stakes to make a decision on interventions to prevent the pandemic from further spreading, which is a dilemma between public health and a steady economy. However, the epidemic control problem has vast solution space and its internal dynamic is driven by population mobility, which makes it difficult for policymakers to find the optimal intervention strategy based on rules-of-thumb. In this paper, we propose a Deep Reinforcement Learning enabled Epidemic Control framework (DRL-EC) to make a decision on intervention to effectively alleviate the impacts of the epidemic outbreaks. Specifically, it is driven by reinforcement learning to learn the intervention policy autonomously for the policymaker, which can be adaptive to the various epidemic situation. Furthermore, District-Coupled Susceptible-Exposed-Infected-Recovered (DC-SEIR) model is hired to simulate the pandemic transmission between inter-district, which characterize the spatial and temporal nature of infectious disease transmission simultaneously. Extensive experimental results on a real-world dataset, the Omicron local outbreaks in China, demonstrate the superiority of the DRL-EC compared with the strategy based on rules-of-thumb. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

eP455: Fetal ultrasound presentation and neonatal diagnosis of Freeman-Sheldon syndrome in son of previously undiagnosed adult male

Background: Freeman-Sheldon syndrome [distal arthrogryposis type 2A (OMIM #193700), DA2A, Freeman-Burian syndrome] is a rare autosomal dominant multiple pterygium syndrome caused by alterations in MYH3. The phenotypic features, particularly of the face, are distinct and easily recognizable, and the diagnosis can be confirmed with molecular gene analysis. Fetal ultrasound imaging may provide important diagnostic clues to facilitate the diagnostic process. Informed consent and parental permission were provided by the parents. Case presentation: The infant’s mother presented for a Maternal Fetal Medicine genetic counseling telehealth appointment (due to COVID-19 pandemic restrictions) as a G7P2132, 32-year old female who had insulin-dependent diabetes and thrombocytosis. Her partner was a 24-year old male with a history of hearing loss, a V-shaped palate, and a lower lip cleft. Gestational age was 14 4/7 weeks and the indications were: increased nuchal translucency, paternal complex medical history, maternal G6PD heterozygote, and recurrent pregnancy loss. During the genetic counseling session, the following were addressed: 1) Maternal heterozygote status for G6PD indicated that if the fetus was male, there was a 50% chance he would be affected with G6PD-deficiency;2) Increased nuchal translucency on fetal ultrasound (US) with measurement at 98th percentile is associated with an increased risk of chromosomal abnormalities, microdeletion/duplications, and Noonan syndrome. The patient reportedly had low risk cell-free DNA but results were not available to the counselor at the time of consult. The option for additional genetic screening and diagnostic testing was declined;3) Three first trimester pregnancy losses with the father of this baby (FOB) were addressed, and parents deferred chromosome analyses at the time;4) Mother shared FOB’s complex history of bilateral sensorineural hearing loss, V-shaped cleft palate, lower lip cleft, and micrognathia. However, father was not present during the telehealth encounter. Mother was counseled regarding the possibility of an autosomal dominant condition with the potential risk to the pregnancy of up to 50%. It was recommended that the FOB have a clinical genetics evaluation, which could potentially provide a specific diagnosis and inform recurrence risk and management guidance. Follow-up MFM genetic counseling telephone visit occurred with the mother at 31 6/7 weeks gestation due to multiple congenital anomalies evident on fetal ultrasound. A 25 week fetal ultrasound revealed hypotelorism and a thickened nuchal translucency. A repeat study at 29 weeks revealed a V-shaped palate with a possible cleft, micrognathia, and midline mandibular cleft. FOB’s history was revisited. It was determined that he had 3 previous “no shows” to Genetics clinic appointments and did not pursue evaluation after the last counseling appointment. Again, it was emphasized that in order to best make a diagnosis for the family, an affected person would need to undergo a thorough evaluation, including medical and family history review, physical examination, and any indicated genetic testing. The parents were comfortable with the likelihood that the baby had the same condition as the father, but variable expressivity and broad range pf phenotypic presentation were explained. Recommendations for postnatal evaluation of the infant and pertinent genetic testing were provided. Consultative Genetics evaluation of the infant at 2 days of age revealed a short, broad forehead with supraorbital fullness leading to a horizontal brow indentation;mask-like facial appearance;hypotelorism;very deep set eyes with blepharophimosis;deep, creased nasal bridge;small, upturned nose with hypoplastic alae and narrow nares;microstomia with pursed lips;glossoptosis;micrognathia;2 deep vertical chin creases;short neck with excess nuchal skin;inverted and wide spaced nipples;clenched hands with 5th digits overlying 4th and 2nd overlying 3rd, bilaterally;bilateral vertical talus;2nd toes longer and overlying rd toes;clinodactyly of 4th and 5th toes bilaterally;and deep gluteal crease with no visible sinus. There were no evident contractures. The father has a complex history with no medical assessments prior to age 18. He reported that he did “not look like anyone else” in his family. He has a diagnosis of autistic spectrum disorder, a submucous cleft, vision issues, hearing loss necessitating a hearing aid on the left, and a history of cholesteatomas and of mastoidectomy. On brief examination, he had a mask-like face, blepharophimosis, left microphthalmia, left esotropia, narrowing of his midface, deep vertical crease on the mandibular region, microstomia, broad great toes, single flexor creases on the thumbs, and contracture of right thumb. Maxillofacial CT of the infant revealed hypoplastic mandibular body, ramus, and condyles bilaterally with micrognathia and retrognathia;hypoplastic maxilla bilaterally;and enophthalmos with retracted appearance of globes in the bony orbits bilaterally. Multiple facial bone abnormalities were seen, including microsomia, micrognathia, retrognathia, orbital hypotelorism and enophthalmos Genetic testing was performed via a custom Whole Exome Slice at GeneDx laboratories and included the MYH3 and TNNI2 genes. Results revealed a heterozygous pathogenic change in MYH3 (c.2015 G>A;p. R6724) consistent with the diagnosis of Freeman-Sheldon syndrome. Conclusion: The presentation of “midline mandibular cleft” on fetal ultrasound was the most specific prenatal finding. This is a very rare fetal finding. Thus, it should prompt further evaluation to assess for true clefting versus ridging or creasing. Additionally, targeted assessment for other findings or clinical clues for Freeman-Sheldon syndrome, such as contractures, “windmill vane” hand, and mouth size, could aid in the differential diagnosis considerations and the diagnostic process. Admittedly, these are position and quality dependent, and are challenging to assess even in ideal situations. The phenotype of the father was immediately recognizable. However, due to COVID-19 pandemic restrictions, prior to the infant’s birth, only telehealth visits were conducted and the father’s participation was by telephone. This limited the ability to narrow the differential diagnosis without visualization of his distinct phenotypic features. Finally, missed opportunities to diagnose the father prior to this pregnancy occurred. Many clinics send “no show” letters to referring providers and patients, as we do. Emphasizing the importance of diagnosis prior to pregnancy for individuals concerned about having a genetic disorder should be considered as part of the information shared in these letters.

[Thumb-tack needles based on "Biaoben acupoint compatibility" for sequela of COVID-19 during recovery period].

OBJECTIVE: To observe the effect of thumb-tack needles based on "Biaoben acupoint compatibility" on sequela symptoms, mental state and pulmonary ventilation function in patients with coronavirus disease 2019 (COVID-19) during recovery period. METHODS: Fifty cases of COVID-19 during recovery period were randomly divided into an observation group and a control group, 25 cases in each group. The patients in the observation group were treated with thumb-tack needles at Guanyuan (CV 4), Zusanli (ST 36) and Taiyuan (LU 9). The patients in the control group were treated with sham thumb-tack needles at identical acupoints as the observation group. The treatment in the two groups was given once a day, 7-day treatment was taken as a course of treatment, and totally two courses of treatment were given. The TCM symptom score, Hamilton anxiety scale (HAMA) score, Hamilton depression scale (HAMD) score, pulmonary function (forced vital capacity [FVC], forced expiratory volume in the first second [FEV1], peak expiratory flow [PEF]), the severity of pulmonary ventilation dysfunction and pulmonary imaging changes in the two groups were compared before and after treatment. RESULTS: Compared before treatment, the total scores and each item scores of TCM symptom scale, HAMA scores and HAMD scores in the two groups were reduced after treatment (P<0.05). Except for the symptom scores of dry throat and dry stool, the total score and each item score of TCM symptom scale, HAMA score and HAMD score in the observation group were lower than those in the control group (P<0.05). Compared before treatment, FVC, FEV1 and PEF in the two groups were increased after treatment (P<0.05), and those in the observation group were higher than the control group (P<0.05). The severity of pulmonary ventilation dysfunction in the two groups was reduced after treatment (P<0.05), and the severity in the observation group was better than that in the control group (P<0.05). After treatment, the lung shadow area in the two groups was decreased (P<0.05), and that in the observation group was smaller than the control group (P<0.05). The improvement of imaging change in the observation group was better than that in the control group (P<0.05). CONCLUSION: The thumb-tack needles based on "Biaoben acupoint compatibility" could significantly reduce the sequela symptoms, anxiety and depression in patients with COVID-19 during recovery stage, and improve the pulmonary ventilation function.

Nailfold capillaroscopy: A sensitive method for evaluating microvascular involvement in children with SARS-COV-2 infection

Introduction: The coronavirus (SARS-CoV-2) pandemic, known as COVID-19 has spread all over the world in a short period of time and caused the death of more than 2 million people to date. Although in severe cases, it mainly progresses as a serious lung disease such as pneumonia or acute respiratory distress syndrome (ARDS), numerous extrapulmonary manifestations due to systemic hyperinflammation associated with COVID-19 have been described. The hyperinflammatory state and the viral invasion may result in endothelial dysfunction and capillaroscopic examination of the nailfold may be a feasible method for monitoring the microvascular circulation in SARS-CoV-2 infection. Objectives: With this study, we aimed to investigate the microvascular circulation in patients diagnosed with COVID-19 and multisystem inflammatory syndrome in children (MIS-C) by nailfold videocapillaroscopy (NVC). Methods: Thirty-one patients with SARS-CoV-2 infection, 26 of whom were diagnosed with COVID-19 and 6 with MIS-C, and 58 healthy peers were included in the study. All fingers except the thumbs were examined paying greater attention to the ring finger of the nondominant hand for the presence of any abnormality bilaterally and two images from eight fingers were obtained from both the study and control groups. Sixteen images were examined for the morphology of capillaries, presence of pericapillary edema, microhemorrhage, avascular area, and neoangiogenesis. These parameters were assessed as present or absent, and the presence of signs in at least two fingers was recorded as capillary abnormality in both groups. Capillary length, capillary width, apical loop, arterial and venous width, and intercapillary distance were measured from three consecutive capillaries from the ring finger of the non-dominant hand. Results: COVID-19 patients showed significantly more capillary ramification (p<0.001), capillary meandering (p=0.04), microhemorrhage (p<0.001), neoangiogenesis (p<0.001), capillary tortuosity (p=0.003). Capillary density (p=0.002) and capillary length (p=0.002) were significantly lower in the patient group while intercapillary distance (p= 0.01) was significantly longer compared with healthy volunteers. Morphologically, patients with MIS-C had a higher frequency of capillary ramification and neoangiogenesis compared with COVID-19 patients (p=0.04). Patients with capillary abnormalities had significantly higher levels of C-reactive protein (CRP) and D-dimer (CRP;16.4 vs 2.2, p=0.04 and D-dimer 900 vs 340, p=0.04). Conclusion: Children diagnosed with COVID-19 and MIS-C present with several microvascular abnormalities on NVC examination. MIS-C is an emergency phenomenon in which evidence suggests activation of ECs as the key determinant in the pathogenesis of the disease, and NVC may be a useful non-invasive, valid method for assessing the microcirculatory status of children with MIS-C. As a preliminary one, our study may take attention to the use of NVC for follow-up of patients with SARS-CoV-2 infection during clinical course and management.

Measurement of perfusion index of all the fingers of both the hands in healthcare volunteers: A cross-sectional study

Introduction: Perfusion Index (PI) is an indirect, non invasive and continuous method to measure peripheral perfusion. In case of circulatory shock, the peripheral tissue bed is assumed to be sacrificed first and reperfused last in resuscitation. Aim: To measure the peripheral PI from different fingers of both hands in healthy healthcare workers of a tertiary care hospital. Materials and Methods: A cross-sectional study was conducted in Coronavirus Disease- 2019 (COVID-19) designated healthcare hospital in January 2021. In this study, healthy volunteers with the age of 18-60 years were included. All the volunteers were evaluated with a pulse oximeter in all extremities of both the hands to check their PI. For significant results of repeated measure of ANOVA, post-hoc Bonferroni test were used to evaluate all multiple comparisons. All p-values <0.05 were considered significant. Results: A total of 96 healthcare volunteers with the mean age of 35.25±11.074 years were included in the present study. Majority of the population were male (80.2%). The highest perfusion was recorded in the right hand ring finger (8.59±4.03%). The lowest reading was noted in the right hand thumb (6.27±2.89%). The PI noted in the right thumb was significantly less than all the other fingers (p-value <0.05) except left thumb and left little finger (p-value >0.05). Conclusion: From this study, authors more emphasis on the choice of the finger during the measurement of PI because both highest and lowest perfusions were reported in the dominant hand.

Quantitative, semi-quantitative and qualitative nailfold videocapillaroscopy assessment of microvascular involvement in pediatric multisystem inflammatory syndrome temporally associated with SARS-COV-2

Introduction: Nailfold videocapillaroscopy (VCP) is an in vivo, noninvasive, rapid, and inexpensive imaging technique that allows quantitative assessment of microcirculation. Pediatric Multisystem inflammatory syndrome in children temporally associated with COVID-19 (MIS-C) affects small, medium and large vessels. Nailfold capillaroscopy findings as pericapillary edema, meandering capillaries and reduced capillary density has been described in adults patients with COVID-19. Case report shows non specific alterations however quantitative microcirculatory impairment has not been clearly documented in MIS-C. Objectives: To describe qualitative and semi-quantitative and quantitative nailfold videocapillaroscopy assessment in Mexican patients with pediatric Multisystem Inflammatory Syndrome temporally associated with SARS-CoV-2. Methods: The present study was a cross-sectional observational study that analyzed 40 images from 5 patients with Pediatric Multisystem Inflammatory Syndrome according the case definition published by Cattalini et al. VCP was performed by the same examiner (AVT), images were obtained from all fingers except thumbs of both hands using a videocapillaroscope equipped with a 200x optical probe. The images were collected, coded, and stored using OptiPix software (version 1.7.16), 2015 Optilia Instruments. Qualitative and semi-quantitative assessment were realized according Cutolo classification. Quantitative assessment consist in the measurement of the number of capillaries per millimeter, capillary loop length, capillary width in micron (μm). Results: 2 patients had coronary abnormalities, 1 valvular insufficiency, 1 myocarditis all patients received intravenous Immunoglobulin. 40 images of 5 patients with MIS-C (Image 1) were included in this series, all patients with Hispanic ethnicity and 60% male (n=5). The qualitative assessment did no reveal images with normal capillaroscopy pattern, nonspecific alterations were found in 100%, no pictures suggestive of sleroderma pattern-like have been observed. The semi-quantitative and quantitative assessment. Lower capillary density (4.8 capillaries/mm), increased capillary width in all patients 2nd Left medium 24.6μm, moderate edema in 90% (n= 36) of images, altered architecture 75% (n=30), peri-capillary stripping hemosiderin deposits probably due capillary leak 60% (n=24), tortuous capillaries 40%(n=16), bizzare capillaries 40% (n=16), meandering 75%(n=30) and irregular ectasias 90% (n=36). Conclusion: This study found qualitative and quantitative abnormalities in VCP suggesting systemic microvascular damage. Further studies are needed to asses the clinical relevance of VCP and its relationship with cardiac alterations and multisystemic damage in MIS-C.

Nailfold capillaroscopy: A sensitive method for evaluating microvascular involvement in children with SARS-COV-2 infection

Introduction: The coronavirus (SARS-CoV-2) pandemic, known as COVID-19 has spread all over the world in a short period of time and caused the death of more than 2 million people to date. Although in severe cases, it mainly progresses as a serious lung disease such as pneumonia or acute respiratory distress syndrome (ARDS), numerous extrapulmonary manifestations due to systemic hyperinflammation associated with COVID-19 have been described. The hyperinflammatory state and the viral invasion may result in endothelial dysfunction and capillaroscopic examination of the nailfold may be a feasible method for monitoring the microvascular circulation in SARS-CoV-2 infection. Objectives: With this study, we aimed to investigate the microvascular circulation in patients diagnosed with COVID-19 and multisystem inflammatory syndrome in children (MIS-C) by nailfold videocapillaroscopy (NVC). Methods: Thirty-one patients with SARS-CoV-2 infection, 26 of whom were diagnosed with COVID-19 and 6 with MIS-C, and 58 healthy peers were included in the study. All fingers except the thumbs were examined paying greater attention to the ring finger of the non-dominant hand for the presence of any abnormality bilaterally and two images from eight fingers were obtained from both the study and control groups. Sixteen images were examined for the morphology of capillaries, presence of pericapillary edema, microhemorrhage, avascular area, and neoangiogenesis. These parameters were assessed as present or absent, and the presence of signs in at least two fingers was recorded as capillary abnormality in both groups. Capillary length, capillary width, apical loop, arterial and venous width, and intercapillary distance were measured from three consecutive capillaries from the ring finger of the non-dominant hand. Results: COVID-19 patients showed significantly more capillary ramification (p<0.001), capillary meandering (p=0.04), microhemorrhage (p<0.001), neoangiogenesis (p<0.001), capillary tortuosity (p=0.003). Capillary density (p=0.002) and capillary length (p=0.002) were significantly lower in the patient group while intercapillary distance (p= 0.01) was significantly longer compared with healthy volunteers. Morphologically, patients with MIS-C had a higher frequency of capillary ramification and neoangiogenesis compared with COVID-19 patients (p=0.04). Patients with capillary abnormalities had significantly higher levels of C-reactive protein (CRP) and D-dimer (CRP;16.4 vs 2.2, p=0.04 and D-dimer;900 vs 340, p=0.04). Conclusion: Children diagnosed with COVID-19 and MIS-C present with several microvascular abnormalities on NVC examination. MIS-C is an emergency phenomenon in which evidence suggests activation of ECs as the key determinant in the pathogenesis of the disease, and NVC may be a useful non-invasive, valid method for assessing the microcirculatory status of children with MIS-C. As a preliminary one, our study may take attention to the use of NVC for follow-up of patients with SARS-CoV-2 infection during clinical course and management.