Long-term support of COVID-19 patients with veno-venous extracorporeal membrane oxygenation: Complications, predictors of mortality and long-term outcome

Objectives: Treatment of severe respiratory distress syndrome (ARDS) due to COVID-19 by veno-venous extracorporeal membrane oxygenation (VV-ECMO) had a mortality of up to 70% in Germany. Many patients with COVID-19 need VV-ECMO support longer than 28 days (long-term VV-ECMO). Evidence on mortality, complications during intensive care, functional status after discharge and mortality-predictors for patients supported with long-term VV-ECMO is lacking. Method(s): Retrospective study of 137 consecutive patients treated with VV-ECMO for ARDS due to COVID-19 at University Hospital Regensburg from March 2020 to March 2022. Result(s): 38% (n=52;87% male) of patients needed longterm VV-ECMO support. In these, SOFA score (median [IQR]) at ECMO initiation was 9 [8-11], age 58.2 [50.6- 62.5] years, PaO2/FiO2-ratio 67 [52-88] mmHg, pCO262 [52-74] mmHg, Murray-Score 3.3 [3.0-3.6] and PEEP 15 [13 - 16] cmH2O. Duration of long-term support was 45 [35-65] days. 26 (50%) patients were discharged from the ICU. Only one patient died after hospital discharge. At VVECMO initiation, baseline characteristics did not differ between deceased and survivors. Complications were frequent (acute kidney injury: 31/52, renal replacement therapy: 14/52, pulmonary embolism: 21/52, intracranial hemorrhage 8/52, major bleeding 34/52 and secondary sclerosing cholangitis: 5/52) and more frequent in the deceased. Karnofsky index (normal 100) after rehabilitation was 70 [57.5-82.5]. Twelve of the 18 patients discharged from rehabilitation had a satisfactory quality of life according to their own subjective assessment. Four patients required nursing support. Mortality-predictors within the first 30 days on VV-ECMO only observed in those who deceased later, were: Bilirubin >5mg/dl for > 7 days, pulmonary compliance <10ml/mbar for >14 days, and repeated serum concentrations of interleukin 8 >150ng/L. Conclusion(s): Long-term extracorporeal lung support in patients with COVID-19 resulted in 50 % survival and subsequently lead to a satisfactory quality of life and functionality in the majority of patients. It should preferably be performed in experienced centers because of a high incidence of complications. Several findings during the early course were associated with late mortality but need validation in large prospective studies.

Comparison of Comorbidities between Adults and Children with Glycogen Storage Disease Type Ia (GSDIA)

Objectives: Glycogen Storage Disease Type Ia (GSDIa) is a rare inherited disorder resulting in acute hypoglycemia due to impaired release of glucose from glycogen. Despite dietary management practices to prevent hypoglycemia in patients with GSDIa, complications still occur in children and throughout adulthood. This retrospective cohort study compared the prevalence of complications in adults and children with GSDIa. Method(s): Using ICD-10 diagnosis codes, the IQVIA Pharmetrics Plus database was searched for patients with >=2 GSDI claims (E74.01) from January 2016 through February 2020, with >=12 months continuous enrollment beginning prior to March 2019 (for one year of follow-up before COVID-19), and no inflammatory bowel disease diagnoses (indicative of GSDIb). Complication prevalence in adults and children with GSDIa was summarized descriptively. Result(s): In total, 557 patients with GSDIa were identified (adults, 67%;male, 63%), including 372 adults (median age, 41 years) and 185 children (median age, 7 years). Complications occurring only in adults were atherosclerotic heart disease (8.6%), pulmonary hypertension (3.0%), primary liver cancer (1.9%), dialysis (0.8%), and focal segmental glomerulosclerosis (0.3%). Other complications with the greatest prevalence in adults/children included gout (11.8%/0.5%), insomnia (10.0%/1.1%), osteoarthritis (22.0%/2.7%), severe chronic kidney disease (4.3%/0.5%), malignant neoplasm (10.8%/1.6%), hypertension (49.7%/8.7%), acute kidney failure (15.3%/2.7%), pancreatitis (3.0%/0.5%), gallstones (7.8%/1.6%), benign neoplasm (37.4%/8.1%), hepatocellular adenoma (7.0%/1.6%), neoplasm (41.1%/9.7%), and hyperlipidemia (45.2%/10.8%). Complications with the greatest prevalence in children/adults included poor growth (22.2%/1.9%), gastrostomy (29.7%/3.2%), kidney hypertrophy (2.7%/0.8%), seizure (1.6%/0.5%), hypoglycemia (27.0%/11.3%), hepatomegaly (28.7%/15.9%), kidney transplant (1.6%/1.1%), diarrhea (26.5%/18.6%), nausea and/or vomiting (43.8%/35.8%), acidosis (20.0%/17.2%), and anemia due to enzyme disorders (43.8%/40.6%). Conclusion(s): GSDIa is associated with numerous, potentially serious complications. Compared with children, adults with GSDIa had a greater prevalence of chronic complications, potentially indicating the progressive nature of disease. Children with GSDIa had more acute complications related to suboptimal metabolic control.Copyright © 2023

Frequency of Diabetes Mellitus and Newly Diagnosed Hyperglycemia and Their Impacts on Hospitalized COVID-19 Patients

Background: The coronavirus disease 2019 (COVID-19) pandemic and its associated morbidities are a great global concern. Diabetes mellitus (DM) is associated with adverse clinical outcomes and high mortality in patients with COVID-19. Objective(s): This study examined the frequency of BM, newly diagnosed hyperglycemia, and their impacts on hospitalized patients with COVID-19. Method(s): This retrospective study examined 810 medical records of PCR-confirmed COVID-19 patients admitted to Razi Hospital, Ahvaz, Iran. The clinical presentations, severity, and impacts of COVID-19 were compared between patients with and without DM. Disease severity was determined based on the NEWS2 scoring system. Result(s): This study included 810 medical records of COVID-19 patients, of whom 326 had pre-existing DM, and 484 were non-DM. The rates of diabetes and newly diagnosed hyperglycemia were 40.2% and 11.2%, respectively. The most common underlying diseases were hypertension (35.3%), ischemic heart disease (17.9%), and chronic kidney disease (11.9%), which were higher in people with diabetes than non-diabetics. The rate of acute kidney injury was higher in patients with diabetes than in non-diabetics (30.7% vs. 19.2%;P < 0.001) and in patients with severe COVID-19 than in those whose disease was not severe (27.8% vs. 21.5%;P = 0.04). The rates of severe COVID-19 (46.3% vs. 34.7%;P = 0.093), ICU admission (40.7% vs. 27.4%;P = 0.012), and mortality (18.5% vs. 10.5%;P = 0.079) were higher in patients with newly diagnosed hyperglycemia than in euglycemic patients. Conclusion(s): This study showed that COVID-19 infection is linked with newly diagnosed hyperglycemia and pre-existing DM, both associated with severe COVID-19, more need for ICU admission, and mortality.Copyright © 2023, Author(s).

The ProtekDuo in ECMO configuration for ARDS secondary to COVID-19 - a systematic review

Objectives: Assessment of the literature on the ProtekDuo cannula when used as venopulmonary (V-P) extracorporeal membrane oxygenation (ECMO) in ARDS secondary to COVID-19. Method(s): Systematic literature search in EMBASE, Medline (Pubmed) and NHS library using appropriate keywords as well as PICOS and PRISMA approach. Result(s): We found 285 publications, of which 5 publications met the search criteria and were included in this review. A total of 194 patients with COVID-19 related ARDS had a ProtekDuo placed to establish venovenous (V-V) ECMO and right ventricular (RV) support. Patients treated with the ProtekDuo cannula had survival rates between between the studies of 59 and 89%, with a significant survival compared to an invasive ventilation group or when compared to dual site V-V ECMO or other double lumen ECMO cannulas. One of the studies focused on extubation and early discontinuation of ventilator support, which the authors achieved in 100% of ProtekDuo patients. The incidence of acute kidney injury (AKI) and use of continuous renal replacement therapy (CRRT) was significantly reduced in the ProtekDuo versus other groups. Conclusion(s): The ProtekDuo displayed lower mortality rates, AKI occurrence and CRRT need as compared to other respiratory support modalities and has shown to be a game changer for ECMO support in patients suffering from COVID-19 ARDS. Many authors suggested the ProtekDuo for first line use in these patients.

The Predictive Value of Cystatin C for AKI in Patients with COVID-19.

Objective. To evaluate a potential of cystatin C blood concentration to predict acute kidney injury (AKI) in patients with severe and extremely severe pneumonia associated with a COVID-19. Materials and methods. An observational prospective study of 117 patients with severe and extremely severe pneumonia associated with a COVID-19 in an ICU setting was conducted in 2020-2022 (site: multifunctional Medical Center, 1586 Military Clinical Hospital of the Ministry of Defense of Russia, Moscow Region, Russia). Routine laboratory tests and instrumental examinations were performed according to generally accepted protocols. Cystatin C concentrations in blood (s-CysC) and urine (u-CysC) were measured by immunoturbidimetric method. Results. AKI was diagnosed in 21 (17.9%) patients, kidney dysfunction without AKI was found in 22 (18.8%) patients with severe and extremely severe pneumonia associated with COVID-19. s-CysC and u-CysC levels in the group of patients with AKI were statistically significantly higher compared to the levels in the group of patients without AKI. The levels of s-CysC obtained within Day 1 - T (-1), and Day 2 - T (-2) prior to AKI onset turned out to be the independent factors for AKI development in patients with severe and extremely severe pneumonia associated with COVID-19: OR 5.37, Wald chi-square 5.534 (CI: 1.324;21.788);P=0.019 and OR 3.225, Wald chi-square 4.121 (CI: 1.041;9.989);P=0.042, respectively. s-CysC T (-2) value is informative, and s- CysC T (-1) is a highly informative predictor of AKI development in severe and extremely severe pneumonia associated with COVID-19: ROC AUC 0.853 (95% CI, 0.74-0.966), P_0.001) with 90% sensitivity and 73% specificity at a cut-off of 1.67 mg/L, and ROC AUC 0.905 (95% CI, 0.837-0.973), P_0.001) with 90% sensitivity and 73% specificity at a cut-off of 1.69 mg/l, respectively. Serum CysC levels started increasing 3 days prior to AKI onset, outpacing the increase of SCr levels. The u-CysC levels were not predictive of AKI development. Impaired renal function probability was increasing with patients' age (P_0.0001). Conclusions. Serum CysC seems to be a statistically significant predictor of AKI. s-CysC levels started increasing 3 days prior to AKI onset, surpassing the increase of SCr levels in patients with severe and extremely severe pneumonia associated with COVID-19. Urine CysC did not achieve statistical significance as a predictor for AKI, although u-CysC concentrations were significantly higher on days 3, 2, 1 prior to AKI onset and on the day of AKI onset in the group of patients with AKI.Copyright © 2023, V.A. Negovsky Research Institute of General Reanimatology. All rights reserved.

Pancreatic Stone Protein (PSP) as a predictive biomarker of multiple organ failure and clinical outcome

Background: COVID-19 syndrome is associated with high morbidity and mortality in haemodialyzed patients. Pancreatic Stone Protein (PSP) is an early biomarker of sepsis and a prognostic biomarker of disease severity in critically-ill patients and can be rapidly measured at the patient's bedside with a point-of-care-test from a small drop of whole blood. The aim of our pilot was to investigate PSP in patients requiring haemodialysis with SARS-CoV-2 infection, at different severities of COVID-19 disease. Method(s): Between February and July 2021, 23 patients (6 severe COVID-19 with Acute Kidney Injury, 6 moderate COVID-19 haemodialyzed, 2 haemodialyzed without COVID-19 and 3 healthy controls) were recruited at the University Hospital of Foggia for PSP evaluation. Biomarker's measurements were performed within 48 hours after admission or upon arrival for haemodialysis (pre-treatment). PSP was measured at the patient's bedside with "abioSCOPE", a point-of-care test capable of evaluating PSP levels in five minutes from a small drop (50mul) of whole blood or serum. Result(s): The preliminary results of this pilot study showed a trend for PSP to increase along with the severity of disease. In fact, serum PSP levels were significantly higher in Intensive Care Unit subjects than in COVID-19 negative haemodialysis subjects and controls (ANOVA p=0.032). Furthermore, PSP levels were significantly higher in subjects who died (p<0.017). Whether this increase is due to the kidney injury or COVID-19 disease remains unknown, and more research is needed to understand the relationship. Conclusion(s): Several clinical studies published in literature have shown the predictive value of PSP in the early identification of sepsis and severity of the clinical outcome. In our experience we have seen a trend for PSP to increase with disease severity also in COVID-19 patients. These results are preliminary, but PSP was significantly higher in patients who died, in accordance with the literature. This experience also has demonstrated the feasibility of a point of care system to be easily implemented in the unit and adopted by personnel and its design enables fast results and immediate decisions to be taken, especially in urgent situations.

Scientific rationale of Indian AYUSH Ministry advisory for COVID-19 prevention, prophylaxis, and immunomodulation

The current outbreak of COVID-19 is caused by the SARS-CoV-2 virus that has affected > 210 countries. Various steps are taken by different countries to tackle the current war-like health situation. In India, the Ministry of AYUSH released a self-care advisory for immunomodulation measures during the COVID-19 and this review article discusses the detailed scientific rationale associated with this advisory. Authors have spotted and presented in-depth insight of advisory in terms of immunomodulatory, antiviral, antibacterial, co-morbidity associated actions, and their probable mechanism of action. Immunomodulatory actions of advised herbs with no significant adverse drug reaction/toxicity strongly support the extension of advisory for COVID-19 prevention, prophylaxis, mitigations, and rehabilitation capacities. This advisory also emphasized Dhyana (meditation) and Yogasanas as a holistic approach in enhancing immunity, mental health, and quality of life. The present review may open-up new meadows for research and can provide better conceptual leads for future researches in immunomodulation, antiviral-development, psychoneuroimmunology, especially for COVID-19.Copyright © 2021, Institute of Korean Medicine, Kyung Hee University.

Blood purification treatment and cytokine removal using Cytosorb device in critically ill patients with COVID-19 infection

Introduction: Acute kidney injury (AKI) is a complication of SARS-CoV-2 disease, associated with worse clinical outcomes. Renal replacement therapy (RRT) in combination with sequential extracorporeal blood purification therapies (EBPT) might support renal function, attenuate systemic inflammation, and prevent or mitigate multiple organ dysfunctions. Method(s): We retrospectively analyzed 20 patients admitted in ICU for ARDS and who developed moderate-to-severe AKI requiring RRT. Cytokine hemadsorption with Cytosorb was performed in association with CRRT. The main indication for this treatment was the worsening of hemodynamic and respiratory conditions and suspicion of cytokine storm. The protocol consisted in the use of 3-4 cartridges in total;among these, the first 2 were changed after 12 hours of treatment to maximize cytokine removal, while the others after 24 hours. We examined comorbidities, clinical and laboratory characteristics and the impact of treatment in terms of mortality rate and changes in data before and after treatment. Result(s): Nineteen patients (95%) had an AKI at any time during their ICU stay. Of these, 5 patients (25%) had AKI stage II and 14 patients (70%) had AKI stage III. All patients included in this subgroup were mechanical ventilated and required vasopressor's use. Mean prescribed CRRT dose was 31.2 +/- 11.7 ml/kg/h. The median time to strating RRT after ICU admission was 7 days (IQR 3.5-15 days) and the median duration was 7 days (IQR 2.5-12.5 days). Mean SOFA score at the time of RRT start was extremely high (14.5 +/- 2.8). Mortality rate was important (18 patients, 90%) in our cohort. Comparing clinical and laboratory data before and after treatment, a significant improvement of inflammatory markers was reported, with the reduction of C-reactive protein (CRP, 143 [62.1- 328.5] vs 83.5 [66.7-153.5] mg/L);however, no significant changes in IL-6, WBC and PCT values were observed. A slight increase of PaO2/FiO2 were described, although not statistically significant (PaO2/FiO2 ratio 144 [82.7-174.2] vs 183 [132-355.5] mmHg). Conclusion(s): Our experience supports the need of an adequate timing for the use of Cytosorb in critically ill patients with Covid-19. Although a discrete efficacy in improving inflammatory cascade, the late use of EBPT, when organ dysfunction was already ongoing, didn't impact survival.

Characteristics, management and outcomes of thirty COVID-19 ARDS patients supported with veno-venous extracorporeal membrane oxygenation at Rikshospitalet, Oslo University Hospital

Background: We reviewed patients with COVID-19 ARDS managed with VV-ECMO support at our center from March 2020 until February 2022. Material(s) and Method(s): We extracted data from electronic health records (Metavision and DIPS). We registered premorbid health status, ventilator-settings before initiation of ECMO, the time-course, and hospital mortality. Result(s): Thirty patients were managed at our hospital, with a median age of 57.2 years (28-65) and median BMI 28 (22-40). No patient had any serious comorbidity. Twenty-two patients received non-invasive ventilation prior to intubation (1-10 days). The median time on ventilator were 8.0 days (1-19) prior to ECMO and median tidal volume was 5.8 mL/kg PBW (3.1-7.5). Hypoxemia (median PaO2-FiO2 ratio 8 kPa, range 6-12 kPa) and hypercapnia (median PaCO2 11.9 kPa, range 4.2-18.5) [SEP1] despite lung protective ventilation were the main indications for VV-ECMO. Two patients had severe respiratory acidosis without hypoxemia. 18 patients developed serious complications while managed with ECMO (acute renal failure, clinically significant bleeding, sepsis, right ventricular heart failure, dislocation of cannulae). Seven patients received renal replacement therapy. Sixteen patients (53%) died. Thirteen patients (43%) died on ECMO, three (10%) after weaning, Twelve (40%) were discharged from hospital, two are currently in ICU (7%). The median duration of ECMO and ventilator treatment, was 27 (6-50) and 37 (9-78) days, respectively. Conclusion(s): Management of patients with COVID-19 ARDS with VV-ECMO is very resource-intensive, and accompanied by serious complications and high mortality. In-hospital mortality in our cohort was 53%, which is comparable with reports from other centers. However, the duration of ECMO, and pre-ECMO mechanical ventilation, were longer than typically reported.

Analyses of kidney biomarkers in patients with sars-cov-2 (Covid-19)

The new coronavirus was first reported in China and caused a widespread global outbreak of pneumonia that spread rapidly across this country and many other countries. Acute kidney injury is one of the important complications of COVID-19, which has been shown in some cases. Exploring the diagnostic features of biomarkers of kidney function in COVID-19 patients may lead to better patient management. We collected laboratory data from 206 people with confirmed COVID-19 disease and evaluated their renal biomarkers, Blood Urea Nitrogen (BUN), and creatinine. The age range of the patients was almost 62 years old. The mean age in the dead patients and recovered patients was 71 and 54 years old, respectively. The average LDH value was 755 U/L, and creatine phosphokinase (CPK) was 267 U/L in the patients. The average BUN was 59.1 U/L, and creatinine was 1.5 U/L in COVID-2019 patients. Among all 193 patients, laboratory results revealed that 163 (85.4%) patients had an elevated BUN level. Based on creatinine levels for total patients, laboratory results revealed that 49 (25.4%) patients had an elevated value. The average BUN value in dead patients was 85 mg/dL, while in recovered patients was 40.5 mg/dL (P<0.0001). Also, the average creatinine level in dead patients was 1.86 mg/dL, while in recovered patients was 1.24 mg/dL (P=0.0004). Inflammation following COVID-19 disease causes kidney damage and elevated urea and creatinine levels, which may increase the risk of death in these patients.Copyright © 2023 Tehran University of Medical Sciences.

Insights Regarding Outcomes for Covid-19 Hospitalizations with Adult Congenital Heart Disease (Achd)

Background: As of December 2022, SARS-CoV-2 coronavirus resulted in over 6 million deaths worldwide.[1] It was realized early into the pandemic, that COVID-19 significantly impacts the Cardiovascular system. [2] Patients with pre-existing cardiovascular comorbidities were particularly at higher risk of adverse outcomes during their hospitalizations. [3] Similarly, it can be safe to assume patients with adult congenital heart disease (ACHD) should considered a high-risk population for the development of severe COVID infection with increased rates of significant cardiovascular complications. Objective(s): Based on this reasoning and the paucity of data available on this topic using a large database, we sought to investigate the outcomes of patients with ACHD who were admitted to the hospital with COVID-19. Method(s): The National Inpatient Sample database for 2020 was queried to identify adult hospitalizations with a primary diagnosis of COVID-19 and a secondary diagnosis of ACHD using International Classification of Diseases - 10 Clinical Modification (ICD-10-CM) codes. The primary outcome studied was inpatient mortality, while secondary outcomes included inpatient complications, mean length of stay (LOS), and total hospital charge (THC). Multivariate logistic and linear regression analyses were used to adjust for possible confounders and analyze the variables. Result(s): Out of 1,050,045 COVID-19 hospitalizations registered, 2,425 (0.23%) had ACHD as a secondary diagnosis. Encounters with ACHD who were hospitalized with COVID-19 had significantly higher adjusted odds of inpatient mortality (Adjusted Odds Ratio [aOR]: 1.4, [95% CI: 1.05-1.88], p=0.022), Longer LOS (Mean 2.4 days, [95% CI: 1.35-3.40], p <0.001), and higher Total Hospital Charges (Mean $53,000, [95% CI: 20811-85190], p <0.001). A Forrest plot (Figure 1) demonstrates a graphical representation of the multivariate analysis of the significant in-hospital complications when adjusted for patient demographics, comorbidities, and hospital characteristics. Conclusion(s): Among COVID-19 hospitalizations, those with a history of congenital heart diseases had significantly worse outcomes in terms of in-hospital mortality, sepsis;the need for endotracheal intubation, mechanical ventilation, and vasopressors;developing acute kidney injury and pulmonary embolism, in addition to the longer length of stay, and higher total hospital charges. [Formula presented]Copyright © 2023

Cool Your Jets Bro

History: Twenty-two year old male basic trainee was brought to the ED after collapsing during a routine ruck march. At mile 8/12, soldier was noted to develop an unsteady gate and had witnessed loss of consciousness. A rectal core temperature was obtained and noted to be >107degreeF. Cooling initiated with ice sheets and EMS was activated. On arrival to the ED, patient demonstrated confusion and persistently elevated core temperatures despite ice sheeting, chilled saline and cold water bladder lavage. Cooling measures were discontinued after patient achieved euthermia in the ED;however, his temperatures subsequently spiked>103degreeF. Given rebound hyperthermia, an endovascular cooling (EVC) device was placed in the right femoral vein and patient was transferred to the ICU. Multiple attempts to place EVC device on standby were unsuccessful with subsequent rebound hyperthermia. Prolonged cooling was required. Physical Exam: VS: HR 121, BP 85/68, RR 22 SpO2 100% RA, Temp 102.4degreeF Gen: young adult male, NAD, shivering, A&Ox2 (person and place only) HEENT: Scleral anicteric, conjunctiva non-injected, moist mucus membranes Neck: Supple, no LAD Chest: CTAB, no wheezes/rales/rhonchi CV: tachycardia, regular rhythm, normal S1, S2 without murmurs, rubs, gallops ABD: NABS, soft/non-distended, no guarding or rebound EXT: No LE edema, tenderness SKIN: blisters with broad erythematous bases on bilateral heels Neuro: CN II-XII grossly intact, 5/5 strength in all extremities. Differential Diagnosis: 216. Septic Shock 217. Hypothalamic Stroke 218. Exertional Heat Stroke (EHS) 219. Neuroleptic Malignant Syndrome 220. Thyroid Storm Test Results: CBC: 18.2>14.5/40.6<167 CMP: 128/3.5 88/1831/2.7<104, AST 264, ALT 80, Ca 8.8 Lactate: 7.1 CK: 11 460 Myoglobin: 18 017 TSH: 3.16 CXR: No acute cardiopulmonary process Blood Cx: negative x2 CSF Cx: Negative COVID/Influenza/EBV: Negative Brain MRI: wnl. Final Diagnosis: Exertional Heat Stroke. Discussion(s): No EVC protocols exist for the management of EHS or rebound/refractory hyperthermia. As a result, the protocol used for this patient was adapted from post-cardiac arrest cooling protocols. It is unclear if this adapted protocol contributed to his delayed cooling and rebound hyperthermia as it was not intended for this patient demographic/ pathophysiology. Furthermore, despite initiating empiric antibiotics upon admission, delayed recognition and tailored therapy for his bilateral ankle cellulitis may have contributed to the difficulty in achieving euthermia. In summary, more research needs to be done to evaluate and develop an EVC protocol for EHS. Outcome(s): Euthermia was achieved and maintained after 36 hours of continuous EVC, at which point it was discontinued. His CK, AST/ALT, creatinine and sodium down-trended after discontinuation of EVC. Patient's antibiotics were transitioned to an oral formulation for treatment of ankle cellulitis and he was prepared for discharge. He was discharged with regular follow-up with the Fort Benning Heat Clinic. Follow-Up: After discharge, patient had regularly scheduled visits with the Fort Benning Heat Clinic. His typical lab markers for exertional heat stroke were regularly monitored. He had continued resolution of his Rhabdomyolysis, acute kidney injury and hyponatremia with typical treatment. Soldier returned to duty after 10 weeks of close monitoring and rehabilitation.

Impact of Kidney Damage on the Course and Prognosis of COVID-19 Infection According to the International Registry <<Analysis of Chronic Non-Infectious Diseases Dynamics After Covid-19 Infection in Adult Patients>>

Objective. To study the course of the new coronavirus infection in patients with chronic kidney disease (CKD), to identify cases of acute kidney injury (AKI) in the setting of COVID-19 infection, and to access the impact of renal function on prognosis in these categories of patients during the acute phase and after hospitalization, at 3, 6, and 12 months after recovery. Materials and methods. The ACTIV and ACTIV 2 registries included men and women older than 18 years with a diagnosis of COVID-19 based on a positive PCR test for COVID-19 and a characteristic chest X-ray or computed tomography chest scan. Results. A total of 9364 patients (4404 men, average age59 [48-69]) were included in the analysis. 716 (7.67 %) patients had CKD. 8496 (90,7 %) patients had their glomerular filtration rate (GFR) measured during hospitalization, and the values were distributed as follows: >=90 ml/min/1.73m2 - in 4289 (50,5 %) patients, 89-60 ml/min/1.73m2 - in 3150 (37,1 %) patients, 59-45 ml/min/1.73m2 - in 613 (7,22 %), 44-30 ml/min/1.73m2 - in 253 (2,98 %), 29-15 ml/min/1.73m2 - in 110 (1,29 %), <15 ml/min/1.73m2 - in 81 (0,95 %) patients. 11.6 % of the subjects (n=1068) developed AKI during hospitalization. This complication was reported more often than cytokine storm (in 7.46 % in 687 patients, p<0,001) or sepsis (in 0.17 % in 16 patients, p=620). CKD increased the risk of death by 3.94-fold in patients with COVID-19 during hospitalization compared with patients without CKD. The mortality of patients with AKI during hospitalization was 3.94 times higher than the mortality of those without AKI. CKD also affected long-term survival after hospitalization: within 3 months of follow-up, the risk of death in patients with CKD increased 4.88-fold, within 6 months - 4.24-fold, after 12 months - 8.36-fold. Conclusion. The prevalence of CKD in COVID-19 patients is similar to that in the general population. AKI developed in 11.6 % of cases with COVID-19 infection and was observed more frequently in patients with overweight and hyperglycemia. CKD and AKI increased the risk of hospital mortality in patients with COVID-19. In the group of patients with CKD, mortality increased in the post-COVID period, 3, 6 and 12 months after. The high mortality rate of patients who had AKI during the coronavirus infection was observed only in the first 3 months of follow-up in the post-COVID period.Copyright © 2023 The authors.

Impact of Atrial Fibrillation and Flutter on the in-Hospital Outcomes of Patients with Covid-19: A Nationwide Retrospective Cohort Study

Background: Atrial fibrillation and/or flutter is a common comorbidity in hospitalized patients with COVID-19. Objective(s): We aimed to assess the effect of atrial fibrillation and/or flutter on the outcomes of COVID-19 patients in a nationally representative sample. Method(s): We conducted a population-based analysis utilizing data from the national inpatient sample database. Hospitalized adults >= 18 years who were hospitalized with COVID-19 during the year 2020 were included. We used multivariate logistic regression models to investigate the outcomes in patients who had atrial fibrillation or flutter. Result(s): Among 1,018,115 (Nationally weighted sample) admissions with COVID-19, 154795 cases (15.2%) had atrial fibrillation and/or flutter. Patients with atrial fibrillation and/or flutter had significantly higher adjusted odds of all-cause in-hospital mortality (Odds Ratio [OR], 1.78 [confidence interval (CI), 1.75-1.80]), acute stroke (OR, 1.96 [CI, 1.85-2.07]), acute coronary syndrome (OR, 1.43 [CI, 1.37-1.48]), acute heart failure (OR, 4.24 [CI, 4.15-4.34]), cardiogenic shock (OR, 3.07 [CI, 2.85-3.30]), need for vasopressors (OR, 2.14 [CI, 2.06-2.22]), cardiac arrest (OR, 1.95 [CI, 1.89-2.02]), need for mechanical ventilation (OR, 1.79 [CI, 1.77-1.82]), acute kidney injury (OR, 1.25 [CI, 1.23-1.27]), major bleeding (OR, 1.82 [CI, 1.73-1.92]) compared to those patients without atrial fibrillation or flutter. On subgroup analysis, the risk for mortality was highest among atrial flutter (OR, 2.91), followed by atrial flutter and fibrillation group (OR, 2.38), followed by only atrial fibrillation group (OR, 1.71) (P value <0.001 for all) when compared to non-atrial fibrillation, non-atrial flutter in patients with COVID-19. Conclusion(s): Atrial fibrillation and flutter are associated with higher inpatient mortality and worse outcomes in COVID-19 patients. [Formula presented]Copyright © 2023

Is It Cancer Hepatic Inflammatory Pseudotumor: An Important Hepatic Mass Differential

Introduction: Hepatic inflammatory pseudotumor (HIP), albeit rare, is an important pathology to be included in differentials for hepatic masses. The benign nature and treatment of this disease process should be considered especially in comparison to malignant hepatic processes. Case Description/Methods: A 66-year-old male with pre-existing history of compensated Hepatitis C cirrhosis status post direct-acting antivirals with sustained virologic response presented in shock after a syncopal episode. Initial work up revealed leukocytosis, thrombocytopenia, acute renal injury, elevated liver enzymes, and COVID-19 positive test. Patient underwent initial liver ultrasound revealing intrahepatic and extrahepatic biliary ductal dilation. Subsequent MRCP demonstrated diffuse thickening of intra and extra hepatic bile ducts suggestive of cholangitis and several hepatic masses concerning for abscesses versus possible metastatic cholangiocarcinoma. Patient improved symptomatically with antibiotics and supportive care. A liver biopsy was performed with pathology showing lymphoplasmacytic inflammation and fibroblastic infiltration suggestive of hepatic inflammatory pseudotumor. A repeat MRCP one week later showed interval decrease in size of liver lesions and repeat liver function tests also showed improvement. Patient was discharged on a course of ciprofloxacin and metronidazole. Patient had repeat MRCP 3 months after discharge, with further significant improvement in size of liver lesions. After multi-disciplinary discussion the plan was for further surveillance with imaging and labs in 2 months. Discussion(s): Inflammatory pseudotumors are benign and non-neoplastic lesions that can occur in any organ. They can appear as a malignant lesion when they arise in the liver and an accurate identification can allow for conservative management and prevent unnecessary invasive procedures. Hepatic inflammatory pseudotumors are often seen with concomitant infection or inflammatory processes. Liver biopsies distinguish these tumors from other malignant processes as they demonstrate a characteristic dense inflammatory infiltrate interspersed in stroma of interlacing bundles of myofibroblasts. This case highlights the importance of maintaining HIP on the differential diagnosis. (Figure Presented).

A Case Report of Iatrogenic Esophageal Perforation: Complication of Orogastric Tube Placement

Introduction: Orogastric tube insertion is a routine procedure in medical care. However, misplacement of the tube can cause a variety of complications, which can be life threatening in some instances. Case Description/Methods: 71-year-old male presented with dyspnea, fever, chills, cough, and myalgia for 2 weeks. He had tachycardia, tachypnea, and was hypoxic to 66% in room air. He was found to have acute hypoxic respiratory failure secondary to COVID-19 Pneumonia and was admitted to ICU. But, he continued to be hypoxic and was started on BiPAP. He eventually became altered, and was intubated. Post intubation orogastric tube (OGT) placement was unsuccessful on the first attempt due to resistance. On the second attempt, the nurse was able to advance partially (Figure). But, a chest XR showed OGT in the mediastinum, and OGT was removed. CT of neck and chest revealed pneumomediastinum with possible mid-thoracic esophageal perforation. The patient was started on broad-spectrum antibiotics and thoracic surgery was consulted. Given his mechanical ventilation requirement, surgery deemed him unfit to tolerate thoracotomy and the endoscopic procedure was not available in the hospital. So, recommendation was to manage conservatively. His hospital course was complicated by hypotension requiring vasopressors and metabolic acidosis in setting of acute renal failure requiring CRRT. Code status was changed by the family to Do Not Resuscitate due to his deteriorating condition. Eventually, he had a PEA arrest and was expired. Discussion(s): OGT intubation is performed at hospitals for feeding, medication administration or gastric decompression. Although it is considered a safe procedure, complications can arise due to OGT misplacement or trauma caused by the OGT itself or the intubation process. OGT misplacement is typically endotracheal or intracranial. Misplacement within the upper GI lumen is usually detected by a kink in the oropharynx or esophagus. The subsequent complications are identified by the structure that is perforated (e.g., mediastinitis or pneumothorax). Regardless of whether counteraction is perceived, the physician must be careful not to apply excessive force. The location of the OGT tip should be determined by a chest radiograph;visualization of the tip below the diaphragm verifies appropriate placement. Complications of OGT insertion are uncommon;however, the consequences are potentially serious, and the anatomy of the upper GI tract should be understood by all who are involved in the care.

Collapsing glomerulonephritis in a COVID-19 patient. Case report

Acute renal injury due to collapsing glomerulonephritis is associated with high morbidity and mortality, requiring chronic dialysis, COVID-19 is one of its causes. A 17-year-old male patient presented with a four-month history of edema, foamy urine and reduction in the urine flow;anasarca was observed at physical examination. Laboratory values showed creatinine 4,2 mg/dl;albumin 1,9 gr/dl;cholesterol and triglycerides were high;proteinuria 6,7 gr/24h: leucocyturia and hematuria with negative urine culture. Serologies for HIV, syphilis and hepatitis were negative. Studies for systemic lupus were negative. An antigenic test for SARS-CoV-2 was positive as well as an IgG. Renal Biopsy showed Focal and Segmental Glomerulosclerosis, Collapsing variant. He received corticosteroids and cyclosporine. Creatinine improved;proteinuria remained >3 gr/24 hours.Copyright © Universidad Peruana Cayetano Heredia, Facultad de Medicina Alberto Hurtado. All Rights Reserved.