A free-standing children's hospital helps a post-partum woman needing VV-ECMO during COVID-19 Pandemic when ECMO resources were limited

Our case is a 21 y/o pregnant female, 26weeks gestation who presented to OB triage with COVID-19. She was admitted to OB/GYN unit in acute hypoxic respiratory failure and started on steroids and remdesivir. On hospital day 6, she underwent an emergent c-section for fetal distress due to increasing hypoxia and severe ARDS. As her arterial blood gas being ph 7.17/81/40/29.6/-0.4, lactate 6.8nmol/L with escalating vasoactive medication and ventilator settings;ECMO was decided. However, all adult ECMO resources were limited, even within other adult facilities in Central Florida. Through multidisciplinary discussions amongst OB/GYN, adult ICU, and our pediatric ECMO activation team, it was decided to transfer the patient to our free-standing pediatric hospital. The patient was successfully transferred and cannulated for VV-ECMO. Total ECMO run was 413 hours. On ECMO day #12 patient underwent a tracheostomy. On ECMO day # 17, patient developed headaches and seizure activity in which CT revealed a subdural hemorrhage. She was taken off ECMO and underwent an emergent decompressive craniectomy with hematoma evacuation by our pediatric neurosurgical team. Once stable enough, she was discharged post ECMO day #15 (PICU day #32) to rehabilitation center. Two weeks later she had her bone flap replaced, trach removed, and she walked out of our unit home. This case exudes two key points for discussion. The first point of understanding ECMO physiology allows a team to treat many different patient populations. Although this patient was unusual to our pediatric bedside providers being post-partum, our team knew we could help. The second key point is excellent multidisciplinary teamwork and that communication is essential. At Orlando Health Arnold Palmer Hospital, our ECMO activation team consists of surgeons, pediatric intensivists, CT surgeons, perfusionists, nursing, and administration. We meet virtually to discuss how to execute initiation and daily ECMO treatment plans. There were some on the virtual call that were hesitant in accepting care of this adult due to variety of reasons, saying no would have been the easier answer, but not the right thing to do. What we learned from this case may seem so obvious and simple but very difficult to execute;multidisciplinary teamwork, humility, and open communication gave this patient the ability to walk out of the hospital with her baby. Other pediatric ECMO teams can learn from this case is they too can help in extraordinary times such as during a pandemic when adult recourses are limited.

Can we detect in vivo hemolysis during extracorporeal membrane oxygenation support using endogenous carbon monoxide production?

Introduction: Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with ARDS due to COVID-19. In vivo hemolysis (ivH) is one of its complications, characterised by peaks of plasma free hemoglobin (fHb). However, an increase in carboxyhemoglobin (COHb) has also been observed due to Hb metabolism by heme-oxygenase that releases carbon monoxide. The aim of this study is to evaluate the incidence of ivH events and their relation to COHb in COVID-19 patients undergoing ECMO. Method(s): Single-centre observational retrospective study that included 33 COVID-19 patients with ARDS who received VV-ECMO treatment in the ICU from March 2020 to September 2021. Daily analytical monitoring was carried out including arterial blood gas test with cooximetry and biochemical parameters, incorporating the estimation of fHb using quantitative hemolysis index (HI). Significant ivH was considered with fHb > 50 mg/dL after discarding in vitro hemolysis. Daily maximum values of HI and COHb were recorded and paired in order to evaluate their correlation by generalised linear model. Result(s): The total prevalence of patients having ivH in our cohort was 27.3%. Mortality during ECMO treatment in our study was 57.6%, higher within the group of patients with ivH events (77.8% vs 50%). A total of 777 daily maximum values of fHb from all the patients were obtained. Values of COHb were significantly higher during ivH episodes. Furthermore, positive significant correlation was obtained between daily analytical values of fHb and COHb (B coefficient 42.156;p = 0.042), as shown in Fig. 1. The cut-off value of COHb to be discriminative for hemolysis (fHb > 50 mg/dL) was 3.85% COHb (90.5% sensitivity and 83.3% specificity). Conclusion(s): Point-of-care carboxyhemoglobin is a cheap and widely available parameter that could be useful when detecting in vivo hemolysis during ECMO treatment.

Mediastinal Pigtail Catheterization for Treatment of Pneumomediastinum in a COVID-19 Patient: A Case Report

Spontaneous pneumomediastinum (SPM) is a decisive complication reported to be associated with COVID-19. Here, we present a case of SPM in a COVID-19positive patient that was not caused by any iatrogenic or known reasons. At the time of admission, the patient was COVID-positive and distressed. He was immediately subjected to hematological and radiological investigations (chest X-ray, HRCT), which confirmed pneumomediastinum. The patient was hypoxic and hypotensive even after receiving ionotropic support. Considering the patient's critical condition, a mediastinal pigtail catheterization was performed instead of a thoracotomy, and the catheter was in situ for nine days. Arterial blood gas was monitored during the hospital stay, and supplementary oxygen therapy was provided accordingly. The patient subsequently recovered and was discharged. Hence, SPM in this COVID patient was treated by pigtail catheterization, and major surgical interventions were avoided.Copyright © 2023 LookUs Scientific. All rights reserved.

Repeated COVID-19 infection in recipients of post-living donor liver transplantation: Two real-life cases

COVID-19 is an emerging pandemic. The course and management of the disease in the liver transplant setting may be difficult due to a long-standing immunosuppressive state. In Egypt, the only available option is living donor liver transplantation (LDLT). In our centre, we have transplanted 440 livers since 2008. In this study, we report a single-centre experience with COVID-19 infection in long-term liver transplant recipients. A total of 25 recipients (5.7 %) had COVID-19 infections since March 2020. Among these recipients, two developed COVID-19 infections twice, approximately three and two months apart, respectively.Copyright © 2021 The Author(s)

Evaluation of lung inflammation using Exhaled breath condensate in patients with post-COVID syndrome

Introduction: The term "post-COVID syndrome" encompasses a wide range of clinical conditions following SARSCOV2 infection. Whether post-COVID syndrome can be associated with a prolonged inflammatory and immune response is still unknown. Exhaled Breath Condensate (EBC) pH has been recognized as a robust marker of lung inflammation in various diseases (Kharitonov et al. Chest 2006;130(5):1541-46). However, evidences on the role of EBC pH in diagnosing lung inflammation in post-COVID syndrome are still lacking. Aims and objectives: We aimed to investigate EBC pH in patients suffering from post-COVID syndrome. Method(s): We enrolled 10 patients hospitalized with acute respiratory failure and COVID-19 pneumonia. We performed a complete follow up after 3 months (T1) and 6 months (T2) from discharge. Each visit included routine blood tests, arterial blood gas analysis, 6 minute walking test and body plethysmography. Finally, bronchial and alveolar EBC pH were collected at the end of each visit. Result(s): Alveolar EBC pH was significantly lower at T1 compared with T2 samples (p= 0.0007). Moreover, in T1 analysis, we found a less acid pH in bronchial EBC compared to the alveolar one (p=0.003). Alveolar and bronchial EBC did not differ at T2, as well as bronchial EBC from T1 to T2. Serum inflammatory biomarkers did not differ from T1 to T2 analysis. Finally, alveolar EBC was directly correlated with Neutrophil-Lymphocyte ratio (R=0.71, p=0.02). Conclusion(s): Alveolar EBC pH is a useful non-invasive tool to characterize and monitor lung inflammation in patients with post-COVID syndrome. Furthermore, no other serum biomarker seems to be sensitive enough to identify residual phlogosis after COVID-19 disease.

Post-recovery pulmonary function test and thorax CT correlations in COVID-19 survivors

Aim: Long-COVID has been described as persistent symptoms involving multiorgan systems in COVID-19 survivors. This single-centred study investigated the correlation between pulmonary function test (PFT) and thorax computed tomography (CT) results in COVID-19 survivors after six months of follow-up period. Material(s) and Method(s): Patients recovered from COVID-19 aged between 18 and 50 years were included in this study and divided into two groups according to PFT results as patients with normal PFT results (PFT normal;n = 74) and with PFT results with restrictive pattern (PFT restrictive;n = 12). The primary aim of this study was to try to predict the prognosis of long-term chronic pulmonary system diseases using pulmonary function test, thorax CT and laboratory findings in the sixth month after recovery. Result(s): There were no significant differences between the patients in PFT normal and PFT restrictive groups in terms of symptoms and CT findings at admission. On the other hand, the rate of dyspnoea and exertional dyspnoea was significantly more pronounced in patients in PFT restrictive group, while there were no significant differences between CT findings. Both univariate and multivariate regression analyses showed that percent forced expiratory volume in one second (%FEV1) and percent forced vital capacity (%FVC) results are associated factors in discriminating normal and PFT results with restrictive pattern in COVID-19 survivors. Discussion(s): PFTs should be included in follow-up evaluations of COVID-19 patients in order to elucidate the post-COVID-19 pulmonary abnormalities.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Ulinastatin for Aki: Should It Be in Our Care Bundle ?

Introduction: In critically ill patients with AKI, unacceptably high mortality rates reaching up to 50-80% in all dialyzed ICU patients are seen despite the availability of intensive renal support. At present there is no specific or targeted therapy for AKI. Pathophysiology of AKI is multifactorial. Systemic inflammation, mediated in part by cytokines, might be contributing majorly to the development of AKI. This mandates a multipronged approach to the treatment of AKI. There are hardly any studies on the use of ulinastatin in AKI. Our premise regarding the use of molecule in AKI was based on the fact that this molecule acts at multiple levels in the sepsis and can act to stop the cascade and thereby stop the "storm." Methods: We studied a total of 200 patients with AKI who needed ICU care in our hospital in the period between June 2017 - Jan 2020. Out of these, 100 patients received Injection ulinastatin 3 doses a day for 5 days, against a similar number of control patients. We included those patients with AKI who had SOFA scores more than 8. None of the patients had COVID 19 infection. We compared the same number of patients who had received ulinastatin with controls. Injection ulinastatin 1,50,000IU was given three times a day for 5 days. All the patients included had received dialytic therapy. We recorded the age of the patients, it varied from 11-94 years (mean age 52 years), > 60 % (120) of the patients being in the age group of 26-40 years. The ratio of males to females 1.8:1 (M: F 129:71). The etiologies were as follows: Malaria - complicated - P vivax, P falciparum (n= 76) 38% Enteric fever (n= 40) 20% UTI (n=30) 15% Post-partum (n=20) 10% Dengue (n = 14) 7% Acute gastroenteritis/diarrheal diseases (n= 12) 6% Pancreatitis (n= 6) 3% Obstructive uropathy (n= 3) 1.5% 33 % (n= 66) patients had diabetes as a co morbid condition. The renal function tests of all the patients along with liver function tests, sepsis parameters like d-dimer, serum procalcitonin levels, CRP-hs levels, coagulation tests, complete blood counts, and arterial blood gas analysis were done We recorded the length of stay, need and duration of renal replacement therapy, time to stoppage of renal replacement therapy, need for mechanical ventilation, mortality and post AKI recovery and progression to CKD. Result(s): The patients who received ulinastatin had a shorter stay in the ICU (p <0.01 vs control group);also, the time to stoppage of renal replacement therapy was shorter (p < 0.05). The recovery of renal function was seen in 84% (n=168). The progression to CKD was seen in 11% (n=22) of patients. The average number of sittings of dialysis needed were 11 (range3-20), lesser number of dialysis were needed in the ulinastatin group. The overall mortality was 36 %(n=72).The average follow up period post discharge has been 141 days (21 - 240 days) Conclusion(s): There definitely seem to be advantages in using ulinastatin and results look promising. But there are limitations to this study - this was a retrospective analysis hence not all the patients received ulinastatin. Moreover, the drug is expensive. This study was done in a semi urban set up where causes for AKI are predominantly infective. A larger prospective double-blind study will be needed to consider ulinastatin as a routine option for treating AKI. Till then preventing AKI should be the aim for us. No conflict of interestCopyright © 2023

Nocturnal hypoventilation and respiratory muscle/cough weakness in COVID-19 ICU survivors

Background: The impact of severe COVID-19 in nocturnal hypoventilation and respiratory muscles/cough strength is unknown. Aim(s): Characterize respiratory function in post-ICU COVID-19 patients and correlate these findings with COVID-19 associated outcomes. Method(s): Retrospective study with 55 post-ICU COVID-19 patients admitted to a rehabilitation center (RC). Clinical data were collected and patients performed arterial blood gas analysis, nocturnal oxy-capnography, maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP) and peak cough flow (PCF) at admission. Result(s): Mean age was 64.4+/-10.2 years, 39 (70.9%) were male. Co-morbidities were present in 50 (90.9%): 39 (70.9%) hypertension;20 (36.4%) diabetes;3 (5.5%) OSA;1 (1.8%) COPD. None had neuromuscular disorders. Median of ICU length was 25.5 (min 5;max 190) days. Fifty-three (96.4%) needed mechanical and invasive ventilation, 6 (10.9%) ECMO and 22 (40%) tracheostomy (all decannulated before admission to our RC). Eighteen (32.7%) had criteria of nocturnal hypoventilation, 17 (30.9%) inspiratory, 16 (29.1%) expiratory and 17 (30.9%) cough weakness. Sepsis correlated with increased length of ICU stay (p=0.007) and with lower PCF values (p=0.048). Neurologic disfunction was associated with lower minimum SpO2 and more time of SpO2<88% (p=0.032;p=0.035). Renal disfunction was associated with higher values of mean and maximum TcCO2 (p=0.003;p=0.011). Patients with previously diagnosed OSA had higher values of MIP and PCF (p=0.006;p<0.001) at evaluation. Conclusion(s): In COVID-19 ICU survivors, nocturnal hypoventilation, inspiratory/expiratory muscle and cough weakness are common and may have an impact in rehabilitation outcomes.

Blowing in the Wind: Use ofIncentive Spirometry in Preventing Acute Respiratory Distress Syndrome for Patients with Moderate COVID

In December 2019, there was an outbreak of COVID-19. This is a pilot study which aims to evaluate whether the use of Incentive Spirometry(IS) has a clinical significance in preventing Acute Respiratory Distress Syndrome (ARDS) among moderate COVID patients. IS, a lung expansion technique, which promotes sustained maximal inspiration helping patients by improving ventilation/perfusion mismatch and alveolar-PaO2 gradient. Prospective study involving 10 moderate COVID patients, aged 18-59 years admitted from November 2021-February 2022. Five were assigned under exposed(IS users) and five under non-exposed(non-IS users) group. Data were extracted on demographics such as age, gender, BMI and pre-morbid health status. Day of illness, admission chest radiograph, Arterial Blood Gas (PaO2/FiO2 ratio), oxygen saturation, vital signs and symptoms were obtained. The primary outcome was development of ARDS, with secondary outcome of further worsening of pneumonia and PaO2/FiO2 ratio on the 4th hospital day, preventing desaturations and shorter hospital stay. Outcomes from the exposed group were compared to the non-exposed group. IS- users were found to have improved PaO2/FiO2 ratio, improved Chest X-ray findings, shorter hospital day and earlier improvement of symptoms. Hence, IS use can be utilized as part of the management of COVID-19 patients during the initial stage of illness to avoid progression to ARDS.

Blood haemoglobin and pulse oximetry oxygen saturation measurement error

Pulse oximetry utilises the differential absorption, by both oxy- and deoxyhaemoglobin, of a light signal passing through tissue to provide a measure of blood oxygen saturation. Although pulse oximetry devices are widely used to monitor patients in real time, and to provide an estimate of risk of deterioration, no studies exist on the association of haemoglobin levels and pulse oximetry measurement error. We examined the effect of different haemoglobin levels on pulse oximetry measurements in patients admitted to a large UK teaching hospital from 1 February 2020 to 31 December 2021 with a possible diagnosis of Covid-19 infection. Pulse oximetry and arterial blood gas oxygen saturations were compared. Two measures of blood haemoglobin levels were available;from a venous sample within 24 hours of the arterial blood gas sampling and directly from the arterial blood gas sample itself. Data were available from 1086 patients. Using the measurement of haemoglobin from the venous blood sample within 24 hours of the blood gas, there was an inverse linear association between haemoglobin and pulse oximetry measurement error of -0.06% per 1 g/L increase of haemoglobin (95% confidence intervals CI: -0.02 to -0.09). This equates to patients with a venous haemoglobin of 70g/L having a measurement error of +8.0% (95% CI: +5.9% to +10.0%) and those with a haemoglobin of 150g/L having a measurement error of +3.6% (95% CI: +2.2% to +4.9%). Similar associations were observed using arterial haemoglobin values. The association between haemoglobin and measurement error of oxygen saturation as determined by pulse oximetry is inverse and linear. It is relatively large in patients with anaemia and may affect clincial assessment.

Phenotyping dyspnea in patients suffering from postCOVID syndrome

Introduction: Post COVID dyspnea is considered one of the most troublesome symptoms, even after the acute phase of COVID-19 disease. Few data are currently available describing features post-COVD dyspnea. Aims and objectives: To phenoype dyspnea in patients with post-COVID syndrome. Method(s): We enrolled 309 patients who suffered from COVID-19 disease. All patients were screened with a complete blood workup, body plethysmography, arterial blood gas analysis and 6 minute walking test (6MWT). Moreover, 80 patients underwent chest Computed Tomography (CT) according to their clinical status. Result(s): Half of the enrolled patients (51.8%) reported residual dyspnea, both at rest and during their daily activities. Among them, 56.7% of patients had also dyspnea as the first symptom at COVID-19 onset (p=0.04). Patients referring dyspnea showed a lower PaO2 (p=0.02) and an increased pre-post test BORG scale difference (p<0.0001), without significant desaturations (>=3%) during the 6MWT. We also found a decreased 6 minute walking distance in these patients (p=0.004), as well as a reduction in diffusing capacity (DLCO, p=0.0005). After performing a multivariate logistic regression, only DLCO resulted to be statistically significant (OR=0.97, p=0.03). Moreover, among our patients who performed chest CT, 76.2% of them were found to have residual abnormalities such as ground glass opacities (50%), lung scars (26.2%) and parenchymal consolidations (12.5%). Conclusion(s): DLCO reduction is the most influencing factor for the development of post-COVID dyspnea. Moreover, PaO2, 6MWT parameters and chest CT alterations can also increase the breathing discomfort in these patients.

Distribution of sequelae in post-covid patients according to previous need of respiratory support

Introduction: "Long COVID" is defined by the persistence of symptoms after 4-12 weeks from COVID-19 disease. Data comparing different clinical phenotypes according to COVID-19 severity are still scanty. Aims and objectives: We aimed to identify different clinical phenotypes of post-COVID syndrome according to the level of respiratory support used. Method(s): We enrolled 309 patients who previously suffered from COVID-19 disease. All patients performed routine blood tests, arterial blood gas analysis, 6 minute walking test and body plethysmography. Then, we assigned each patient to a "severity group" according to the respiratory support needed during COVID-19 disease. Severity group 0: no respiratory support needed Severity group 1: oxygen only Severity group 2: positive airway pressure (CPAP or NIV) Severity group 3: Invasive Mechanical Ventilation (IMV) Results: Patients belonging to Group 0 experienced less fatigue (p=0.004) and mood disorders (p=0.007) compared to the other groups. Group 0 and 3 reported less frequently insomnia (p<0.0001). Hospitalized patients developed sleep and mood disorders during hospitalization due to several factors (fear, acoustic/visual triggers ect.). Patients who underwent IMV, instead, were completely sedated for the entire course of the acute phase of the disease, not being exposed to these triggers. Among blood markers, only Galectin-3 (p=0.004) and IL6 (p=0.004) had significant lower serum concentrations in patients belonging to Group 0, confirming their lower inflammatory status Conclusion(s): Awake hospitalization seems to deeply affect post-COVID sequelae in several patients.

Complete Heart Block: A Case Report and Review of a Rare Manifestation of COVID-19

Covid19 is still one of the major public health problems of all countries nowadays. The most common cardiac manifestations reported till now are acute coronary syndrome, myocarditis, and arrhythmia. The prevalence of COVID-19 induced arrhythmias is different in recent reports and varies from benign sinus tachycardia to more ominous cases of severe bradycardia or even malignant ventricular arrhythmias. Here in, we describe a case of complete heart block in severe covid-19 pneumonia and review all recent relevant case reports published to date in order to understand the probable mechanisms and contributing factors of this rare complication of the disease.Copyright © 2022, Isfahan University of Medical Sciences(IUMS). All rights reserved.

Effect of Hemoperfusion on the Clinical Outcome of Severe and Critical Covid-19 Patients Admitted at the University of Santo Tomas Hospital: An Analytical Cohort Study

Introduction: Severe sepsis is a life-threatening end organ dysfunction resulting from dysregulated host response to infection and poses a significant burden to healthcare systems worldwide. Since the advent of CoVID-19, cytokine release syndrome has also been attributed to clinical deterioration presenting as acute respiratory distress syndrome and acute kidney injury of infected individuals. Objective(s): To determine the clinical outcome of Severe and Critical COVID-19 patients who underwent hemoperfusion compared with patients who did not undergo hemoperfusion. Method(s): This study entailed a retrospective cohort analysis of patients aged >= 18 and < 90 years old admitted at University of Santo Tomas Hospital who were diagnosed with Severe or Critical COVID-19. Subjects were grouped between those who underwent hemoperfusion (HP group) using HA 330 cartridge and those who did not undergo the procedure (non-HP). Demographic and clinical data collected for both groups included age, sex, comorbidities present, time to initiation of hemoperfusion, total hemoperfusion time, use of other medications specifically: immunomodulator and anti-viral drugs, antibiotics and steroid, length of hospital stay and in-hospital mortality. Mean arterial pressure, cardiac rate, oxygen saturation, arterial blood gas, complete blood count, oxygen requirement, inotropic score, serum creatinine, urine output, lactate dehydrogenase (LDH), ferritin, high sensitivity C-reactive protein (HsCRP), Interleukin-6 values and Acute Physiology and Chronic Health Evaluation II (APACHE II) score were compared from baseline and after 4 sessions of hemoperfusion for the HP group. The clinical outcomes: length of hospital stay, in-hospital mortality and time to off high flow nasal cannula (HFNC) between two groups were also compared. Result(s): A total of 98 cases were included, 49 subjects underwent hemoperfusion using HA 330 and 49 patients did not undergo hemoperfusion. Demographic data is similar between both groups. Baseline clinical data between Hemoperfusion and non-Hemoperfusion group did not show statistical difference. However, Baseline LDH, HsCRP, Ferritin, IL-6, PF ratio and APACHE II score were statistically different between two groups. Effect on Disease Severity Length of hospital stay and time to off HFNC was shorter in the non-HP group vs the HP group, median of 13 days vs 18 days (p-value 0.003) and 107 hours vs 222 hours (p- value <0.001), respectively. There is also no significant difference in in-hospital mortality between two groups. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): This retrospective study did not show survival benefit with the use of hemoperfusion. Undergoing hemoperfusion did not show a significant effect on changes in disease severity as represented by no significant difference seen in APACHE II score, PF ratio, acute kidney injury, length of hospital stay and in-hospital mortality. Hemoperfusion also has no significant effect in terms of decreasing the values of inflammatory markers LDH, ferritin, and IL-6. A large, multi-center, randomized clinical trial is warranted to truly determine the clinical benefit of hemoperfusion not only in severe to critical COVID-19 but also in severe sepsis and conditions that trigger systemic inflammatory response and cytokine storm. *This abstract was also submitted for the ISN Frontiers:Infections and the Kidneys congress. No conflict of interestCopyright © 2023

Original Article Evaluation of clinical outcomes, laboratory and imaging data of patients with solid tumor infected with COVID-19 infection

Background: COVID-19 is associated with higher mortality rates in patients with cancer. In this study, we aimed to evaluate the clinical outcomes, and laboratory and imaging data of patients with solid tumor infected with COVID-19 infection. Method(s): This is a cross-sectional retrospective study performed in 2020-2022 on 85 patients with a previous diagnosis of solid tumors infected with COVID-19. We included all patients with tumors of solid organs that were diagnosed with COVID-19 infection and required hospitalization those patients previously hospitalized for treatments and were infected with COVID-19 during hospitalization. Demographic data of patients were collected using a checklist. We collected data regarding clinical outcome (discharge, hospitalization or death), duration of hospitalization, requiring ICU admission, duration of hospitalization divided by received drugs and type of tumor and mean survival time. Furthermore, we collected laboratory data from all patients. The radiologic characteristics of patients were also extracted from their data. Result(s): Breast cancer was the most common solid tumor (34.9%), followed by lung cancer (19.3%). The mortality rate was 24.1% (20 patients). The highest mortality rate in this study was for metastatic intestinal cancer to the lung (100%, one patient), followed by metastatic prostatic cancer to lung (50%, three patients). The highest hospitalization duration was for patients with glioblastoma multiform (GBM) (30 days). The mean survival time among patients with mortality was 19.15+/-1.80 days. The mean CT severity score of all patients was 27.53+/-22.90. Patient's most common radiologic sign was air space consolidation (89.1%). The highest CT severity score was found in patients with stomach cancer (46.67+/-5.77). Conclusion(s): The mortality rate in this study was 24.1%. Based on the results of our study and previous research, special care should be provided to patients with solid tumors during the COVID-19 pandemic and in infected cases.Copyright © 2022, E-Century Publishing Corporation. All rights reserved.

CPAP-associated changes in oxygenation and clinical outcomes in severe COVID-19 pneumonia

Background: Continuous positive airway pressure (CPAP) can improve oxygenation in severe COVID-19 pneumonia. Objective(s): To assess whether CPAP-associated improvements in oxygenation can inform clinical outcomes in patients with severe COVID-19 pneumonia. Method(s): Retrospective study in patients with severe COVID-19 pneumonia treated with CPAP in three academic respiratory units in Milan, Italy. Arterial gas analysis obtained before and 1 hour after starting CPAP. CPAP failure defined as either death in the respiratory units while on CPAP or need for intubation. Result(s): 211 patients (mean age 64 years, 74% males) were included. Baseline median PaO2was 68 (57-83) mmHg, PaO2/FiO2(P/F) ratio was 129 (91-179) mmHg and alveolar-arterial (A-a) O2 gradient was 310 (177-559) mmHg. On CPAP, PaO2and P/F increased to 100 (79-141) (p<0.001) and 195 (132-257;p<0.001) mmHg and A-a gradient decreased to 240 (188-308;p<0.001) mmHg. 42 (19.9%) patients died in the respiratory units while on CPAP and 51 (24.2%) required intubation. There was a substantial overlap of baseline and CPAP-associated values of PaO2, P/F ratio and A-a gradient in CPAP failures and successes (Figure). CPAP-associated changes in PaO2, P/F ratio and A-a gradient in both groups were similar. Conclusion(s): CPAP-associated improvements in oxygenation cannot be used to inform clinical outcomes of the individual patient with severe COVID-19 pneumonia.

Analysis of combined non-invasive respiratory support in the first six waves of the COVID-19 pandemic. Outcome according to the first respiratory support

Introduction: COVID-19 can lead to acute respiratory failure (ARF) requiring admission to intensive care unit (ICU). This study analyzes COVID-19 patients admitted to the ICU, according to the initial respiratory support. Its main aim is to determine if the use of combination therapy: high-flow oxygen system with nasal cannula (HFNC) and non-invasive ventilation (NIV), is effective and safe in the treatment of these patients. Methods: Retrospective observational study with a prospective database. All COVID-19 patients, admitted to the ICU, between March 11, 2020, and February 12, 2022, and who required HFNC, NIV, or endotracheal intubation with invasive mechanical ventilation (ETI-IMV) were analyzed. HFNC failure was defined as therapeutic escalation to NIV, and NIV failure as the need for ETI-IMV or death in the ICU. The management of patients with non-invasive respiratory support included the use of combined therapy with different devices. The study period included the first six waves of the pandemic in Spain. Results: 424 patients were analyzed, of whom 12 (2.8%) received HFNC, 397 (93.7%) NIV and 15 (3.5%) ETI-IMV as first respiratory support. PaO2/FiO2 was 145 ± 30, 119 ± 26 and 117 ± 29 mmHg, respectively (p = 0.003). HFNC failed in 11 patients (91.7%), who then received NIV. Of the 408 patients treated with NIV, 353 (86.5%) received combination therapy with HFNC. In patients treated with NIV, there were 114 failures (27.9%). Only the value of SAPS II index (p = 0.001) and PaO2/FiO2 (p < 0.001) differed between the six analyzed waves, being the most altered values in the 3rd and 6th waves. Hospital mortality was 18.7%, not differing between the different waves (p = 0.713). Conclusions: Severe COVID-19 ARF can be effectively and safely treated with NIV combined with HFNC. The clinical characteristics of the patients did not change between the different waves, only showing a slight increase in severity in the 3rd and 6th waves, with no difference in the outcome. © 2022 Elsevier Ltd

Clinical Dilemma of Diabetic Ketoacidosis and COVID-19 Infection

The COVID-19 Pneumonia with diabetic ketoacidosis is a dreadful health condition. Diabetic ketoacidosis is one of the severe metabolic complications and it can be precipitated by infection. We presented a case of 48 years female with no known comorbidities who presented with COVID-19 symptoms and with Diabetic Ketoacidosis. The case presented with elevated inflammatory markers, high anion gap metabolic acidosis with type I respiratory failure. During admission, the oxygen saturation had marked drop, later her improvement was steady followed by gradual tapering of the oxygenation. Marked improvement was noticed in the subsequent follow-up. COVID-19 infection can be precipitated by preexisting diabetes or newly diagnosed diabetes and the severity of COVID-19 infection is more pronounced in patients with diabetes mellitus, thus should be managed timely and accordingly. The scarce studies among the COVID-19 cases with diabetic ketoacidosis reflect the need for further studies for the availability of a wider range of information. Copyright © 2021, Kathmandu University. All rights reserved.

Impact of Active Cycle of Breathing Technique on Selected Pulmonary Outcomes in Post-COVID Syndrome Patients

Background Worldwide, the 2019 coronavirus disease (COVID-19) pandemic has imposed a substantial burden. A large number of post-Covid-19 patients have long-lasting symptoms like fatigue and exercise intolerance. This condition been labelled 'post-acute sequelae of Covid-19' (PASC). Pulmonary rehabilitation is a comprehensive treatment that is based on a thorough assessment of the patient and is meant to improve the health of people with respiratory disease. Purpose To determine how active cycle breathing affects specific pulmonary outcomes in patients having post-COVID syndrome. Materials and methods 60 patients of both sexes (29 men and 31 women) took part. Their age was ranging from 40-50 years. Patients were randomized into 2 groups of the same size. Variables were assessed before and after training and statistically analyzed: Arterial blood gas analysis (ABG), the six-minute walk test (6MWT) and fatigue level Results: The mixed MANOVA statistical analysis results indicated no substantial change in any outcome measures between the two groups prior to treatment (p > 0.05). After treatment, comparisons across the groups showed that Group A had significantly increased (6MWT 11.09%, PaO2 3.5%, SaO2 2.7%) (Decrease fatigue 35.92% PaCO2 4.35%). Group B: (6MWT 21.61%, PaO2 12.41%, SaO2 6.43%) (Decrease fatigue 61.05%, PaCO2 10.75). Conclusion ABG parameters, fatigue level and six-minute walk test (6MWT) for post-COVID syndrome patients were all positively impacted by the active cycle of breathing technique, which is an efficient modality that may be incorporated into conventional physical therapy protocols. Copyright © 2023 Authors. All rights reserved.