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Objectives: Extracorporeal membrane oxygenation has been widely used in patients with severe respiratory failure due to Covid-19 infection. ECMO was initiated at ECMO center or implantation performed in regional hospitals and patients transferred to ECMO center for further treatment. The aim of the study was to evaluate characteristics and outcomes of patients retrieved with ECMO versus thoseimplanted in our institution. Method(s): Retrospective, single center study. Data of all Covid-19 patients, supported with ECMO from 2020.04.01 to 2022.06.01 in our institution were evaluated. Data of patients retrieved on ECMO to our hospital were compared with data of patients when ECMO support was initiated at our institution. Result(s): During Covid-19 pandemic 54 patients with severe respiratory failure were supported with ECMO. Out of them 24(44.4%) patients were retrieved on ECMO. In all patient VV configuration was used. There were no significant differences of preoperative characteristics between retrieved vs institutionally cannulated patients (mean age 44 +/- 16 vs 45 +/- 12 years, pre-ECMO arterial pO2 62 +/- 16 vs 66 +/- 14 mmHg, pre-ECMO mechanical ventilation 2.1 vs 2.2 days). The overall survival to hospital discharge was 32%, 33% in patients retrieved with ECMO vs 30% in the group of patients with ECMO implantation on site. Conclusion(s): Patient characteristics and hospital survival of patients who were retrieved with implanted ECMO to our ECMO center were comparable to those patients with ECMO implantation on site.
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Background: There is still no specific treatment strategy for COVID-19 other than supportive management. The potential biological benefits of ozone therapy include reduced tissue hypoxia, decreased hypercoagulability, modulated immune function by inhibiting inflammatory mediators, improved phagocytic function, and impaired viral replication. This study aimed to evaluate the effect of intravenous ozonated normal saline on patients with severe COVID-19 disease. Method(s): In this study, a single centralized randomized clinical trial was conducted on 80 hospitalized patients with severe COVID-19. The patients were selected by random allocation method and divided into two groups A and B. In group A (control group), patients were given standard drug treatment, and in group B (intervention group), patients received ozonated normal saline in addition to the standard drug treatment. In the intervention group, 400 mL of normal saline was weighed by 40 mug/ kg of body weight and was injected into patients within 15 to 30 minutes (80 to 120 drops per minute). This process was done daily every morning for a week. Primary and secondary outcomes of the disease included changes in the following items: length of hospital stay, inflammatory markers including C-reactive protein (CRP), clinical recovery, arterial blood oxygen status, improvement of blood disorders such as leukopenia and leukocytosis, duration of ventilator attachment, and rapid clearance of lung lesions on CT scans. The need for intensive care unit (ICU) hospitalization, the length of ICU stay, and the mortality rate in patients of the two groups was compared. Result(s): According to the results of the initial outcome variable analysis, the probability of discharge of patients who received the normal ozonated saline intervention was 33% higher than patients who did not receive this intervention;however, this relationship was not statistically significant (HR = 0.67, 95%, CI = 0.42-1.06, P value = 0.089). The chance of ICU hospitalization in patients of the intervention group was three times more than that of the comparison group, but this relationship was not significant (odds ratio = 4.4 95% CI = 1.32-14.50, P value = 0.016). The use of ozonated normal saline was found to increase the risk of death by 1.5 times but this relationship was not statistically significant (odds ratio = 1.5, 95% CI = .24-9.75, P value = 0.646). Ozonated normal saline had a significant effect on changes in respiration rate (in the intervention group the number of breaths was decreased) and the erythrocyte sedimentation rate (in the intervention group the erythrocyte sedimentation rate was increased);however, it had no significant effect on other indicators. Conclusion(s): The present study showed that ozone therapy in hospitalized patients with severe COVID-19 could help improve some primary and secondary outcomes of the disease. Governments and health policymakers should make ozone therapy an available care service so that the need for advanced treatment facilities decreases;consequently, this measure may improve patient safety, prevent lung tissue destruction, and control cytokine storms in patients. Additionally, health decision-makers need to aim for the effective clinical improvement of patients, especially severe ones, and the reduction of their mortality. However, further large-scale multicenter studies with larger sample sizes considering drug side effects and other variables influencing the clinical course of COVID-19 can provide more information on the effectiveness and importance of ozone therapy.Copyright © 2023 The Author(s);Published by Kerman University of Medical Sciences.
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Since beginning of 2020, SARS-CoV2 pandemic has been prevailing in humans causing COVID-19. Airways are strongly impacted during virus mediated inflammation and damage. Exact pathomechanisms during COVID-19 are still under investigation. We now further characterized limitations in exercise capacity in outpatient patients after symptomatic infection with SARS-CoV2 using bicycle cardiopulmonary exercise testing (CPET). 45 patients (21female/24 male) underwent standard pulmonary function testing (PFT) including spirometry, bodyplethysmography, CO-diffusion-measurement (DLCO, DLCO/VA), capillary blood gas-analysis (BGA) and symptom limited CPET on a bicycle. Patients' disease history was evaluated in advance. Severity of the disease was quantified according to reported data. At rest, there were no statistically relevant abnormalities in spirometry, bodyplethysmography, CO-diffusion-measurement or blood gas-analysis, even in those patients less than 40 days post infection. We found significantly impaired alveolar-arterial oxygen gradients (A-aO2) and decreased peak V'O2 level post-COVID-19 patients up to up to 80days post infection. Reevaluating 10 patients 3 month later, a markedly increase in peak oxygen-uptake (V'O2) and a normalized A-aO2 at rest was noted. We conclude that COVID-19 resulted in decreased cardiopulmonary exercised capacity as demonstrated by CPET (significantly decreased peak V'O2). The underlying mechanism is limitation of oxygen-diffusion indicated by significantly elevated A-aO2 level in post-COVID-19 patients. Limitation was temporary and patients reached age-appropriate level 3 month later.
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Vitamin D is a hormone rather than a vitamin in the strict sense. In fact, the active form 1,25 dihydroxyvitamin D3 [1,25(OH)2D3] exerts several effects on the inflammatory response of autoimmune rheumatic and infectious diseases. Low serum concentrations (less than 20 ng/ml) of 25-hydroxyvitamin D3 [25(OH)D3], the precursor of 1,25(OH)2D3, are common in COVID-19 patients and are associated with an impairment of the innate (neutrophils, monocytes/macrophages, dendritic cells) and adaptive (T and B lymphocytes, antibodies production) immune responses. Respiratory parameters (partial pressure of arterial oxygen-PaO2, partial pressure of arterial carbon dioxide-PaCO2, pressure of arterial oxygen to fractional inspired oxygen concentration-PaO2/FiO2), radiological pulmonary involvement, and serum concentrations of 25(OH)D3 were evaluated in sixty-five hospitalized COVID-19 patients (mean age 76 +/- 13 years) and sixty-five sex- and age-matched control subjects (CNT). COVID-19 patients showed significant lower 25(OH)D3 serum concentrations than CNT (median 8 ng/ml vs 16 ng/ml, p=0.001). 25(OH)D3 serum concentrations correlated positively with PaO2 (p=0.03) and PaO2/FiO2 (p=0.02). Moreover, 25(OH)D3 serum concentrations were significantly lower in COVID-19 patients with diffuse/severe radiological lung involvement (p=0.05) or multiple lung consolidations (p=0.0001) than in those with mild radiological lung involvement. Finally, significantly lower 25(OH)D3 serum concentrations were found in COVID-19 patients who died during hospitalization, compared to those who survived (p=0.05). In conclusion, vitamin D deficiency is associated with a more severe lung involvement and a higher risk of death in old COVID-19 patients.
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The value of (A-a)DO2 (alveolar-arterial oxygen gradient) is a simple way to measure alterations of the alveolarcapillary unit and could represent a reference of respiratory worsening. The aim of our study was to establish if the (A-a)DO2 values in patients with moderate/severe forms of COVID-19 could predict the evolution of the patients. We enrolled 41 adult patients with confirmed SARS-CoV-2 infection and respiratory failure, evaluated in the Hospital of Pneumology over three months. Considering only patients with available data from arterial blood gases analysis: three representative samples - between days 1-3, 4-7 and 8-10 on the same FiO2 (fraction of inspired oxygen), the (A-a)DO2 was measured and compared to the expected values for age. From a final population of 24 patients, 12 under RM (reservoir mask) and 12 under NIV (non-invasive ventilation), 9 died (55% under NIV). The gradient curves showed that in the group of the deceased, the (A-a)DO2 average values remained high (RM: 447- 470- 482 mmHg;NIV: 136- 171- 198 mmHg), whereas in the survivors' group, the values of the gradient described an ascending-decreasing slope (RM: 467- 458- 426 mmHg;NIV: 151- 167- 119 mmHg) that corresponds to the improvement of the pulmonary damage. The (A-a)DO2 resulted to be a good predictor of severity and mortality in patients with SARS-COV-2 infection and also for the need of oxygen therapy and NIV. Therefore we decided to use (A-a)DO2 instead of PaO2 (partial pressure of oxygen) in the surveillance of patients with COVID-19 because of its better capability to underline the presence of ventilatory/perfusion mismatch, mechanism underlying in the pathophysiology of hypoxemia in COVID19.
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Aim: We primarily aimed in this study was to evaluate risk factors for COVID-19 infection and if any association between dialysis inadequacy in COVID-19 infection in maintenance hemodialysis (MHD) patients. Secondly aimed to describe prevalence and risk factors associated with long-lasting symptoms of non-deceased COVID-19 MHD patients before vaccination. Material(s) and Method(s): One hundred one MHD patients infected with COVID-19 and 100 MHD patients without the infection were enrolled in this retrospective cross-sectional study. Risk factors for mortality, need to intensive care unit (ICU) stay and long-lasting symptoms were analyzed. Result(s): The mean age of patients was 59.13+/-13.58 years. COVID-19 infected patients had significantly higher number of patients with DM, COPD, CHF. The need for ICU was found to be statistically significantly higher in patients with COPD and DM. In our results, the patients who had lower Kt/V at admission hospital had more than 5 fold higher rate of COVID-19 those have higher Kt/V. We analyzed risk factors for mortality at, one year included higher age, higher CRP and lower base-line Kt/V were diagnostic criteria. Older MHD patients had a high frequent of long-lasting symptoms. Low Kt/V, low hemoglobin level and high CRP level associated with a higher risk of long-lasting symptoms (p=0.00, p=0.001, p=0.02) Discussion: We conclude that DM, CHF, COPD, older age, obesity were poor prognostic factors for in infected with COVID-19. Dialysis adequacy parameters of Kt/V, serum albumin level, hemoglobin level were significantly lower in need to ICU and deceased patients.Copyright © 2023, Derman Medical Publishing. All rights reserved.
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Introduction: Covid-19 patients present symptoms and complications after the declaration of cure, which defines the post-covid-19 period, The objective of this study was to identify persistent symptoms and thromboembolic complications 4-6 weeks after recovery from COVID-19. Patients and Methods: In January 2022, We conducted a retrospective, analytical and descriptive study of 220 patients seen in the post-covid-19 consultation of the pneumology department of the Hassan 2 hospital in Agadir. Result(s): The average age was 50.3 years with a sex ratio (M/F) of 0.83. The prevalence of the post-COVID-19 syndrome was 45%, the persistent symptoms in post-COVID-19 were: 43% fatigue, 36% dyspnea, 24% cough, 29% sleep disorders, 14% oppressive chest pain, 10% smell disorders, 4% taste disorders, 13% myalgia and arthralgia, 12% cognitive disorders, 5% arterial oxygen desaturation. Thromboembolic complications noted in our series were mainly pulmonary embolisms found in 6% of patients and one case of ischemic cerebrovascular accident. Conclusion(s): The post-covid-19 manifestations in the omicron wave were present in a significant number of subjects as in the other waves, hence the interest of post-covid-19 follow-up for the management of these manifestations.
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Targeted therapeutics for SARS-CoV-2 virus caused COVID-19 are in urgent need. Chansu has been reported to have broad-spectrum antiviral effects and widely used in Southeast Asian countries. This study aims to assess the efficacy of Chansu injection in treating patients with severe COVID-19. A randomized preliminary clinical trial was conducted and eligible patients were allocated to receive general treatment plus Chansu injection or only general treatment as control for 7 days. The primary outcomes of the oxygenation index PaO2/FiO2 and ROX, secondary outcomes of white blood cell count, respiratory support step-down time (RSST), safety indicators, etc were monitored. After 7 days of treatment, the oxygenation index was improved in 95.2% patients in the treatment group compared with 68.4% in the control group. The PaO2/FiO2 and ROX indices in the treatment group (mean, 226.27+/-67.35 and 14.01+/-3.99 respectively) were significantly higher than the control group (mean, 143.23+/-51.29 and 9.64+/-5.54 respectively). The RSST was 1 day shorter in the treatment group. Multivariate regression analysis suggested that Chansu injection contributed the most to the outcome of PaO2/FiO2. No obvious adverse effects were observed. The preliminary data showed that Chansu injection had apparent efficacy in improving the respiratory function of patients with severe COVID-19.Copyright © 2021 The Authors
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Maintaining an active medical research career is a multifaceted undertaking, and many challenges arise, even under normal circumstances. Therefore, the Australian government mandated COVID19 lockdowns and worksite restrictions from 2020 2021 inflicted an additional layer of complexity to an already complicated career for most researchers. A critical issue I faced during these COVID19 lockdowns was to establish whether our research focus was considered an essential service during a period of time when the public health advice was to restrict the movement of research staff and students by enacting new laws to ensure they stay at home. My research team members were also rightfully worried about contracting COVID19 during a period when a viable vaccine was not available. In this presentation, I will be covering some of the adaptive changes I implemented during the COVID19 lockdowns to ensure the continuity of our research program, which includes: 1) Proactive engagement with our medical institute and university COVID-19 taskforces to formulate a joint vision of which research areas should be prioritised during these lockdowns in pursuit of both treatments and vaccines;2) Continuous communication with my research team to encourage, motivate and energise staff and students to allow them to contribute to the research program meaningfully;3) Provide flexible working hours for research team members to work within the confinements of a reduced worksite footprint with an appreciation for social distancing;and 4) Contingency planning to ensure if one research team member contracts COVID-19, there are others with the cross-functional skillset to take over their responsibilities. Taking such steps ensured the rapid development of a new treatment regime that was showing impressive results in reversing multi-organ dysfunction in another clinically challenging area in intensive care units (sepsis). Following the preclinical assessment of safety and efficacy of this new treatment regime, we were able to compassionately treat a critically ill COVID19 patient receiving intensive care at Austin Health. In a short period of time, we saw improved regulation of blood pressure, arterial blood oxygen levels and kidney function. The patient was able to be taken off machine ventilation 12 days after starting sodium ascorbate treatment and discharged from hospital without any complications 22 days later. This research has now informed the design and commencement of multi-centre randomised controlled clinical trials at four hospital intensive care units in Australia.
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Background: COVID-19 is associated with dangerous thromboembolic complications, such as stroke, heart attack, pulmonary em-bolism, and arterial and venous thromboembolism (VTE). Early diagnosis and even prediction of thromboembolic complications using biomarkers could facilitate the treatment and decrease the mortality rate. Objective(s): This study evaluated and compared the clinical and laboratory findings of COVID-19 patients with thrombotic events with other COVID-19 patients. Method(s): A total of 114 confirmed COVID-19 patients referred to Taleghani Hospital, Tehran, Iran, between February and September 2020 were included in this cross-sectional study. Those with a history of thromboembolic disease were excluded. The laboratory data, including the levels of lactate dehydrogenase (LDH), D-dimer, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and counts of lymphocyte and neutrophil, along with clinical findings (such as oxygen saturation and lung involvement percent-age), were retrospectively collected from the patients' clinical files. The incidence of thrombotic events was evaluated in patients. Result(s): The prevalence of thrombosis in the right and left main pulmonary arteries, right and left sub-segmental pulmonary ar-teries, and right and left deep veins was 2.7%, 3.5%, 7%, 7.9%, 4.4%, and 1.8% of all patients, respectively. The results showed that throm-boembolic complications were significantly associated with mortality (P < 0.001). Besides, it was found that LDH (P < 0.001) and neutrophil (P = 0.002) levels in thromboembolic COVID-19 patients were respectively higher and lower than those without throm-boembolic manifestations. Conclusion(s): High LDH and neutropenia might serve as biomarkers for thromboembolism in COVID-19 patients. Copyright © 2022, Author(s).
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The use of methylprednisolone in patients with Coronavirus disease 2019 (COVID-19) requiring intensive care hospitalization: a longitudinal observational study. Background : For a long time, the use of corticosteroids in critically ill patients with coronavirus disease 2019 (COVID-19) has been a controversial treatment. However, given the conflicting evidence on this topic, we studied the effects of methylprednisolone on critically ill patients and - share here our experience on laboratory findings and the Pa02/FiO2 ratio (ratio of partial oxygen concentration on arterial blood gas sample to fraction of inspired oxygen). Methods : In a population of 68 patients hospitalized in the intensive care unit due because of COVID-19 infection, 28 patients with severe respiratory failure received methylprednisolone on a fixed 12-day regimen (125 mg IV for 2 days, followed by 2x0.5 mg/kg IV twice daily for 5 days, and then a decreasing regimen for 4 days until discontinuation). After day 5 and day 10, we analyzed the levels of CRP (C-reactive protein), lymphocytosis, D-dimer, LDH (lactate dehydrogenase) and PaO2/FiO2 ratio of our patients. Results : We observed a significant decrease in median CRP levels between day 0 (start of methylprednisolone treatment) and day 5 (p=0.001), and between day 0 and day 10 (p=0.005). No decrease was seen between day 5 and 10 (p=0.352). The same increase in PaO2/FiO2 was recorded between day 0 and day 5 (p=0.009), and between 0 and day 10 (p=0.019). For D-dimer, only a significant difference was found between day 0 and day 10 (p=0.018). No significant difference could be observed for lymphocytosis and LDH levels between the beginning of the treatment and day 5 or day 10. Conclusion : There is a strong and sustained significant decrease in CRP levels and a tilt in the PaO2/FiO2 ratio after starting methylprednisolone. A slower, but also significant decrease was found for D-dimer. Further research and control group analyses are needed to confirm that this effect is due to corticostreoid treatment. However, this indicates that methylprednisolone may play a very important role in the treatment of the severely ill COVID-19 patients requiring ICU admission. Copyright © Acta Anaesthesiologica Belgica, 2021.
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Purpose of the study is to determine the success rates of alveolo-arterial oxygen gradient (AaDO2) and the pneumonia severity index (PSI) in predicting mortality for the patients diagnosed with COVID-19 pneumonia. This retrospective study included patients who were treated with the diagnosis of COVID-19 pneumonia in the ICUs. Demographic characteristics, arterial blood gas values, radiological images and laboratory data of the patients were used through the hospital database and patient files. Group I patients consist of alive and Group II patients consist of deceased persons. 150 of 263 patients included in this study are in Group I and 113 are in Group II. RT-PCR test was positive in 20.9% of the patients. The most common symptom was dyspnea with 76.5% and the most common additional disease was hypertension with 58.1%.65% of patients had radiological involvement in both lungs, and the most common finding was the ground-glass opacity at 71.5%. In predicting mortality, PSI value was 135 in group I and 174 in group II (p<0.001);AaDO2 value was 154.88 mmHg in group I, 177.13 mmHg in group II (p<0.001), and this rate was different between the groups. Sensitivity is found at 84.1% and specificity at 67.3% for PSI, whereas sensitivity is found at 49.6% and specificity at 82.7% for the AaDO2 variable. It is important to estimate the mortality risk earlier for the patients with COVID-19 pneumonia who are also followed up in intensive care units. PSI is beneficial in detecting mortality risk whereas AaDO2 is valuable in determining the surviving patients. Copyright © 2022 Ondokuz Mayis Universitesi. All rights reserved.
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SESSION TITLE: Global Case Reports in Critical Care SESSION TYPE: Global Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Thrombotic complications in patients diagnosed with COVID-19 pneumonia are emerging as an important and significant morbidity and mortality burden, with overwhelming inflammation, hypoxia, immobilization, and diffuse intravascular coagulation among possible causes of a procoagulant state (1). Obstructive sleep apnea (OSA), with intermittent arterial oxygen desaturation, may in its turn contribute to a procoagulant state, causing hemodynamic alterations as polycythemia and sluggish blood flow (2). Here we report on a case of sudden and massive non-lethal pulmonary thromboembolism (PTE) in a patient with COVID-19 severe pneumonia, for whom OSA was suspected and documented as a possible concurrent mechanism of thromboembolic complication during follow-up. CASE PRESENTATION: A 55-year-old male non-smoker obese (BMI 33 Kg/m2) was admitted to our hospital after 9 days of fever. In the Emergency Room, a chest HRCT scan showed bilateral diffuse ground glass opacities. He was treated with subcutaneous Tocilizumab (324 mg) single shot, Remdesivir (200 mg/day for first day and 100/daily for further 4 days), methyl-prednisolone 40 mg/daily, Enoxaparin 6000 UI/twice daily, azithromycin 500 mg/daily, high flow nasal cannula oxygen (50 L/min, TC 34°C, FiO2 35%) for moderate acute respiratory failure due to COVID-19 pneumonia (pO2: 58 mmHg, PCO2 34 mmHg pH 7.50, P/F 275). After 10 days, patient's clinical conditions worsened, needing non-invasive respiratory support;D-dimer increased abruptly, rising to 10 ng/mL, with findings consistent with PTE at a computed tomographic angiography (CTA, Fig 1). The patient was successfully treated with 10 mg/daily subcutaneous fondaparinux for 12 days, while assisted in the Intensive Care Unit, being discharged home in room air shortly later with oral anticoagulants. At the 3-month follow-up visit, OSA was suspected due to reported excessive daytime sleepiness and weakness, snoring, disturbed night sleep, morning headache in the last 4 years. The patient underwent a home sleep apnea test (HSAT) overnight. Test results revealed an AHI of 50 events/h, with several prolonged episodes of obstructive sleep apnea (307 apnea and hypopnea (A+H) events, 70 obstructive apnea and 233 hypopnea events, with a mean duration of 10% and an average arterial saturation of 93% (Fig. 2). He was adapted to CPAP therapy, with benefit and good correction of polygraphic indexes. DISCUSSION: The pathogenetic mechanisms of COVID 19 and OSA could have played a synergistic effect on endothelial damage, thus increasing the risk of thromboembolism. CONCLUSIONS: The presence of underdiagnosed comorbidities may well worsen the clinical course and complication of COVID-19;an earlier diagnosis of OSA is a prerequisite for timely treatment and, potentially, improved long-term clinical outcomes. Reference #1: Suh YJ, et al. Pulmonary embolism and deep vein thrombosis in COVID 19: a systematic review and meta-analysis. Radiology 2021;298 (2): E70-E80. Reference #2: Alfonso-Fernandez A., Garcia Surquia A., de la Pena M. OSA is a risk factor for recurrent VTE Chest. 2016;150 (6): 1291-1301. DISCLOSURES: no disclosure on file for Antonietta Esposito;no disclosure on file for Antonella Frattari;no disclosure on file for Giustino Parruti;no disclosure on file for Giorgia Patrizio;no disclosure on file for Pierpaolo Prosperi;no disclosure on file for Giorgia Rapacchiale;No relevant relationships by ANTONELLA SPACONE no disclosure on file for Giacomo Zuccarini;
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CASE: A Hispanic-speaking 63-year-old lady presented with left shoulder pain and dyspnea since two weeks. Past history was significant for cirrhosis due to autoimmune hepatitis and portal hypertension diagnosed 1.5 years prior. Upon further questioning, she revealed that she had exertional dyspnea for 2 years, which got progressively worse after her COVID-19 infection, 14 months prior. On initial exam, her hemoglobin levels were unchanged with previous. Troponin and BNP levels were unremarkable. CT Pulmonary Embolus scan and shoulder X-ray were negative. However, her SpO2 which was 90% on lying flat, fell to 84% on walking and she was admitted for further workup. On exam, she had a loud S2, spider angioma, and clubbing. ABG showed an alveolar-arterial oxygen gradient of 54.7 mm and PO2 of 61.7 mm. A contrastenhanced transthoracic echo with saline showed significant shunting with dilated pulmonary veins. Upon close inspection, she had a small right to left intracardiac shunt through an incidental PFO and a rather large intrapulmonary shunt. This was confirmed on trans-esophageal echo. Right heart catheterization showed a high cardiac index (5.3 L/min) suggestive of a high-output state, as typically seen with cirrhosis. It also revealed increased right-sided oxygen saturations, confirming the presence of a significant left to right shunt. Finally, pulmonary CT angiography was negative for AVMs. These findings were congruent with hepato-pulmonary syndrome (HPS) and based on her presenting symptoms she was referred to hepatology for consideration of liver transplantation. IMPACT/DISCUSSION: HPS is characterized by abnormal oxygenation due to intrapulmonary vascular dilations (IPVD) in the setting of advanced liver disease. Diagnosis needs an elevated A-a gradient (≥ 15mm or ≥ 20 mm if >64 years). IPVDs may not be seen on CT scans and are optimally detected on CE-TTE. The delayed appearance of injected microbubbles in the left heart, 3 or more cardiac cycles after visualization in the right heart signifies abnormally dilated pulmonary capillaries which don't trap the bubbles. TTE can help differentiate intracardiac and intrapulmonary shunts, by revealing the source of the microbubbles entering into the left atrium (across the atrial septum vs pulmonary veins). Shunting classically causes platypnea-orthodexia (worsening dyspnea on standing or sitting, alleviated by lying down). Alterations in lung parenchyma due to COVID-19 could have increased the flow through intrapulmonary AVMs and contributed to the worsening of symptoms. Management of HPS is supportive. Liver transplantation improves survival. CONCLUSION: Evaluation and management of HPS involves multiple modalities of testing and specialists in gastroenterology, cardiac imaging, interventional cardiology, interventional radiology, and transplant surgery. The diagnosis of HPS should escalate referral to a liver transplant center. Engaging medical interpreters can help elicit more detailed history and improve clinical outcomes.
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Rationale: Severe coronavirus disease 2019 (COVID-19) is associated with significant morbidity attributed from the complications of acute respiratory distress syndrome. Poor outcomes in severe COVID-19 patients have been related to cytokine release syndrome, which may be mediated by CX- C chemokine ligand 8/interleukin 8 (CXCL8/IL-8) acting through C-X-C chemokine receptor types 1 and 2 (CXCR1/2). The aim of this clinical trial was to determine if CXCR 1/2 blockade by reparixin, an IL-8 inhibitor, can improve clinical outcomes in hospitalized patients with severe COVID-19 pneumonia. Methods: This was a Phase 2, open-label, adaptive, multicenter, randomized trial in hospitalized adult patients, conducted in Italy and Brazil, with severe COVID-19 pneumonia between May and November 2020. Eligible patients had respiratory distress (respiratory rate ≥30 breaths/minute without oxygen and/or partial arterial oxygen pressure (PaO2)/fraction of inspiration O2 (FiO2) >100 to <300 mmHg), pneumonia confirmed by chest imaging, and elevated inflammatory markers. Patients were randomized 2:1 to receive oral reparixin 1200mg three times daily or the standard of care (SOC) for up to 21 days. Patients were followed for up to seven days after the end of treatment. The primary endpoint was defined as a composite of clinical events: use of supplemental oxygen, need for mechanical ventilation, intensivecare unit admission, and/or use of rescue medication. This study was funded by Dompé Farmaceutici SpA (ClinicalTrials.gov: NCT04794803). Results: Fifty-five patients were enrolled and included in the final analysis comparing reparixin (n = 36) to the SOC (n = 19). The rate of clinical events was statistically significantly lower in the reparixin group compared to the SOC group (16.7% [95% CI: 6.4-32.8%] vs 42.1% [95% CI: 20.3-66.5%], p=0.02). After controlling for covariates, this statistical significance was maintained with a hazard ratio of 0.33 (95% CI, 0.11 to 0.99;p = 0.047). Reparixin treatment appeared to be well-tolerated with no discontinuation of therapy. Conclusions: In patients with severe COVID-19, reparixin led to a significant improvement in clinical outcomes when compared to the SOC. The results of this phase 2 study allowed progression to a Phase 3 clinical trial to further explore the efficacy and safety of reparixin for the treatment of severe COVID- 19.
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Background/Introduction: As Coronavirus Disease 2019 (COVID-19) continues to perpetuate in pandemic proportions, much needs to be understood on the various risk factors that can serve as reliable predictors of severe COVID-19. There is an urgent need to gather local data from our hospitalized patients that will aid our clinicians in risk stratifying subsequent COVID- 19 admissions and provide appropriate and timely interventions. Rationale: To determine the various demographic, clinical and laboratory risk factors on admission that could predict the development of severe to critical pneumonia among COVID-19 patients admitted in a tertiary hospital in the Philippines from March 2020 - December 2020. Methods: In this retrospective cohort study, demographic details, clinical features and laboratory work-up of all adult hospitalized patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) infection were obtained from the medical records of a tertiary hospital in the Philippines from March to December 2020. Anonymized data were analyzed from February to April 2021 using multiple logistic regression and univariate analysis to determine the possible predictors of severe COVID-19. Results: Of the 845 hospitalized patients analyzed in this study, the mean age of the population was 55.9 years and 54.9% were male. Severe cases comprised majority of the COVID-19 admissions (49.36%), followed by critical cases (23.3%), then mild (12.87%) and moderate cases (14.47%). Overall mortality was 18.09% with majority from the critical cases. Among those who developed severe and critical COVID-19 pneumonia, older age, male, previous/current smoker, hypertension, type 2 diabetes mellitus, chronic kidney disease and decreased baseline peripheral oxygen saturation were noted to be potential predictive factors. Among laboratory values, factors associated with severe COVID-19 included leukocytosis, neutrophilia, lymphopenia, elevated levels of alanine aminotransferase, blood urea nitrogen, creatinine, lactate dehydrogenase, C-reactive protein, D-dimer and ferritin and decreased levels of absolute lymphocyte count, partial pressure of oxygen and arterial oxygen partial pressure to fractional inspired oxygen ratio (PO2/FiO2). Conclusion: In this cohort, there were various demographic data, clinical features and specific laboratory derangements associated with severe to critical COVID-19 pneumonia. These findings can aid clinicians in the risk stratification of COVID-19 admissions. (Table Presented).
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BACKGROUND AND AIMS: Electrolyte abnormalities are common among patients with coronavirus disease 2019 (COVID-19). This study aims to investigate the electrolyte changes in severe and non-severe COVID-19 patients. Hypocalcaemia, hypomagnesaemia and hypoalbuminemia and their relationship with the severity of symptoms and prognosis will also be determined. METHOD: We enrolled 270 COVID-19 patients. Serum tests were taken from each patient on the day of admission to check the level of variables. Thereon, calcium, magnesium and phosphorus levels were measured twice a week and albumin levels were measured once a week. Variables such as PTH and 25 (OH) D were measured once at the beginning of the study. Other laboratory results like complete blood count, C-reactive protein and clinical data such as arterial blood oxygen levels, length of stay in the ICU and the treatment regimen were extracted from patients' medical records and history. Finally, patients were categorized as mild, moderate, severe and critical group based on the severity of the disease. The data analyses were carried out via SPSS software (version 21.0). RESULTS: Of 270 patients, 135 people (50%) were men. The mean age of patients was 46.7 years. Based on the severity of the disease, 91 patients had mild disease, 90 patients presented with moderate disease, 54 patients were in severe condition and 35 patients were critical. Hypocalcaemia (Ca2+ ≤8.6 mg/dL) was detected in 49 patients (18.1%) on admission. The mean of serum magnesium, phosphorus and albumin levels on admission was 2.2 ± 0.22 mEq/L, 3.39 ± 0.79 mg/dL and 4.49 ± 0.66g/dL, respectively. Phosphorus level was lower than 2.63 mg/dL in 11 patients (4.07%) and 43 patients (15.92%) had hypoalbuminemia. The mean 25(OH) D level was 32.92 ± 10.29 μg/L;therefore, 182 patients (67.40%) fall within the normal range (>30 μg/L). CONCLUSION: Patients with mild and moderate disease tend to develop hypocalcaemia, hypoalbuminemia and hypomagnesaemia more often than severe and critical COVID-19 patients during treatment. 25(OH) D deficiency rate was higher in the moderate group. Patients with hypocalcaemia during treatment had higher mortality than other patients. We recommend electrolytes be measured at initial presentation and serially monitored during hospitalization in order to establish timely and appropriate corrective actions and prevent the serious complications of the disease.
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Insertion of nasogastric tube is one of the commonest clinical procedures. However, very rarely, the tube can coil on itself to form something called a Lariat loop. This is a knot that can cause the tube to get stuck inside the pharynx and can precipitate emergencies like laryngeal obstruction or esophageal rupture. A brief discussion of a case along with the causes and prevention of this complication has been done.
ABSTRACT
Background: Second wave of SARS-CoV-2 pandemic showed a devastating impact in term of absolute mortality, higher than observed in the first wave. Objective of the study was to evaluate factors associated with mortality among COVID patients in hospital setting. Materials and Methods: We retrospectively evaluated clinical data, SARS-CoV-2 E and N2 genes expression on nasal swab and outcomes of patients hospitalized for COVID pneumonia in a lowintensity medical care unit during the second wave of pandemic. Results: We evaluated 163 patients (64,4% M, 35,6% F), mean age 69,6±14 years, Decease was observed in 11,7% of cases. A significant higher mortality was present in patients with diabetes (p=0,027;OR 2,91), hematologic diseases (p=0,002;OR 7,4) and cirrhosis (p<0,0001). Remdesivir was the only treatment associated with a lower mortality (p=0,01, OR 0,5). Deceased patients showed a longer duration of symptoms before hospitalization (p=0,032) and lower levels of arterial oxygen tension (pO2) at the admission (p=0,22). Lower admission pO2 levels showed a good accuracy to identify patients who deceased (AUC=0,73, p=0,022), with an optimal cut-off of pO2<45 mmHg (Sns 77%, Spc 81%). An inverse relation between oxygen saturation and gene E (R=-0,28;p=0,009) and N2 (R=-0,36;p=0,003) expression was present. Conclusions: Several factors may stratify the risk of death in patients with COVID pneumonia, including comorbidities, pO2 at the admission and levels of viral replication. A pO2<45 mmHg detected in the emergency department may identify patients with higher risk of death. Remdesivir treatment was associated with a lower mortality.