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Background/Aims We report the features of chronic chilblain-like digital lesions newly presenting since the start of the covid-19 pandemic. Comparison with primary perniosis and acrocyanosis, reveals a unique phenotype which appears to be a long-covid phenomenon. Methods The case records of 26 patients with new onset persistent chilblain-like lesions presenting to the Rheumatology service of St George's University Hospital, London between Autumn 2020 and Spring 2022 were reviewed. Demographic and clinical features, serology, imaging, treatment response and outcome up to Summer 2022 were collated retrospectively. Results Chilblain-like lesions first occurred between September and March;2019/ 2020 6 cases, 2020/2021 18 cases and 2021/2022 2 cases. Mean age 35.4 (17-60) years, 88% female, 85% white, all non-smokers. Median body mass index (BMI) 20.2, range 17.0 - 33.2. BMI underweight (<18.5) in 27%. All cases reported new red-purple-blue colour changes of the fingers, some with pain, swelling and pruritis, affecting both hands in 12, one hand in 6, and both hands and feet in 8 cases. There was a past history of cold sensitivity or primary Raynaud's in 54%. Covid was confirmed in 3 cases, 2 - 8 months prior to onset of chilblain-like symptoms. Possible covid, unconfirmed, was suspected in 5 cases, 1 - 11 months earlier. Affected digits appeared diffusely erythro-cyanotic in 81%, with blotchy discrete maculo-papular erythematous lesions in 42%, some with both features. Involvement was asymmetric in 54%, thumbs spared in 69%. Complement was low in 50% (8/16), ANA positive in 26% (6/23). MRI of hands showed phalangeal bone marrow oedema in keeping with osteitis in 4 of 7 cases. More severe signs and symptoms were associated with low BMI, low C3/4 and a past history of cold sensitivity or Raynauds. Cold avoidance strategies were sufficient for 58%. Pain prompted a trial of NSAIDs, aspirin, nitrates, calcium channel blockers, hydroxychloroquine, oral or topical corticosteroid or topical tacrolimus in 42%. In general, these were minimally effective or not tolerated. 4 severe cases received sildenafil or tadalafil, effective in 2. In 27% complete remission occurred during the first summer season after symptoms commenced, median duration 6 (range 2 - 10) months. In the remaining 19 cases, chilblain-like symptoms returned or worsened in the subsequent second winter period, with 6 of 19 entering remission the following summer. For the remaining 13 persistent cases the total duration of symptoms spans more than a year, and in four cases more than 2 years. Conclusion This series illustrates a distinct chronic chilblain-like condition. Features similar to primary perniosis include female predominance, middle age, pruritic painful blotchy lesions, asymmetry and low BMI. Features in keeping with acrocyanosis include chronicity, extensive diffuse erythro-cyanotic discoloration, relative improvement in warm weather and lack of association with smoking.
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Background: Nirmatrelvir/ritonavir (NMV/r), a preferred antiviral for high-risk outpatients with COVID-19, is associated with major drug-drug interactions (DDIs). Given the lack of DDI data with short course ritonavir (RTV), initial NMV/r product information was extrapolated from chronic, full dose RTV use. In Jan 2022, DDI experts from the University of Liverpool (UoL), NIH COVID-19 Guidelines Panel, and Ontario Science Table (OST) contributors established a global collaboration to address DDI challenges limiting NMV/r use in real-life settings. We report how safe, pragmatic, and consistent resources were developed to support NMV/r prescribing, and the utilization of these resources globally. Method(s): The 3 teams met monthly to discuss DDIs, review NMV/r DDI literature, and achieve consensus on recommendations. Additional experts were invited as needed. Metrics from the UoL DDI checker guided review of most searched DDIs overall and by severity. 2022 usage metrics for each DDI guide were collected. Differences in recommendations between initial DDI guides and product information were compared. Result(s): In 2022, 12 meetings were convened. Each team's DDI guide was revised and expanded (Table 1). To factor in the lower RTV dose and shorter treatment duration, some recommendations differed from product information. Drug categories that required the most discussion and revision included: anticoagulants (ACs), immunosuppressants, calcium channel blockers. NMV/r accounted for 85% of queries on the UoL site. NMV/r DDI guidance was the most viewed page of the NIH guidelines and among the OST ID/clinical care Science Briefs. Top searched drugs on the UoL site with serious DDIs were certain ACs and statins. Utilization of DDI guides was not limited to in-country resources: 51% and 7% of UoL queries came from the USA and Canada, respectively. NIH users followed links to the UoL and OST sites 161,478 and 37,619 times, respectively. Conclusion(s): Significant efforts have been made by the 3 teams to provide upto-date, complementary DDI guidance. Usage metrics confirm the demand for DDI guidance during the pandemic. Cross-utilization of the DDI guides confirms the need for consistency. DDI recommendations were more permissive than initial product information, expanding clinicians' ability to prescribe NMV/r. DDI guidance for ACs and immunosuppressants was particularly challenging. During drug development, complex interactions likely to be encountered in target populations should be addressed.
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Introduction: The main prevention of cardiovascular disease (CVD) and healthcare cost reduction depend on the early identification and treatment of cardiovascular disease (CVD) risk factors through screening. Hypertension, obesity, a large waist circumference, smoking, poor diets, physical inactivity, and excessive alcohol consumption are well-known and potentially treatable risk factors for cardiovascular disease. This allows for early detection of instances, informs the start of CVD prevention medication, and is also very cost-effective. Method(s): At rural India, between March and August 2021, a cross-sectional survey was conducted in community pharmacies. One thousand two hundred healthy individuals were screened for signs of obesity, high blood pressure, waist circumference, and history of smoking and alcohol intake. A structured questionnaire was used to get participants' physical activity and diet. Result(s): The gender split of the 1200 participants who were screened was 67.8% male and 32.3% female. Participants' ages ranged from 18 to 60 years old in 43.3% of cases, 41 to 60 years old in 26.3%, and over 60 in 30.4% of cases. There were 43.7% of drinkers and 47.3% of smokers, respectively. A BMI of 25 kg/m2 or more indicates being overweight, whereas a BMI of 30 kg/m2 indicates being obese. Using a diagnostic cutoff of >140/90mmHg prevalence of hypertension was 44.3%, and 14.9% out of these were previously hypertensive. 31.5% had high waist circumference, 13.9% had insufficient physical activity, and 34.9% had insufficient intake of fruits and vegetables. Conclusion(s): The majority felt that screening for CVD risk factors was helpful, and more than one-fourth of the study participants had two or more CVD risk factors combined. A cost-effective strategy for the primary prevention of CVD that can have a positive influence on the healthcare delivery system is the capacity to further discover previously undetected risk factors.Copyright © 2023, Global Research Online. All rights reserved.
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Background: The outbreak of a new coronavirus in China in 2019 (COVID-19) caused a global health crisis. Objective(s): This study was performed to investigate the effect of different underlying diseases on mortality in patients with COVID-19. Method(s): This retrospective cohort study was performed on COVID-19 patients admitted to the Shahid Rahimi and Sohada-ye Ashayer teaching hospitals in Khorramabad, Iran, from 2019 to 2021. Data on disease severity, clinical manifestations, mortality, and underlying disorders were collected and analyzed using the SPSS software version 22 at a 95% confidence interval and 0.05 sig-nificance level. Result(s): The study included 9653 men (48%) and 10332 women (52%). Patients with chronic kidney diseases, cancer, chronic obstruc-tive pulmonary disease, hypertension, cardiovascular disease, and diabetes were at higher mortality risk than those without these underlying diseases, respectively. However, there was no significant relationship between asthma and mortality. Also, age > 50 years, male gender, oxygen saturation < 93 on admission, and symptoms lasting <= 5 days were associated with increased mortality. Conclusion(s): Since patients with underlying diseases are at higher mortality risk, they should precisely follow the advice provided by health authorities and receive a complete COVID-19 vaccination series.Copyright © 2022, Author(s).
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Aim: Angiotensin-converting enzyme 2 (ACE2) acts not only as an enzyme but also as a thought to be central receptor by which severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) enters host cells. Angiotensin-converting enzyme inhibitors (ACEIs) are thought to $1 are central to SARS-CoV-2 progression. However, its effect on clinical outcomes is still not fully explained. In this study, we investigated the effects of ACEIs use on pulmonary computed tomography findings. Method(s): The data of the patients who were hospitalized for SARS-CoV-2 pneumonia and were using medications for the diagnosis of hypertension from 20th March to 20th June 2020 were evaluated retrospectively. Patients were divided into 2 groups patients using ACEIs and not using ACEIs. Result(s): The study was conducted with 107 patients. Mild cases without signs of pneumonia were excluded from this study. Moderate cases were accepted as patients with symptoms related to the respiratory system and pneumonia detected on imaging. SpO2<=93%, >=30 breaths/min respiratory rate, and patients who developed respiratory failure, mechanical ventilator need, shock, or multiorgan failure were included in the severe and critically ill cases group. Severe and critical cases were evaluated as a single group. When the radiological images of the patients were examined, it was remarkable that multilobar findings were less common in the ACEIs using group (p<0.001). At the clinical end point, mortality rates in patients using ACEIs (12.7%) were significantly lower than patients without using ACEIs (32.7%). Conclusion(s): In our study, we showed that SARS-CoV-2 progresses with less multilobar involvement in pulmonary computed tomography in patients using ACEI.Copyright © 2023 by The Medical Bulletin of Istanbul Haseki Training and Research Hospital The Medical Bulletin of Haseki published by Galenos Yayinevi.
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Objective: To study the association of calcium channel blockers (CCBs), the renin-angiotensin-aldosterone system (RAAS) inhibitors or their combination as antihypertensive medications and the clinical outcome of COVID-19 infection. Design and method: This is a retrospective cohort study using de-identified data retrieved from clinical records of COVID-19 patients in two isolation centers. Medical history, demographic data, symptoms, complications and laboratory investigations were extracted from clinical records of 406 confirmed COVID-19 hospitalized patients between Feb 2020 and July 2021. Hypertension and antihypertensive treatments were confirmed by medical history and clinical records. Continuous variables were presented as means ± standard deviation (SD) while categorical variables were presented as percent proportions. Logistic regression was used to assess the impact of antihypertensive drugs (RAAS inhibitors, CCBs, combination of RAAS inhibitors and CCBs and those not receiving medication) on the prognosis of COVID-19 patients and to explore the risk factors associated with mortality. Result: Out of 406 hospitalized COVID-19 patients, 242 (59.6%) had a history of hypertension. Hypertensive patients under the age of 65 years and receiving RAAS inhibitors or the combination of both RAAS inhibitors and CCBs were at higher risk of mortality than those on CCBs only (odds ratio [OR]: 4.45, 95% confidence interval [CI]: 1.56-12.56, P = 0.005 and OR:3.57, CI: 1.03-12.36, P = 0.045 respectively). Antihypertensive medications did not seem to influence mortality rates among hypertensive patients above 65 years. Routine laboratory investigations were not significantly different between the subgroups receiving different antihypertensive medications regardless of age. Cough was the only symptom associated with mortality among patients under 65 years (OR:2.34, CI:1.24-4.41, P = 0.009). Type II respiratory failure was significantly associated with death among hypertensives under 65 years (OR:5.43, CI:1.08-28.07, P = 0.044) whereas acute kidney injury and septic shocks are the common complications related to death among hypertensives above 65 years (OR:3.59, CI:1.54-8.36, P = 0.003 and OR:7.87, CI: 1.68-36.78, P = 0.009 respectively). Conclusion: Administration of CCBs may improve the outcome of COVID-19 hypertensive patients under 65 years of age. Antihypertensive treatment does not seem to influence the prognosis of COVID-19 patients above 65 years. Such results may affect management strategy of COVID-19 hypertensive patients. Type-II respiratory failure among patients under 65 years of age, acute kidney injury and septic shock among those above 65 years are the most serious complications that can lead to death regardless of blood pressure.
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SESSION TITLE: Cases of Overdose, OTC, and Illegal Drug Critical Cases Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: The COVID-19 pandemic raised economic strife, social isolation, fear from contagion, and anxiety to a level where 45% of surveyed U.S. adults report a detriment to their mental health. With U.S. suicide rates up from 10 to 14 cases per 100,000 over the past 20 years, the health and safety of a vulnerable mental health population becomes more of a concern. We report a case of an individual with depression who was resuscitated after severe toxicity from alcohol and beta-blocker ingestions. CASE PRESENTATION: A 58-year-old woman with prior suicide attempts was found in an obtunded state after finishing a 20-pack of beer and swallowing a propranolol 20 mg pill bottle. On admission, she presented with bradycardia, hypotension, and alteration to a Glasgow Coma Scale of 9 with emesis residue on her face. Her blood gas revealed an anion-gap metabolic acidosis with a pH of 7.26, lactate of 2.53, normal potassium and calcium, and glucose of 134 mg/dL. Toxicity labs were notable for an alcohol of 199 mg/dL. Her EKG demonstrated a junctional bradycardia with a p-wave complex after the QRS consistent with retrograde depolarization of the atrium (Image 1). She was intubated to protect her airway. She subsequently developed cardiac arrest secondary to pulseless electrical activity. She underwent CPR for 33 minutes with boluses of intravenous epinephrine, glucagon, insulin, calcium gluconate, and sodium bicarbonate prior to return of spontaneous circulation. Due to failure of transcutaneous pacing, a transvenous pacer was placed. In concert with Poison Control, she was started on an a euglycemic insulin drip and an intralipid infusion. Her hemodynamics improved, and she was weaned off pacing and ICU interventions within 24 hours. She was discharged a week after admission with no residual morbidities. DISCUSSION: Overdose from nonselective beta-blockers can result in bradycardia, hypotension, seizures, QRS widening, QTc prolongation with ventricular tachy-arrhythmias, hyperkalemia, and hypoglycemia. Understanding the pharmacodynamics of beta-blocker toxicity enables targeted interventions to improve: chronotropy with epinephrine, glucagon, and pacing;inotropy with insulin, calcium, glucagon, and phosphodiesterase inhibitors;QRS widening with sodium bicarbonate;and QTc prolongation with magnesium or lidocaine. The high lipid solubility of propanol allows for intravenous lipid infusions to aid in drug elimination for patients in refractory cardiogenic shock. CONCLUSIONS: Despite a lack of labs for monitoring beta blocker toxicity, our case demonstrates successful resuscitation in a severe overdose. Perhaps an absence of hyperkalemia, hypoglycemia, QRS and QTc changes, and tachy-arrhythmias in this incident portended to a decreased morbidity and mortality. Ultimately, we reaffirmed the role of intralipid infusions as a critical treatment adjunct for recovery from cardiogenic shock secondary to beta blockade. Reference #1: Sher L. The impact of the COVID-19 pandemic on suicide rates. QJM. 2020;113(10):707-712. Reference #2: Kerns W 2nd. Management of beta-adrenergic blocker and calcium channel antagonist toxicity. Emerg Med Clin North Am. 2007;25(2):309-viii. Reference #3: Anderson AC. Management of beta-adrenergic blocker poisoning. Clin Pediatr Emerg Med. 2008;9(1):4–16. DISCLOSURES: No relevant relationships by Jackie Hayes No relevant relationships by Andrew Salomon
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SESSION TITLE: A Look Into Poisoning and Drug Overdoses SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: We present a case of a 64-year-old woman with severe obesity (BMI 53) who presented with shock after beta-blocker (BB) and calcium channel-blocker (CCB) overdose. CASE PRESENTATION: The patient presented after an intentional suicide attempt, taking multiple antihypertensive medications, including tablets of nifedipine 90mg, carvedilol 25mg, and losartan 100mg. She had also been experiencing shortness of breath and lower extremity pain for several days. Upon arrival, she was lethargic and minimally responsive, and was found to be in shock with a heart rate 63. She was intubated for airway protection and started on multiple vasopressors including norepinephrine, phenylephrine, vasopressin, dopamine and epinephrine for circulatory support. She was also found to be positive for SARS-CoV-2. She was given activated charcoal, received gastric lavage, and whole bowel irrigation. She received a bolus of regular insulin at 1U/kg, and subsequently started on a high-dose insulin infusion titrated to 11U/kg/h along with dextrose infusion and calcium gluconate. By day four of admission, vasopressor requirements had been reduced to only norepinephrine and the insulin infusion had been successfully discontinued. However, her hospital course was further complicated MRSA and Pseudomonas pneumonia, and renal failure requiring hemodialysis. She continued to develop refractory shock, and remained over 50 liters net positive. Her condition progressively deteriorated and her gross volume overload was difficult to manage, and ultimately expired on day ten of admission. DISCUSSION: The management of CCB and BB overdose has been studied, with hyperinsulinemic euglycemic therapy (HIET)1,2 as our choice. Our patient's decline was likely secondary to the high volumes of dextrose infusion required after HIET. With underlying renal failure, insulin clearance proved to be a significant challenge. Such severe obesity with a weight-based regimen resulted in over 1500U insulin/hr at any given point with our patient. Renal clearance is governed by a proportion of t/V, where t denotes length of a dialysis session and V the volume of fluid in the patient's body.3 Patients with significant volume would require extensive dialysis sessions and fluid balances would be challenging. Continuous renal replacement therapy (CRRT) was attempted later in her hospital course. However, the patient was not able to tolerate it as she had progressed to multiorgan failure. CONCLUSIONS: HIET has shown to be a successful management strategy for CCB and BB overdose. However, weight-based dosing can prove to be a challenge in patients with severe obesity. CRRT should be considered early in severely obese patients that undergo HIET, given the rapid accumulation of fluid secondary to the large-volume insulin and dextrose infusions. Further investigations should look into identifying maximal safe dosages of HIET, especially in severely obese patients. Reference #1: Cole JB, Arens AM, Laes JR, Klein LR, Bangh SA, Olives TD. High dose insulin for beta-blocker and calcium channel-blocker poisoning. Am J Emerg Med. 2018 Oct;36(10):1817-1824. doi: 10.1016/j.ajem.2018.02.004 Reference #2: Krenz JR, Kaakeh Y. An Overview of Hyperinsulinemic-Euglycemic Therapy in Calcium Channel Blocker and β-blocker Overdose. Pharmacotherapy. 2018 Nov;38(11):1130-1142. doi: 10.1002/phar.2177 Reference #3: Turgut F, Abdel-Rahman E, M: Challenges Associated with Managing End-Stage Renal Disease in Extremely Morbid Obese Patients: Case Series and Literature Review. Nephron 2017;137:172-177. doi: 10.1159/000479118 DISCLOSURES: No relevant relationships by Alejandro Garcia No relevant relationships by Vishad Sheth no disclosure on file for Andre Sotelo;
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Introduction In a study involving > 10,000 patients hospitalized with COVID-19, we found that liver injury, which was present in ~70% of patients upon hospital admission, correlates with in-hospital mortality (Satapathy et al., Eur J Gastroenterol Hepatol 2021). Curiously, severe liver chemistry abnormalities (LCA) were seen less often in patients with diabetes or hypertension, although these diseases confer increased risk of severe disease. This raises the question whether home medications protect from COVID-19 associated liver injury. We now analyzed associations between LCA and twenty-six groups of antidiabetic, antihypertensive, and other common mediations. Results 9898 patients hospitalized with COVID-19 in 13 hospitals in New York between March 1 to August 31, 2020, who had an complete records on admission were retrospectively analyzed. LCA measured were alanine and aspartate aminotransferases, alkaline phosphatase, and bilirubin, and were defined as absent, mildmoderate (up to four times elevated), or severe. Diseases and socioeconomic factors were similar to the initial study. 67.2% had hypertension, and 40.8% had diabetes. The most common medications included insulin (12.2%), metformin (18.3%), sulfonylureas (6.8%), DDP4 inhibitors (6.3%), ACE inhibitors (14.8%), ARBs (18.6%), beta-blockers (33.2%), calcium-channel blockers (26.5%), diuretics (21.6%), statins (41.5%), PPIs (22.1%), H2- blockers (6.8%), antiplatelets (31.0%), anticoagulants (20.5%). Comparisons between groups were analyzed using Kruskal-Wallis test, chi-squared test, and Fisher's exact test. Univariate and multivariate regression analysis were performed. Univariate analysis showed a higher risk for severe LCA in men, Asian and Black race, non-Hispanic ethnicity. As in our prior analysis, hypertension and diabetes were associated with less frequent severe LCA. In addition, hyperlipidemia, CAD, CHF, atrial fibrillation, CKD, ESRD, GERD, asthma, COPD, cancer, and liver disease were inversely associated with severe LCA. Medications that were associated with less frequent severe LCA included statins, ACE, ARBs, calcium-channel blockers, betablockers, diuretics, antiplatelet medications, insulin, biguanide, sulfonylureas, PPIs, H2- blockers, and anticoagulants, but not oral steroids. In multivariate analysis, male gender, Asian and Black race were associated with increased risk of severe LCA. Hypertension, ESRD and asthma were associated with less frequent severe LCA, but not diabetes. Among medications, only metformin showed a statistically significant correlation with severe LCA on admission, with a hazard ratio 0.57 (p 0.0002). Conclusions Metformin use was inversely associated with severe liver chemistry abnormalities upon hospital admission with COVID- 19 in a large cohort of patients during the initial pandemic in New York.
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Background: Arterial hypertension has been described as one of the main risk factors for poor prognosis in Covid-19. In this context, the role of angiotensin-converting enzyme 2 (ACE2) in this infection has been studied, with studies showing how this enzyme acts as a functional receptor for SARS-CoV-2, favoring the penetration of the virus into the cell. The main objective of this work is to study the impact of chronic antihypertensive treatment in a cohort of SARS-CoV-2 positive patients with arterial hypertension, as well as clinical outcomes during hospitalization. Method: Single-center observational retrospective cohort study conducted at a tertiary level university hospital from 1st March 2020 to 31st May 2020. All adult patients admitted with a diagnosis of COVID-19 and a history of arterial hypertension on chronic treatment with an antihypertensive drug during the three months prior to contracting the infection were included. For the analysis, patients were divided into three groups according to the chronic antihypertensive treatment they were receiving: angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor antagonists (ARB) or other treatment, excluding those patients who during the three months prior to the start of the study had been on concomitant treatment with ACE inhibitors and ARB, as well as those on treatment with more than four antihypertensive drugs. Results: A total of 475 cases with positive PCR for SARS-CoV-2 cases had hypertension as an associated comorbidity on antihypertensive treatment in the three months prior to admission. The mean age of this cohort of patients was 77.05 (SD 10.95) years, most of them male (56.8%) Regarding the prolonged length of stay variable, 127 patients (26.7%) were admitted for 14 days or more, with no statistically significant differences between the three groups. For patients admitted to the Intensive Care Unit (ICU) (29 patients, 6.1%) no differences were observed between the three study groups either.Regarding the outcome variable, all-cause in-hospital mortality, no statistically significant differences were observed between the groups (p = 0.836). Conclusions: Patients admitted with SARS-CoV2 respiratory infection with a diagnosis of hypertension and pre-admission treatment with an antihypertensive drug showed no statistically significant differences in mortality between those hypertensive patients who received renin-angiotensin-aldosterone system (RAAS) inhibitor antihypertensive drugs and those who received other antihypertensive treatments.
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Objective: The aim of the study was to assess the clinical particularities and the lab tests in patients hospitalized for SARS-COV2 infection, with new onset of hypertension on admission. Design and method: We performed a retrospective study on 217 patients admitted to a Clinical Emergency Hospital between January 2021 and October 2021. Results: We had 217 patients admitted in internal medicine clinic for infection with SARS-COV2 virus, most of them with moderate and severe form of disease. From them, 148 patients had hypertension, 83.78% with medical history of hypertension and 16.22% with new onset of high blood pressure on admission. Patients were aged between 23 and 99 years, with an average age of 65 years. In comparison, the patients with new onset of hypertension (subgroup 1) were aged between 37 and 90 years, with an average age of 66 years. The most affected group of age was 60-69 years. In subgroup 1, the gender distribution was: 58.33% male, 41.66% female. At admission, the stages of SARS-COV2 infection in subgroup 1, according to CT examination, were severe in 52.38%, moderate 19.04%, and mild 28.57% of patients. As comorbidities in subgroup 1: cancer in 8.33%, metabolic syndrome 54.16%, dyslipidemia 4.16%, obesity 50%, type II diabetes mellitus 45.83%, chronic heart failure in 12.5% of cases (37.5% NYHA I class, 54.16% NYHA II class and 8.3% NYHA III class), atrial fibrillation in 12.5%, atherosclerosis in 16.66%, anxiety disorders in 4.16% and dementia in 8.33% of cases. High levels of inflammatory markers in Subgroup 1: CRP in 95.83%, procalcitonin in 87.5%, ferritin 79.16%, D-dimers in 83.33%, troponin 4.16%, NT-proBNP in 50% of cases. Decreased GFR was found in 65.21% of patients. Microalbuminuria was present in 29.16% of patients. The antihypertensive medication during hospitalization was: diuretics in 45.83%% of cases, betablockers in 33.34%, calcium blockers in 8.33%, angiotensin converting enzyme inhibitors in 16.67%. Conclusions: Hypertension with new onset during SARS-COV2 infection and its persistence in post-covid syndrome may have complex pathogenic mechanisms and require personalized therapeutic decision.
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Objective: To assess the severity of coronavirus infection in patients with hypertension, including resistantand refractory hypertension, and to assess the effect of taking ACE inhibitors and ARBs on the course of COVID-19. Design and method: We called 252 people with an established diagnosis of hypertension, included in the database from November 2018 to July 2021, in order to identify patients who have recently undergone COVID-19. Initially, the patients were divided into groups depending on the number of drugs taken and the achievement of target blood pressure levels. Results: 21 (8.3%) of 252 people had a coronavirus infection. 10 out of 21 patients (48%) noted blood pressure destabilization. 6 (60%) of these 10 initially belonged to the group of uncontrolled hypertension (4 of 6 had refractory hypertension, 2 of 6 had uncontrolled resistant hypertension), however, all of them noted worsening blood pressure control and increased frequency of hypertensive crises compared with the period before COVID-19. In 4 out of 9 patients with initially controlled hypertension, BP was destabilized with subsequent normalization of BP during the recovery period. COVID-19 lasted no more than 14 days in all patients and hypertensive crises was treated by taking short-acting drugs, including an ACE inhibitor (Captopril) and an imidazoline receptor agonist (Moxonidine). 7 (33.3%) and 12 (57.1%) of 21 patients continued to take ACE inhibitors and ARBs, respectively, during coronavirus infection. In 2 (9.6%) of 21 patients, the target BP values were achieved during monotherapy with calcium channel antagonists. All patients with Covid-19 had mild or moderate disease;hospitalization was not required in any of the cases. Conclusions: COVID-19 can destabilize blood pressure in patients with hypertension. Taking an ACE inhibitor / ARB does not worsen the course of coronavirus infection in patients with both controlled and uncontrolled hypertension.
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Objective: Cardiovascular diseases including hypertension are common comorbidities in patients hospitalized due to COVID-19. We assessed the impact of hypertension on in-hospital mortality in patients hospitalized due to COVID-19. Design and method: We retrospectively analyzed the medical records of all consecutive patients who were admitted to the University Hospital in Krakow, Poland, due to confirmed SARS-CoV2 infection from March 2020 to May 2021. Results: Overall, data of 5191 patients (mean age 61.9 ± 16.7 years) were available for analysis. Patients with preexisting hypertension (58.3% of the study population) were older and had more comorbidities than patients without hypertension (p < 0.05). In-hospital mortality was significantly higher in patients with hypertension compared to those without hypertension also after adjustment for age (22.2% vs 12.9%;P = 0.02). Age above median (64 years, odds ratio [OR] 3.93;95% confidence interval [CI] 3.23-4.83), male gender (OR 1.19;CI 1.01-1.40), a history of heart failure (OR 2.01;CI 1.58-2.56) or chronic kidney disease (OR 2.35;CI 1.86-2.96) and increased C-reactive protein levels (OR 1.09;CI 1.08-1.10), but not preexisting hypertension (OR 0.90;CI 0.74-1.09) were significantly associated with a higher risk of in-hospital death after multivariate logistic regression analysis. However, hypertension (OR 1.45;CI 1.06-1.97) was an independent predictor of in-hospital death in patients without established cardiovascular disease and antihypertensive treatment. Treatment with any first-line antihypertensive drug class in patients with hypertension at the time of hospitalization was associated with a lower risk of in-hospital death (beta-blockers OR 0.52;CI 0.41-0.65;angiotensin converting enzyme inhibitors OR 0.52;CI 0.38-0.68;angiotensin receptor blockers OR 0.24;CI 0.12-0.41;calcium channel blockers OR 0.61;CI 0.44-0.84;thiazide diuretics OR 0.40;CI 0.24-0.64). Conclusions: Besides the high prevalence, hypertension was not an independent risk factor of in-hospital death in the overall group of hospitalized COVID-19 patients. Treatment with all first-line antihypertensive medications was associated with significant reduction of in-hospital death in patients with hypertension.
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Objective: Our aim was to explore COVID19-related mortality in hypertensive patients as compared to other associated conditions as well as antihypertensive treatment effect. Design and method: We performed a retrospective, unicentric study on COVID19 patients admitted to our department between 1st of September and 1st of December 2021. Collected data included medical history, treatment, echocardiographic data and lab test results. SPSS version 23 was used for descriptive and inferential statistics. Results: The lot consisted of 139 consecutively enrolled patients. The median age was 68 years (range: 18-91) and 48.9% females. Only 14.9% of patients were fully vaccinated (3.9% partially vaccinated, 81.3% unvaccinated). Associated conditions were: arterial hypertension (64.7%), heart failure (41.7%), T2DM (29.5%), stroke (13.7%) and coronary artery disease (12.2%). The inhospital mortality rate was 24.5% without differences between hypertensive and non-hypertensive patients (RR: 1.31 ;0.68 - 2.50). However, T2DM, coronary artery disease and stroke had higher relative risk than hypertension, AF and HF for COVID19 death (T2DM: 2.13 ;1.21 - 3.74;CAD: 2.21 ;1.20 - 4.06;stroke: 7.11 ;4.45 - 11.35). Hypertensive patients underwent treatment with ACEi/ARB (37.8%), diuretics (32.2%), calcium channel blockers (13.3%) and betablockers (40%) prior to admission. There was a statistical trend showing that fewer hypertensive patients receiving ACEi/ARB prior to admission required ICU management (20.6% vs 39.3%, p = 0.052) with no difference of inhospital mortality (23.5% vs 28.6%, p = 0.394). Hypertensive patients undergoing BB treatment had lower ICU admission rates (16.7% vs 42.6%, p = 0.008). Conclusions: Most hospitalised COVID19 patients were not fully vaccinated. Inhospital mortality was higher among patients withT2DM, CAD and history of stroke, but not HTN. Home treatment with ACEi/ARB or BB treatment was associated with lower ICU admission rates.
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Background: Emergency physicians must be updated about the variations in poisoning pattern during Covid19 pandemic. Limited data exist on the incidence and characteristics of patients presenting with poisoning in Indian Emergency Departments (ED) during the COVID 19 pandemic. Hence, we aimed to explore the impact of Covid19 pandemic on poisoning cases presenting to the ED. Methods: This cross-sectional retrospective study was conducted on poisoning patients presenting to ED during the pandemic period (April 1-October 30, 2020 (period 2)), and a matching period before the pandemic (September 1,2019 to March 31, 2020 (period 1)). The rate of prevalence and clinical profile were compared between period 1 and 2 using appropriate statistical test. Results: A total of 111 (periods 1 = 57, and periods 2 = 54) cases were analysed. Poisoning prevalence rates had slightly increased by 2.7% before the pandemic (51.33%) in comparison to during the pandemic (48.6%) period (p=0.3). Females were predominant in both periods, and the mean age of 32.5 years. The predominant (57%) patient age group was 15-34 years. 36.9% (n=41) patients consumed multiple poisons, 19.8% (n=22) consumed paracetamol, and 14.4% (n=16) patients consumed psychiatric medications. Before lockdown, 27.02% (n=30) patients presented within 3 hours ingestion, and 21.6% (n=24) presented after 3 hours ingestion (p=0.12). A significant delay in arrival of poisoning cases during lockdown (p= 0.12) with increased hospital admission (p=0.03) was observed. A psychiatric disorder was observed in 36.03% cases. Majority of the cases were admitted in the ICU, and 0.9%(n=1) death was recorded. Conclusions: This is the first Indian study that describes the incidence of poisoning cases and their pattern during the COVID 19pandemic period, study revealed that increased mental health crisis in low resource settings in rural Kerala affects predominantly young population. Study implies the importance of priming the mental health care professionals to initiate their mental health screening programmes.
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Background/Aims Chilblain-like lesions (perniosis) have been reported frequently during COVID-19 pandemic in children and adolescents with no history of exposure to cold temperatures or underlying autoimmune conditions. Patients with these skin changes reported mild COVID-19 symptoms or previous contact with confirmed COVID-19 cases before they became symptomatic. In the majority of cases, a causal relationship between SARS-CoV-2 infection and chilblain-like lesion has not been proven. Methods Retrospective review of patients with chilblain-like lesions, possibly secondary to SARS-CoV-2 infection, presenting to a tertiary Adolescent Rheumatology service between January and August 2021. Results We identified five, male, adolescent patients (mean age, 16 years old) who presented with new onset of chilblain-like lesions affecting fingers, toes and heels in December 2020, which coincided with the peak of second wave of COVID-19 infection. One month prior to skin changes occurrence, 3 out of 5 patients experienced mild respiratory COVID-19-like symptoms and the rest of the patients were asymptomatic but were in contact with COVID-19 positive cases following outbreaks in schools. 1 of 3 symptomatic patients had a positive COVID-19 PCR test prior to skin manifestations. 2 out of 4 patients with heel lesions had deep, full thickness skin loss heel ulcers and 2 of 5 patients had superficially ulcerated lesions on a finger and toes, respectively, resulting in inability to attend school. None of the patients had any other symptoms or signs to suggest an underlying autoimmune connective tissue disorder. Demographics, clinical features and serological data are summarised in Table 1. One patient underwent a biopsy of heel ulcer which was histologically consistent with perniosis. In two patients (40%) chilblain like lesions resolved spontaneously within 2 months. Three patients (60%), with progressive ulcerated lesions, required various combinations of treatments with aspirin, calcium channel blockers (nifedipine), topical or oral steroids and hydroxychloroquine with complete resolution of symptoms within 6 months. Conclusion Chilblain-like lesions, including heel involvement associated with mildly symptomatic COVID-19 infection, have been reported before. Our mini-case series raises awareness of ulcerating chilblain like lesions possibly secondary to COVID-19 in adolescent patients, which require early recognition and instigation of treatment leading to better patient's outcomes.
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Background/Aims Phalangeal microgeodic syndrome (PMS) is a rare condition with only a handful of published case reports. Most of these cases are recognised in childhood, typically in Japan. It presents with pain and dusky discolouration in the digits, distinct from Raynaud's phenomenon in that the colour change is fixed and pain constant. Symptom onset is related to cold exposure with first presentation usually occurring in winter. Features on magnetic resonance imaging (MRI) are striking and characteristic, with a distinct pattern of bone marrow oedema. Methods We report five cases of MRI-proven PMS all identified in the last 12 months, with symptom onset during the winter. The patients were all female, aged between 25 and 79. One patient was already under the care of rheumatology with an established diagnosis of systemic lupus erythematosus (SLE), but the remainder were De novo referrals presenting specifically with pain and discolouration of the digits. One patient developed symptoms 2 days after receiving the first dose of Pfizer/ Biontech RNA vaccine against COVID-19. One patient had to self-isolate following a COVID-19 contact and developed symptoms shortly thereafter, although there was no proven infection in the affected individual. Results Four out of five cases were managed conservatively, with advice on maintaining core and peripheral temperature and skin integrity. Without any specific therapy, these four cases improved spontaneously to coincide with increasing seasonal temperatures. The fifth case with existing SLE was treated with intravenous pamidronate and subsequently with a calcium channel blocker, with some improvement in symptoms. Conclusion In these authors' experience, it would seem PMS is increasing in incidence. It is unclear if this relates to wider availability and image quality of MRI, clinician bias due to personal experience of more cases or a genuine increase. The winter 2020/21 was particularly cold with sub-zero conditions lasting well into May, which may have impacted on this flurry of new cases. We have identified one prior case report which describes PMS in a patient with existing connective tissue disease. Our patient with SLE appeared to have a more severe clinical presentation requiring additional medical therapy to control the symptoms compared with the four cases where PMS was a standalone condition. Dermatological manifestations of acute COVID-19 infection are well documented in children and include chilblain-like lesions and acrocyanosis. Any association between COVID-19 and PMS is purely hypothetical and would require more study to identify any true relationship.
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Background: Louis-Dietz syndrome (LDS) Type 3 is a rare disorder caused by an autosomal-dominant mutation in SMAD-3, altering the TGF-β pathway. LDS Type 3 typically manifests as aortic aneurysms and early-onset osteoarthritis, however other dermatologic, cardiovascular, and skeletal abnormalities have been reported. Case: A 51-year-old woman was referred to the cardiology clinic for episodes of palpitations, syncope, chest pain, and shortness of breath during the COVID-19 pandemic. She had a history of congestive heart failure, cardiomyopathy, patent foramen ovale, atrial septal aneurysm, pre-COVID myocarditis, mitral valve prolapse, mitral regurgitation, and pericarditis. She also has a pertinent medical history of hypermobile Ehlers-Danlos syndrome (hEDS) and systemic lupus erythematosus (SLE). Her family and social history were remarkable for a daughter with SLE. Cardiopulmonary and general physical exams were remarkable for hypermobility. Evaluation with an ECG and Holter monitor showed normal sinus rhythm with unifocal premature ventricular contractions (PVCs) that correlated with her symptoms. Decision-making: The patient was initially managed un-successfully with beta and calcium channel blockers. Cardiac ablation was subsequently performed on a left ventricular septal focus with remote magnetic navigation using the Niobe system from Stereotaxis inc. (due to its low risk for cardiac perforation). At 6 months follow up, the patient exhibited an increase in left ventricular ejection fraction from 40-50% to 55-60%, fewer symptoms, and fewer PVCs. She was later diagnosed with a right internal carotid artery aneurysm that prompted genetic testing that was positive for LDS Type 3. Conclusion: This patient’s unique combination of illnesses required a multidisciplinary team for management. The Stereotaxis robotic system safely and successfully treated the patient’s PVCs and resulted in improvement of left ventricular function. Due to previous reports of arrhythmias associated with these connective tissue disorders, additional studies are necessary to understand the role of the SMAD-3 mutation, EDS, and SLE in contributing to arrhythmogenicity.
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Introduction: Patients presenting with Complete heart block (CHB) are emergently referred for placement of a temporary transvenous pacemaker (TTVP) for hemodynamic stability. Data on the immediate management and outcomes of such patients are lacking. Methods: Data collected;through retrospective chart review of patients presenting to the Emergency Department (ED) at a regional hospital from October 2017 to January 2021 with a diagnosis of new CHB;included age, sex, clinical, laboratory and ECG data, medications, interventions and length of stay. Results: There were 71 patients (31 women) of whom 19 were on beta blocker or Calcium channel blockers. Data (see Table 1) for all variables was available in 68 patients. Syncope, lightheadedness and dyspnea were common symptoms. The median age was 77 years. The median heart rate was 41bpm. Atropine was used in 13 patients. Five patients with initial Systolic Blood Pressure (SBP) < 100mmHg received sympathomimetics. Syncope with pause occurred in 3 patients. A TTVP was placed in 12 patients. Among 22 patients with initial SBP > 160mmHg one patient with a recent TAVR had a TTVP placed. All but five were managed in the ICU setting. On Univariate logistic regression (R statistical software 3.6.1) initial SBP, SBP < 100mmHg and Initial Serum K level were clinically significant. In multivariate analysis, SBP was significant with a lower SBP predicting need for a TTVP [OR 0.96 (CI 0.91-0.99, p = 0.019)]. A permanent pacemaker (PPM) prior to discharge was placed in 64 patients on average in 1.6 days from presentation. 3 patients with STEMI and TTVP did not need a PPM. 1 transitioned to hospice and 1 patient died of sepsis. In 1 it was attributed to COVID-19 infection. Conclusions: TTVP was infrequently needed (16.66%) among patients presenting to the ED with CHB. Initial SBP and Serum K were clinically relevant factors. Prospective data related to the acute management of CHB is needed to identify predictors that can improve the care for such patients.
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Case report-IntroductionThis is a case of Pakistani female with limited systemic sclerosis and associated mild interstitial lung disease. The lung disease was complicated by SARS-COV-2 related pneumonitis in April 2020 and that led to treatment challenges.She was previously seen in multiple private hospitals and labelled as Rheumatoid arthritis. She was being treated with long term steroids and Methotrexate. After her initial presentation to our Rheumatology services, her diagnosis was correctly revised to Systemic Sclerosis with phenotype of CREST. Her treatment was adjusted to Vasodilators and Mycophenolate due to skin and Lung involvement.Case report-Case descriptionThis is a case of 40-year-old Pakistani female who had been having multiple joint pains since 2010. She also experienced severe Raynaud's.She presented to our Rheumatology clinic in December 2018. Her symptoms included recurrent digital ulcers, tight and tough skin at fingers and Raynaud's worse during winter months. Her examination confirmed peripheral cyanosis with multiple digital ulcers with superimposed infection, marked sclerodactyly and calcinosis. She was started on Vasodilator therapy including calcium channel blocker and PDE5 inhibitor due to severity of ulceration. Infection was managed with prolonged course of antimicrobial therapy. Her immunology showed positive anti nRNP/Sm. Anti-centromere and anti Scl 70 were negative. Her condition fit description of CREST (Calcinosis, RP, Oesophageal dysmotility, telangiectasia). Her management included weaning off Methotrexate and reduction in the dose of corticosteroids.In February 2019, Respiratory work up showed normal Chest radiograph, High resolution CT chest showing no significant abnormality and FEV1 82%, FVC 86%, and DLCO 77%. Her PASP was 25mmHg. Overall, her condition remained stable over the course of next year. Her medication included Cellcept, low dose prednisolone, hydroxychloroquine, and Sildenafil. More importantly, Digital ulcers have been well controlled with combined vasodilator therapy.In April 2020, she developed SARS-CoV-2 with mild respiratory symptoms and was admitted to a different hospital. Fortunately, she responded well to ward based supportive and symptomatic treatment with no need for respiratory support. Subsequently, she has seen a different respiratory physician and had repeat imaging of chest which has led to dilemma whether the ground glass opacities in both lungs is due to scleroderma lung or COVID-19 related lung disease. She was given high dose prednisolone by the respiratory physician which has been reduced in rheumatology clinic. The new findings on chest imaging are sequelae of SARS-COV-2.Case report-DiscussionThis case highlights few important points as below:Systemic sclerosis diagnosis was not made for many years even though she has had severe digital ulcers for a long time. She was being managed as Rheumatoid arthritis. Systemic sclerosis remains a difficult disease to diagnose and is still under recognised.SARS-COV-2 related illness has not affected this patient adversely despite the fact of being on long term maintenance prednisolone of 7.5mg daily dose and Cellcept 2gm. Her cellcept was temporarily stopped during acute illness.We know that viral pneumonitis can present with typical ground glass opacities in bilateral areas of lungs and differential diagnosis does include connective tissue related lung disease but this lady had no significant respiratory involvement prior to COVID-19 illness and follow up scan will help to decide if this is disease progression or related to viral cause.Case report-Key learning pointsThere are multiple learning points in this case:Continuity of care under same primary team can avoid confusion related to diagnosis and diagnosis related complications. This lady had none, or mild subclinical lung involvement related to systemic sclerosis prior to contracting COVID-19 illness. Her CT chest findings after the episode of SARS-COV-2 were attributed to systemic sclerosis as she was seen by different respiratory team. This conti uity is not always possible, but MDT collaboration needs to be improved across hospitals and across various departments.Systemic sclerosis remains an under diagnosed and under recognized complex rheumatic disorder and more primary care physicians need to be educated so they can appropriately refer these cases to Rheumatology services.Multi-disciplinary collaboration between Rheumatology, Respiratory and other specialties is the key point to manage these complex cases.This case also highlights an interesting observation that presence of significant immune disorder and immunosuppressant medication does not always equate to worse outcome if patient contracts SARS-COV-2. Supportive care, appropriate observation, and temporary suspension of DMARD in such cases can avoid any further complications.