Memory SARS-CoV-2 T-cell response in convalescent COVID-19 patients with undetectable specific IgG antibodies: a comparative study.

Background: During the COVID-19 pandemic, a variable percentage of patients with SARS-CoV-2 infection failed to elicit humoral response. This study investigates whether patients with undetectable SARS-CoV-2 IgG are able to generate SARS-CoV-2 memory T cells with proliferative capacity upon stimulation. Methods: This cross-sectional study was conducted with convalescent COVID-19 patients, diagnosed with a positive real-time PCR (RT-PCR) from nasal and pharyngeal swab specimens. COVID-19 patients were enrolled ≥3 months after the last PCR positive. Proliferative T-cell response after whole blood stimulation was assessed using the FASCIA assay. Results: A total of 119 participants (86 PCR-confirmed COVID-19 patients and 33 healthy controls) were randomly filtered from an initial cohort. Of these 86 patients, 59 had detectable (seropositive) and 27 had undetectable (seronegative) SARS-CoV-2 IgG. Seropositive patients were subclassified as asymptomatic/mild or severe according to the oxygen supplementation requirement. SARS-CoV-2 CD3+ and CD4+ T cells showed significantly lower proliferative response in seronegative than in seropositive patients. The ROC curve analysis indicated that ≥ 5 CD4+ blasts/µL of blood defined a "positive SARS-CoV-2 T cell response". According to this cut-off, 93.2% of seropositive patients had a positive T-cell response compared to 50% of seronegative patients and 20% of negative controls (chi-square; p < 0.001). Conclusions: This proliferative assay is useful not only to discriminate convalescent patients from negative controls, but also to distinguish seropositive patients from those with undetectable SARS-CoV-2 IgG antibodies. Memory T cells in seronegative patients are able to respond to SARSCoV-2 peptides, although at a lower magnitude than seropositive patients.

Eosinophilic fasciitis triggered by intensive exercise

A 59-year-old white female who was previously fit and well, developed gradual tightening and thickening of the skin on her forearms progressing to the abdomen, chest and lower legs associated with restricted movement. She also noticed bruise-like patches on her trunk. There were no systemic symptoms and no history of Raynaud syndrome. Since the beginning of the COVID-19 lockdown, the patient had engaged in increasing amounts of exercise compared with normal;this included yoga once weekly for 75 min, high-intensity interval training for 20 min on alternate days, running three times weekly for 45 min, lifting 2.5 kg weights for the arms every day and regular long walks. Examination showed a 'groove' sign on her forearms and a peau d'orange appearance of the skin with a woody induration and hardness on palpation. Symmetrical and circumferential involvement on the forearms and lower legs and bruise-like indurated patches on the abdomen were noted. Differential diagnoses included eosinophilic fasciitis (EF), morphoea, EF/morphoea overlap, scleroderma, scleromyxoedema and nephrogenic systemic fibrosis. Blood investigations showed an eosinophilia of 1.2 x 109 cells L-1, erythrocyte sedimentation rate of 31 mm h-1, a C-reactive protein of 20 mg L-1 and negative autoimmune and viral serology. She underwent two incisional biopsies down to fascia. The first was taken from the back, which showed an interstitial inflammatory cell infiltrate composed of lymphocytes, plasma cells and very occasional eosinophils. The subcutaneous septa were minimally thickened. The second biopsy taken from the left forearm showed striking thickening of the subcutaneous septa, with an associated inflammatory cell infiltrate, composed predominantly of lymphocytes and plasma cells. This process was deeper and more established than that seen in the biopsy from the trunk. The appearances were clearly those of a sclerosing process of the dermis and subcutis and consistent with eosinophilic fasciitis. Our diagnosis was EF with morphoea overlap and she was treated with oral methotrexate 15 mg weekly and oral prednisolone 50 mg once daily (weight 60 kg), reducing the dose by 5 mg every 2 weeks. An 80% improvement was seen in functionality within 3 months, but the skin remained tight and thickened and therefore the patient was referred for phototherapy [ultraviolet A 1 (UVA1)] as combination therapy. We present a rare case of EF, which appears to have been triggered by intensive exercise. Other causes include insect bites, radiation, infections (Mycoplasma and Borrelia) and paraneoplastic. Haematological associations have been seen, including aplastic anaemia and lymphoma. Treatment options for EF include prednisolone, UVA1/psoralen + UVA, immunosuppressive systemic agents (including ciclosporin and methotrexate), biological agents (including infliximab and rituximab) and physiotherapy.

"Fibromyalgia" and "Long COVID-19" as a chronic compartment-like syndrome of the whole body (Nineveh, the Shadow is in the Fascia)

Background: The Coronavirus pandemic has impact on our community far beyond the acute phase, "Long COVID-19" is recognized as a new medical entity and resembles "fibromyalgia" which, likewise, lacks a clear mechanism. "Fibromyalgia" is a prevalent and misunderstood condition with significant burden and morbidity. "Central sensitization" and biopsychosocial theories describe "fibromyalgia" as the misfortunate neurological fate of traumatized and stressed individuals that have behavioral, cognitive, social, and/or genetic predisposition for an "infinite-positive- feedback of pain with no peripheral organic lesion/injury". Diagnostic criteria seem biologically arbitrary, treatments are insufficient, and physicians are frustrated. This work suggests a theoretical model with an organic mechanical mechanism to help explain "fibromyalgia", "long COVID-19" and "functional psycho/ somatic syndromes", based on cross-disciplinary empirical studies. A practical evidence-based treatment arsenal, which is derived from this model, is discussed briefly. Method(s): Systematically searched multiple phrases in MEDLINE, EMBASE, COCHRANE, PEDro, and medRxiv, majority with no time limit. Inclusion/exclusion based on title and , then full-text inspection. Additional literature added on relevant side topics. Review follows PRISMA-ScR guidelines. Result(s): 831 records included. The theory of "facial-armoring" suggests fibromyalgia-like entities may be a disease of connective-tissue driven by myofibroblast-generated- tensegrity- tension. This mechanism may explain fibromyalgia's pain, distribution of pain, decreased pressure-pain threshold, tender spots, fatigue, cardiovascular and metabolic abnormalities, autonomic abnormalities, absence of clear inflammation, silent imaging investigations, and other phenomena (e.g., complete resolution soon after surgery). "Long-COVID- 19" is predicted to involve fascial armoring. Conclusion(s): "Fibromyalgia" is a mild-moderate- chronic- compartment- like- syndrome- of- the- whole- body. Treatment should focus on lifestyle and non-pharmacological modalities. Early detection is key. The body and the mind are one being.

Résultats de la reconstruction du ligament croisé antérieur avec ténodèse latérale par une plastie continue utilisant la bandelette ilio-tibiale. À propos d’une série prospective de 186 cas à 2 ans de recul

Introduction L’objectif de ce travail est d’analyser les résultats cliniques, et en particulier le taux de re-rupture, de la reconstruction du ligament croisé antérieur avec une ténodèse latérale par une plastie continue utilisant la bandelette ilio-tibiale chez des patients pratiquant des sports de pivot. Matériel et méthode Il s’agit d’une étude prospective multicentrique incluant 186 patients opérés entre le 1er janvier et le 31 juillet 2019. Le recul minimum est de 2 ans. Les patients étaient des pratiquants de sports à pivot. L’objectif principal était d’analyser le taux de re-ruptures. Le recueil des données concernait les scores fonctionnels (IKDC subjectif, Tegner, Lysholm), psychologiques (ACL-RSI), la laxité (Rollimeter, Lachmann, Pivot Shift), les résultats isocinétiques et la reprise du sport (questionnaire spécifique). Les complications et reprises chirurgicales ont été répertoriées. Tous les tests statistiques ont été bilatéraux au niveau de risque alpha global de 5 %. Le Comité d’éthique a donné son accord favorable (No IDRCB : 2018-A0456-49). Résultats Neuf patients ont été perdus de vue. L’âge moyen était de 24,3 ans, avec 75 % d’hommes. Quatre-vingt-onze pour cent pratiquaient des sports pivot contact. On notait 38 % de lésions méniscales. 94 greffes ont été augmentées (plastie locale au fascia lata ou gracilis). Les scores IKDC subjectif, Lysholm, ACL RSI et IKDC objectif étaient significativement améliorés, le niveau d’activité Tegner restant identique (8,1 vs 8,2). La laxité différentielle était de 6,6mm en préopératoire contre 0,3mm en postopératoire. 81 % des patients avaient un ressaut marqué ou explosif avant l’opération et 97 % aucun ressaut en post-opératoire. Au bilan isocinétique, 79 % avait un déficit inférieur à 15 % au quadriceps et 70 % aux ischiojambiers. Au total, 97 % ont repris une activité sportive : 77 % au même niveau, au délai moyen de 7,5 mois. 7 patients ont été réopérés pour méniscectomie, 6 ont re-rompu leur greffe (3,4 %), 4 ont présenté une rupture du LCA controlatéral. Conclusions Avec 3,4 % de re-ruptures, notre étude confirme que cette technique donne des résultats similaires aux autres, sans morbidité augmentée. L’analyse des re-ruptures incite à proposer une technique augmentée dés lors que la laxité différentielle initiale est supérieure à 8mm. L’épidémie Covid rend d’interprétation difficile la reprise du sport.

EMS 2022

The proceedings contain 42 papers. The topics discussed include: adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis;family members screaming for help makes it very difficult to don PPE. a qualitative report on ambulance staff experiences of personal protective equipment (PPE) use and infection prevention and control (IPC) practices during the COVID-19 pandemic;resuscitation academy Germany - systemic improvements for better out-of-hospital cardiac arrest outcomes;nurse practitioners EMS (NP-EMS) performed ultrasound (US)-guided fascia iliaca compartment block (FIC-BLOCK) in patients with a suspected proximal femur fracture. preliminary data;developing a young persons advisory group (YPAG) to inform the design of a study to improve pre-hospital pain management for children and young people (CYP);and introduction of video triage of children with respiratory symptoms at a medical helpline.

Appropriate Needle Length Determined by Ultrasonic Echography for Intramuscular Injection in Japanese Elderly over 50 Years.

Adjuvanted vaccines are administered through intramuscular injection. To perform appropriate injection using an appropriate needle in different age groups or different daily living activities, we investigated the depth from the skin surface to muscle fascia and bone in the deltoid muscle area in 156 elderly aged ≥ 50 years by ultrasonic echography. Subjects consisted of 50 healthy elderly aged 50-64 years, 50 subjects aged 65-74 years, and 56 subjects aged ≥ 75 years (20 outpatients, 18 who needed nursing care, and 18 bedridden in a nursing home). The mean depth ± 1.0 SD from the skin surface to muscle fascia was 7.52 ± 2.13 mm for subjects aged ≥ 75 years, being shorter than 9.16 ± 3.02 mm in those aged 50-64years (p < 0.01). The depth from the skin surface to bone was 22.54 ± 3.85 mm for subjects aged ≥ 75 years and 25.41 ± 4.24 mm for those aged 65-74 years, significantly shorter than those aged 50-64 years (p < 0.01), depending on the reduced muscle volume. The subcutaneous volume length was greater in females (8.29 ± 2.63 mm) than in males (5.62 ± 2.80 mm) aged 50-64 years (p < 0.01). A similar result was obtained in those aged 65-74 years, but there was no difference in the muscle volume length. Our study found that a five-eighths of an inch (16 mm) needle was an appropriate length for average-sized elderly aged ≥ 50 years, but it should be longer for those with large body sizes.

Novel ecosystemic awareness: Singing-dancing-laughing with Earth

When was the last time you danced and sang together with other people, just for the joy of it? As the COVID pandemic exacerbates mental health issues, we are seeing also a rise in so-called eco-anxiety. Awareness of humans forming part of larger ecologies can no longer be ignored as a medically relevant topic. Can contemporary eco-somatic practices contribute to shifting eco-anxieties, and to shaping human awareness of ecosystemic diversity and embeddedness? Singing-dancing together are time-honoured ways of maintaining and restoring individual or group health and happiness, and engendering embeddedness. Drawing on research with egalitarian Baka groups in Central Africa and with shifting-sliding fascia connective tissues, the proposition made here is to activate singing-dancing-laughing, not only as a method of somatic vocal training or pedagogy, but also as a way o f shaping community and honouring ecosystemic nestedness. Through this, we may further come to appreciate Earth as co-guider in eco-somatic practices.

A novel, cost-effective and easily reproducible simulation method for teaching fascia iliaca blocks significantly improves peri-operative administration rates in neck of femur fracture patients

Despite high-level evidence supporting early fascia iliaca block (FIB) administration in patients sustaining neck of femur (NOF) fractures, administration remains suboptimal, restricted primarily by limited training opportunities. We present a novel, cost-effective and easily reproducible simulation session designed to teach the landmark technique during the Covid-19 pandemic. A simulation mannequin was used with four absorbent swabs, two banana skins and a clear dressing were applied to the inguinal region to recreate the 'two-pop' texture of the landmark technique. Ten participants attended, limited by social distancing. A 1 (poor) to 5 (excellent) feedback sheet was handed to all participants for the five domains of content, delivery, interaction, usefulness, and quality of the practical skills session, with opportunities for qualitative feedback. The FIB administration rates in all NOF fracture patients between August -October 2019, before the simulation session, were statistically compared to November-December 2020, following it. All participants gave a 5/5 (excellent) rating for all five domains, confirming good acceptability amongst practitioners. In the time period before the session, 9/29 NOF fracture patients received a FIB, improving to 18/31 patients following it (p=0.042;two-tailed Fisher's exact test), a statistically significant increase in administration. The average cost per participant for the single-use materials in the session was £1.56, whereas the multiple-use items costed £7.88 per participant. Adoption of this novel, cost-effective and widely reproducible simulation method is deemed highly useful and acceptable by a diverse range of healthcare professionals, resulting in a statistically significant increase in FIB administration in NOF fracture patients.

Advancing hip fracture peri-operative care: A quality-improvement project utilising local audit data to target interventions and enhance multidisciplinary engagement

Peri-operative hip fracture care is a core service that must be maintained at the highest standard despite the COVID-19 pandemic. We re-audited our hip fracture pathway in January 2021 as a litmus test of the quality of hip fracture service during challenging times, in comparison with an inaugural January 2020 audit and national recommendations [1]. This identified areas requiring improvement;the findings were presented at the local governance meeting and used to develop a quality-improvement (QI) project to embed good clinical practice and systems resilient to external stresses. The first QI cycle focused on three specific peri-operative parameters. Methods Key parameters identified for improvement were intra-operative fascia iliaca/ femoral nerve blocks, tranexamic acid administration and near-patient haemoglobin measurement in the post-anaesthesia recovery unit. The first 2-week QI cycle was carried out in July 2021. QI interventions comprised of conspicuous yellow laminated reminders on the worktops of the anaesthesia room and recovery areas of the orthopaedic theatres, full engagement of the theatres' multidisciplinary team (MDT), discussions of rationale and data with individual anaesthetists and anaesthetic assistants, and empowering the team to remind each other of the best practice guidance. Results The 2-week cycle captured 17 patients reflecting local incidence. Discussion Our January 2021 audit highlighted issues requiring attention, likely influenced by the challenges of COVID-19. Presentation of data to anaesthetists established a consensus to improve hip fracture care. The subsequent QI cycle was carefully planned to involve the entire MDT including dialogue with theatre managers to encourage participation in the initiative, and integrated interventions into the existing workflow of trauma lists. The successful results of the first cycle were disseminated to promote sustained engagement, and further interventions such as incorporation into surgical safety checklists as a cognitive aid are in progress. We intend to steadily improve on the progress to instil good practices, build resilient systems and sustain high-quality peri-operative care for our hip fracture patients.

A case report: Necrotising leukocytoclastic vasculitis (NLV) of the breast mimicking necrotising fasciitis (NF)

Leukocytoclastic vasculitis (LV) is an inflammation of the small vessels in the dermis characterised by the deposition of immunocomplexes in the involved vessel walls. It commonly manifests as palpable purpura, limited to the skin and predominantly of the lower limb. We report a rare case of necrotising LV (NLV) affecting bilateral breast, manifesting clinical features of necrotising fasciitis (NF), and emphasizes the potential diagnostic challenges that markedly influence the treatment and survival of patients. A 48-year-old female presented with an acute onset left breast skin necrosis and discolouration that rapidly progressed to the contralateral breast with surrounding erythema and oedema of the chest wall yet spared the intermammary cleft. Some non-blanching purpuric rash were also noted on upper abdomen and left lower limb. COVID-19 test was negative. CT scan showed extensive bilateral breast fat stranding and oedema. Patient became clinically septic with a moderately raised CRP and mild acute kidney injury. Radical mastectomies and chest wall excision were performed with intra-operative findings of cloudy fluid and easily peeled away subcutaneous tissue from fascia. Urgent gram stain and culture showed no organisms. Tissue biopsies subsequently showed the diagnosis of NLV. Chest wall defect was then reconstructed with split skin grafts, NLV treated with corticosteroids and patient made an uneventful recovery. This case highlights the incidence of a rare and aggressive manifestation of NLV on the breast that mimics NF, emphasizing the clinical differentiation that may lead to catastrophic results and significant cosmetic defect, if a differential diagnosis cannot be determined at the time.

A flow cytometry-based proliferation assay for clinical evaluation of T-cell memory against SARS-CoV-2.

In general, the method of choice for evaluating immunity against Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is detection of antibodies against the virus in patient sera. However, this is not feasible in patients who do not produce antibodies, either due to a primary immunodeficiency or secondary to treatment with immunosuppressive drugs. Assessment of the antiviral T cell response is an alternative to serological tests, but most T cell assays are labor-intensive and unsuitable for a clinical routine laboratory. We developed a flow cytometry-based assay for T cell proliferative responses against SARS-CoV-2, based on the detection of blast transformation of activated cells. The assay was validated on previously SARS-CoV-2 infected individuals and healthy seronegative blood donors, displaying 74% sensitivity and 96% specificity for previous infection with SARS-CoV-2. The usefulness of the assay was demonstrated in a patient with common variable immunodeficiency with a history of COVID-19. The described T-cell assay is a clinically relevant complement to serology in the evaluation of cellular immunity against SARS-CoV-2, which can be emulated by any routine lab with flow cytometric competence.

Traumatic Nonmissile Penetrating Transnasal Anterior Skull Base Fracture and Brain Injury with Cerebrospinal Fluid Leak: Intraoperative Leak Detection and an Effective Reconstruction Procedure for a Localized Skull Base Defect Especially After Coronavirus Disease 2019 Outbreak.

BACKGROUND: Cerebrospinal fluid (CSF) leakage after penetrating skull base injury is relatively rare compared with close head injuries involving skull base fractures. CASE DESCRIPTION: We report the case of a 65-year-old man who had presented with epistaxis and serous rhinorrhea. When he had fallen to the ground near his bee boxes, a garden pole had poked into his right nostril. He had instantly removed the pole from his nostril himself. However, immediately after removal of the pole, he had developed nasal bleeding and serous rhinorrhea. He then drove to our emergency room. Computed tomography showed pneumocephalus with a minor cerebral contusion in the left frontal lobe and a penetrating injury in the left anterior skull base. His CSF leakage had not resolve spontaneously within 1 week after the injury with strict bed rest. We repaired the CSF leakage using a fat (adipose tissue)-on-fascia autograft plug and caulked the defect in the anterior skull base with the fat-on-fascia graft (FFG) plug through the left nostril with endoscopic guidance. The CSF rhinorrhea was successfully controlled. Intranasal local application of fluorescein aided in the detection of the direction of flow of the CSF leakage. CONCLUSIONS: Endonasal endoscopic caulking of a skull base defect using an FFG plug can be useful to treat CSF leakage due to the localized skull base defect, especially in the coronavirus disease 2019 pandemic. It is simple, inexpensive, and timesaving. It requires no special skills nor sophisticated instruments that can cause aerosolization, reducing the risk of infection during the surgery.

Protocol for a randomized controlled trial comparing wound COmplications in elective midline laparotomies after FAscia Closure using two different Techniques Of Running sutures: COFACTOR trial.

BACKGROUND: Wound complications following midline laparotomies are common and the main source of postoperative morbidity including superficial or deep wound infection, skin dehiscence, fascia dehiscence, and incisional hernia. Abdominal closure complications are strongly associated with suture technique and material, in addition to other factors related to the patient and type of surgery performed. The traditional technique is to place the fascia sutures 1 cm apart and at least 1 cm away from the fascia edge. A Swedish study described a new technique of placing the sutures 5 mm apart and 5 mm away from the fascia edge, resulting in lower rates of abdominal wound complications. This study has a number of limitations. There is a need for improved quality evidence to convince the surgical community to change the closure technique of abdominal wounds aiming to reduce morbidity, which is exemplified in incisional hernias and other various postop complications. METHODS: This is a 1:1 randomized, controlled, patient- and assessor-blinded, parallel design, superiority trial, with a primary endpoint of incisional hernia at 1 year. The study will be conducted at AUBMC over a 3-year period. Patients planned for a non-emergent midline laparotomy for general surgery or vascular procedure will be randomized to either fascia closure technique. In order to detect a drop of 12% in the incidence of incisional hernia, with 80% power and an alpha of 0.05, we will need to recruit 114 patients per arm. After adjusting for loss to follow-up, target recruitment is 274 subjects. We will compare both arms for the primary, secondary, and exploratory outcomes, using chi-square or t test as appropriate. Univariate and multivariate logistic regression will be done. DISCUSSION: This trial will assess postop complications following abdominal midline wound closures via two different suturing techniques. This trial will generate evidence-based conclusions that will allow surgeons to assess the role of a new abdominal closure technique in decreasing short- and long-term postoperative complications, for a commonly performed procedure. TRIAL REGISTRATION: ClinicalTrials.gov NCT03527433 . Registered on 17 May 2018 before starting participant enrollment.