One-Year Long-Term Follow up for Post-Acute Sequelae of Covid-19 Pots Patients

Background: Persistence of orthostatic tachycardia, palpitations, and fatigue beyond 4 weeks of an acute COVID-19 infection has been termed Post-Acute Sequelae of COVID-19 (PASC) POTS. We have previously reported 6-month outcomes of PASC POTS. Long-term management and outcomes of these patients is unknown. Objective(s): To examine the long-term management and outcomes of PASC POTS patients. Method(s): We conducted a retrospective study of all patients who were diagnosed with POTS at Cardiology, Neurology, and Rehabilitation Post-COVID clinic after a COVID-19 infection between March 1, 2020, and November 1, 2022, at the University of Texas Health San Antonio. We examined COVID history, POTS diagnosis, management, and one-year outcomes of post-COVID POTS patients. Result(s): In 42 patients that were diagnosed with PASC POTS, 33 had a one-year follow-up. 100% were female, 60.6% were Caucasian. Average age was 40.6 + 11 years while the average BMI was 31.9 + 10.4 kg/m2. The most common symptoms were fatigue (87.9%), palpitations (75.7%), brain fog (72.7%), orthostatic tachycardia, exercise intolerance, and dyspnea (70%). The mean heart rate change with 10-minute standing test was 42.68 + 26.73 beats per minute. At 12-months follow-up, the most common symptom was still fatigue (66.7%), palpitations (45.5%), orthostatic tachycardia, and orthostatic intolerance (42.4%). All patients were managed with increased salt and fluid intake, lower compression stockings and rehabilitation. Fifty five percent of patients were treated with Enhanced External Counter Pulsation (EECP), 42% were treated with beta blockers, 18% with fludrocortisone, 15% with midodrine, and 15% with Pyridostigmine. At 1 year follow-up, 33% of patients reported improvement in their symptoms, 33% reported worsening of symptoms, 24% reported stable symptoms, and 9% had resolution. Conclusion(s): PASC POTS patients continue to experience adverse symptoms even at one year. Physical therapy and rehabilitation and pharmacological therapy appear improve symptoms in a minority of patients.Copyright © 2023

Ventilator-associated events: From surveillance to optimizing management

Mechanical ventilation (MV) is a life-support therapy that may predispose to morbid and lethal complications, with ventilator-associated pneumonia (VAP) being the most prevalent. In 2013, the Center for Disease Control (CDC) defined criteria for ventilator-associated events (VAE). Ten years later, a growing number of studies assessing or validating its clinical applicability and the potential benefits of its inclusion have been published. Surveillance with VAE criteria is retrospective and the focus is often on a subset of patients with higher than lower severity. To date, it is estimated that around 30% of ventilated patients in the intensive care unit (ICU) develop VAE. While surveillance enhances the detection of infectious and non-infectious MV-related complications that are severe enough to impact the patient's outcomes, there are still many gaps in its classification and management. In this review, we provide an update by discussing VAE etiologies, epidemiology, and classification. Preventive strategies on optimizing ventilation, sedative and neuromuscular blockade therapy, and restrictive fluid management are warranted. An ideal VAE bundle is likely to minimize the period of intubation. We believe that it is time to progress from just surveillance to clinical care. Therefore, with this review, we have aimed to provide a roadmap for future research on the subject.Copyright © 2022 The Author(s)

Evaluation of a nutrition education and cooking programme (NEST) in vulnerable adults who are at high risk of food insecurity

Within Australia, the prevalence of food insecure individuals increased from 2.6 million in 2014-2016 (10.8%) to 3.1 million in 2018- 2020 (12.3%) due to the COVID-19 pandemic.(1) OzHarvest is a not-for-profit organisation that prioritises food salvaging, food waste prevention and nutrition education.(2) OzHarvest's education sector facilitates a programme known as Nutrition Education Skills Training (NEST). NEST is a 6-week programme providing weekly workshops of 2.5-hour duration offering skills training on cooking simple, healthy, and affordable meals to adults at risk of food insecurity. This study aimed to determine the immediate and longerterm impacts of participation in NEST. A quasi-experimental study with pre-post surveys (n = 258) and follow-up surveys (n = 20) was conducted from June 2019 to July 2022. Survey results were obtained from NEST program participants (18 years) from Adelaide Canberra, Melbourne, Newcastle, Queensland, and Sydney. Baseline (pre-) and post-surveys (at program completion) were administered to participants, with an option for a 6-month follow-up survey. Participants were required to complete both surveys to be eligible for this study. Questionnaires included 23 core questions adapted from previous studies,(3) allowing evaluation of nutrition knowledge confidence and self-efficacy, shopping, and food preparation behaviours, and eating behaviours. Food security was assessed using the standard 6-item indicator set for classifying households by food security status level. Using paired t-tests, Shapiro Wilks, and Wilcoxon sign-ranked tests for pre and post survey data, participants demonstrated overall improvement in nutrition knowledge (p < 0.001), confidence and self-efficacy (n = 222;p < 0.001) and food preparation behaviours (p < 0.001). The intake of discretionary foods overall decreased (p < 0.001) while fruit, vegetable and water intake increased (p < 0.001). Food security improved from 57% to 68% immediately within the population (p < 0.001). Using RMANOVA and Shapiro Wilks tests, the 6-month survey results were compared to the pre surveys suggested longer lasting improvements in nutrition knowledge (p < 0.001), cooking confidence (n = 8;p = 0.033), food preparation behaviours (p = 0.003), and increased vegetable intake (p = 0.032) and fruit intake (p = 0.012) Participation in OzHarvest's NEST programme results in short-term improvements in food security levels and dietary behaviours Over the longer term, these changes were sustained but to a lesser degree, indicating that systemic changes are required to address underlying socioeconomic disadvantage.

Preventive nutritional style for new type 2019 Coronavirus SARS-CoV-2 (COVID-19) pandemic

The COVID-19 infection, which emerged at the beginning of 2019 and spread all over the world, led to the global pandemic. The destructive effects of the pandemic are tried to be stopped all over the world. In this process, scien-tific methods should be applied to combat the pandemic. Personal precautions are personal hygiene, apply social isolation and strengthen the immune system, support a natural, balanced, healthy diet, support nutrition with exercise and have a healthy lifestyle. Strong individual immunity is the main factor in avoiding virus infection or the severity of the infection. Social isolation advice has changed the lifestyle of some individuals and brought with a sedentary lifestyle and an irregular diet. As an expected result of this condition, the immune system has been weakened. Therefore, switching to a natural and balanced diet that will create a strong immune system will protect against the destructive effects of the new type of corona virus pandemic. It is very important to supplement food containing vitamins, minerals, prebiotics and probiotics naturally with adequate water intake. Vitamin C, probiotics, prebiotics, thymoquinone, selenium and zinc supplements will strengthen the immune system, increase body resistance, thereby activating possible protective effects mechanisms for COVID-19 infection.Copyright © 2021 Necati Ozpinar. All rights reserved.

Finding an Answer for an Adolescent with Back Pain

Case report - Introduction: This is the case of an adolescent referred to rheumatology following 5 years of back pain. After years of trying a number of treatments without much success, the cause was found to be a previously undiagnosed urological pathology. The case highlights awareness of non-rheumatological causes and incidental findings which can redirect a patient towards more appropriate treatment and reduce the potential for long-term adverse health issues and anxiety. Case report - Case description: B was referred age 16 to rheumatology with a 5-year history of lower back pain. She had previously seen paediatricians with symptoms initially attributed to constipation due to intermittent straining and hard stool. However, constipation remedies had not relieved the pain which progressed gradually to a more persistent dull ache with impact on daily activities. Various analgesics (including paracetamol and non-steroidal anti-inflammatories), exercises and acupuncture had not helped. There was no history of recurrent urinary tract infections or symptom correlation with fluid intake, menstruation or bowel habit. No inflammatory features or connective tissue disease symptoms were noted and family history was unremarkable Clinical examination was normal apart from mild tenderness in the lumbar region. Rheumatoid factor was borderline positive (15 iu/mL) with the rest of blood tests normal including renal function, inflammatory markers (CRP, ESR), anti CCP and ANA. She had minimal microscopic haematuria without proteinuria. MRI spine in 2015 was normal. In view of her young age and symptoms affecting daily activities, STIR sequence spinal MRI was requested. This excluded any new or old inflammatory changes but incidentally identified a dilated left pelvi-calyceal system. Renal ultrasound confirmed a grossly hydronephrotic left kidney with hydroureter and minimal renal tissue suggesting longstanding obstruction. No calculi were seen. The patient was referred to urologists. Further investigations (including MRI abdomen) confirmed similar findings and a distal ureteric stricture. A MAG 3 renogram showed a normal right kidney but only 12% functioning of the left kidney. Urologists have advised surgery (removal of left kidney and ureter) which may relieve symptoms or a conservative non-surgical approach (continue analgesia, physiotherapy and monitoring). The patient and her family are relieved to have a possible cause identified and are considering the surgical option due to ongoing flank discomfort. Case report - Discussion: This was an interesting finding of hydroureter and hydronephrosis causing longstanding back pain presenting to rheumatologists. Until completion of the spondyloarthropathy protocol MRI (STIR images), aetiology had been unclear. Hydronephrosis and hydroureter has no specific age or racial predilection. Signs and symptoms may depend on whether obstruction is acute/chronic. Chronic cases may be asymptomatic or present as a dull discomfort (like this case). Some cases may only present in adulthood with pain precipitated by fluid intake. Blood tests may show impaired kidney function. Post-mortem studies suggest 50% of people have at least one renal abnormality (e.g., renal cysts, duplex ureters) with autopsy series incidence of hydronephrosis reported as 3.1%. Causes include anatomical abnormalities such as vesico-ureteric reflux, urethral strictures (usually present in childhood), calculi, benign prostatic hyperplasia, or intrapelvic neoplasms, pregnancy and infections (e.g., TB). Sudden onset unilateral renomegaly was reported in one case of primary Sjogren's with lymphocytic interstitial nephritis and positive Sjogren's autoantibodies. Our patient has no clinical or serological evidence of connective tissue disease. Minor pelvi-calyceal distension can occur as a normal finding in wellhydrated patients and pregnancy. However, significant hydronephrosis requires assessment to determine cause as it may affect long term renal function. Imaging via computed tomography, ultrasound and urograms can help guide further management. In this case the preceding cause and duration of pathology is unknown. Sterile, giant hydronephrosis treatment options include observation and ureteric stent or nephrostomy in patients unfit for surgery. Nephrectomy is advised for pain and recurrent infection in a non-functioning kidney. Complications may include bowel perforation, vascular injury and urine leakage. Both open and minimally invasive procedures have good reported outcomes. The COVID-19 pandemic and exams have affected timing of any elective procedures and the patient understands surgery may or may not offer complete symptom resolution. Case report - Key learning points: . Non-inflammatory causes of back pain should always be considered in cases of persistent back pain, particularly in young people to ascertain if there is a treatable cause . Hydronephrosis cases can be asymptomatic or present with vague, intermittent, non-specific abdominal symptoms with normal physical examination with or without haematuria. This can cause diagnostic uncertainty and delay referral to urology and appropriate renal investigations . Assessment of renal function (including MAG 3 renogram) is important to guide further management . Surgical interventions (pyeloplasty/nephrectomy) may ease symptoms long term but there is no guarantee of a successful outcome and operative risks need to be considered too . Left undiagnosed, potentially this patient could have had further disruption to daily activities and both physical and mental well being.

Is Lockdown Good for Constipation?

Background Children's routines have been disturbed during the last 2 years due to national lockdowns with school closures. It is acknowledged that daily routine is important for a healthy bowel habit and we therefore had concerns that this may have a detrimental effect on children with constipation. Aim of Study To examine the effects of lockdown due to COVID19 on children's symptoms of constipation. Method Prospective data was obtained by questionnaires, which were handed to 50 children and parents attending a childhood constipation clinic in the normal way following the easing of lockdown. The questionnaires asked about symptoms that would normally be asked in the clinic appointments. Parents were asked if the child's symptoms had become worse, improved or stayed the same and asked respondents to give reasons for their answers. The questionnaires were then collated and common themes noted. Ethics approval was not required. Results 38% of parents reported improvement in symptoms 34% of parents reported deterioration in symptoms 28% of reported no change in symptoms. The reasons given for improvements in symptoms included an increase in the ability of parents to monitor children's fluid intake and toileting routines at home, easier access to toilets and less with holding behaviour, usually adopted to avoid using school toilets. These children were also reported as being generally more relaxed and happier to be at home. Of note in this group were reports that symptoms often deteriorated on returning to school. The reasons given for a deterioration in symptoms included a lack of physical activity, lack of routine in toileting and taking medication, and changes in diet. This group also commonly included reports of children and parents experiencing anxiety, isolation, anger and lack of motivation. The most common symptom to be reported as problematic was children either beginning to soil or their soiling becoming more frequent. Most who gave reasons in the group reporting no change did recognise some of the above observations and in some cases positive aspects such as easier access to toilets were counterbalanced by lack of exercise. Summary Many reasons for changes in symptoms of childhood constipation during the national lockdowns were reported. There was a balance, with almost equal numbers, reporting improvements and a worsening of symptoms. Others did not notice any change in their child's condition. Physical, behavioural and emotional reasons were cited as being responsible for changes in children's experience of constipation. Conclusion Lockdown due to COVID19 has had a varied effect on symptoms of constipation in children. The assumption that children's constipation would become worse has been challenged in that slightly more children improved during this time with some then deteriorating again when lockdown was eased. These results re-iterate the need to tailor approaches to treatments and care of children with constipation on an individual basis. It is also important to equally understand the anxieties of being in school for some but the effects of social isolation and uncertainty for others.

Effectiveness of Home Bowel Preparation for Children Living Long Distances from Endoscopy Centre

Introduction The North of Scotland Paediatric Gastroenterology, Hepatology and Nutrition Network (NoSPGHANN) manages children over an area of 53,000 km2. Travel distances to Royal Aberdeen Children's Hospital (RACH) were previously felt to preclude the adoption of home bowel preparation (HBP) for elective colonoscopies but a trial period of HBP commenced in March 2020. The same drugs (senna and Picolax) were used for inpatient bowel preparation (IPBP) or HBP but the timings were changed for HBP to complete all doses on the day prior to procedure to allow travel to RACH. This audit evaluates the impact of this change of practice. Methods All children undergoing elective colonoscopy at RACH between December 2019 and November 2020 were identified. Electronic were records reviewed to determine IPBP vs HBP, distance to RACH from patient's home, bowel preparation score, morning or afternoon list, requirement for intravenous (IV) fluids during the procedure, day case procedure and length of stay. Bowel preparation score was derived from the Aronchick Scale and converted as follows: 0 (unacceptable), 1 (poor), 2 (fair), 3 (good) and 4 (excellent). Results Summary The high standard of bowel preparation achieved with IPBP was maintained when delivered at home, despite some children travelling >100 miles and having travelling times of >3 hours. Delivering all doses of drugs on the day before procedure did not affect the quality of bowel preparation for afternoon lists. There is a trend to a higher proportion of children with HBP receiving IV fluids during anaesthetic which may suggest that some are dehydrated. The proportion of day case procedures has increased from 0% to 72%, which since March 2020, has saved NHS Grampian 18,000. Conclusion Home bowel preparation delivered on day prior to procedure is well tolerated and as effective as inpatient delivered, even for children with long travelling times to hospital. Covid-19 distancing measures have reduced the number of available inpatient beds so HBP has aided bed management in addition to providing a cost saving. The risk of dehydration may be higher for HBP and guidance will be changed to increase the emphasis on oral fluid intake, including during travelling time, on day of procedure.

Kt/v, mortality and risk of complications*

Background: Dialysis quality ismeasured by Kt/V, it is one of the most important parameter for assessing hemodialysis for patients. Decreased Kt/V is associated with increased mortality and increased risk of complications, normal or increased Kt/V is associated with decreased mortality and complication rates. Guidelines have recommended Kt/V of 1.2 as the minimum dose for thrice-weekly HD. We analyzed the Kt/v, mortality and risk of complications in our hemodialysis center patients Methods or Case description: We analyzed patients from 2021-2022, within 1 year 50 patients undergoing hemodialysis 3 times a week were analyzed. Results or Learning points: The average Kt/V was 1.38. Patient mortality was minimal during this period and was related to Covid 19 infection, 3 patients died, one from sepsis and two from Covid 19 infection. 5 patients were hospitalized several times with hyperhydration and accompanying consequences, which were not related to dialysis, but with non-compliance with the regimen and increased fluid intake. Conclusion(s): In general, the patients felt satisfactory and there were no complaints. Therefore, it can be considered that Kt/V above 1.3 is satisfactory and reduces the risk of mortality and complications.

The Impact of Nutrients on Coronavirus (Covid-19): A Review

A properly balanced diet can improve the immunity system and also prevent various diseases including COVID-19 which is caused by severe acute respiratory syndrome coronavirus 2 (SARC-Co2). This review mainly describes dietary guidelines or approaches to build up our immunity as well as better health and protect from corona virus. As we all know one line "Health is Wealth". So this wealth can be established or secure by optimal diet. Basic food components that are carbohydrates, protein, fat, vitamin and minerals have various important functions to fight against diseases. Most of the documents encourage to consumption of fruits, green vegetables, proteins, whole grains and fluids. Vitamins such as C, E, D, A most important to boost up our immunity. Vitamin C and E also known as natural antioxidants because they protect our body from infection and vitamin C also helps to absorption of iron. Zinc selenium, amino acid and omega 3 fatty acids are necessary to fight COVID-19. Besides this good hygiene practice, proper physical practice or daily work out and proper amount of water intake can improve good health status and prevent chronic illness. Sleep is necessary to heal and rest our body especially during critical illness. Exercise helps to increase the level of white blood corpacell and antibody which helps to fight against infections. This paper discussed the role of these nutrients and specific functions related to improving COVID patients. These nutrients can protect our health from various infectious diseases as well as can decreases mortality and the morbidity rate of COVID-19 patients by improving immunity levels. Copyright © RJPT All right reserved.

An Outbreak Investigation of Pulmonary Infections Caused by Mycobacterium abscessus in a Cardiothoracic Transplant Population

Background. Nontuberculous mycobacteria (NTM) are environmental organisms that can form biofilms in municipal water systems and as such are difficult to eliminate. Mycobacterium abscessus is a rapid-growing NTMthat can cause skin and soft tissue, disseminated, and pulmonary infections. M. abscessus is difficult to treat, often requiring prolonged therapy with several antibiotics due to its intrinsic drug resistance. In 2021, our institution identified a significant increase in pulmonary infections caused by M. abscessus in the cardiothoracic transplant population. Methods. All M. abscessus cases among inpatients at our institution were extracted from the electronic medical record (EMR) between January 2019 and September 2021. Clinical characteristics were determined through EMR review and included demographics, transplant status, specimen type, COVID-19 history, and patient care practices involving water. A multidisciplinary team conducted an investigation to identify possible variations in practice related to the source of water used for clinical care activities in this identified population. Results. Between January 2021 and September 2021, there were 12 cases of M. abscessus among inpatients at our institution compared to 6 cases in 2019 and 5 in 2020 (Figure 1). Between 2019 and 2020, post-heart and pre-/post-lung transplant patients comprised 9% of cases, 55% of cases were pulmonary infections, and none had a history of COVID-19 infection. In 2021, post-heart and pre-/post-lung transplant patients comprised 58% of cases, 83% of cases were pulmonary infections, and 33% of cases had a history of COVID-19 infection. There were varying sources of water utilized for the clinical care activities in this identified population (Table 1). Conclusion. To investigate the potential outbreak, we are actively collecting water samples and swabs from water fixtures in both patient and nourishment rooms for water culturing. To mitigate a potential water-borne source, we will use sterile water for all clinical care practices involving water and for all patient water drinking needs in the post-heart and pre-/post-lung transplant population impacted by the outbreak. The only use of tap water is hand hygiene and patient bathing.

Determining the Nutritional Levels and Physical Activity Habits of Physical Education and Sports Teachers during the Covid-19 Process

Covid-19 has largely maintained its effect in our country as well as in the world. This has adversely affected the lives of people by staying in quarantine or curfew. It was aimed to determine the Nutritional Levels and Physical Activity Habits of Physical Education and Sports Teachers during the Covid-19 Process with this study. The model of our study was applied to determine the nutritional habits and physical activity levels of physical education and sports teachers in the Eastern Anatolia region during the COVID-19 process. The population of our research consists of physical education and sports teachers among the teachers in the Eastern Anatolia region. The sample of our study consisted of 278 randomly selected people from among physical education teachers. In our study, in order to determine the healthy lifestyles of physical education and sports teachers, a questionnaire aimed at "Examination of Nutritional Habits and Nutritional Knowledge Levels of Healthcare Professionals" through Yucel (2015) and a short form of "International Physical Activity Questionnaire" were developed by Erdogan(2021) and adapted to the pandemic process by developing "Nutritional Knowledge Level, Nutritional Habits and Physical Activity Levels in the Pandemic Process" and a questionnaire with 26 questions was applied to determine the nutritional knowledge levels, nutritional habits and physical activity levels of teachers. The data obtained in our study were transferred to the SPSS 22 package program and analyzed and the significance level was accepted as p<0.05. It was determined that 37.1% of physical education teachers had changes in their eating habits, they ate 2 meals with 56.8% of their daily main meals, Lunch with 56.1% of the meals they skipped during the day, Meal skipping reasons were caused by changes in their sleep pattern with 30.9%, 36% of them did not change the type of food they consumed at the snack, the most common type of food/beverage they consumed between meals was fruit/dry fruit with 40.6%, and 47.8% of them did not change their daily fluid consumption and as daily water consumption, 33.5% of physical education teachers consumed 1.5 liters of water. When the physical activity levels were examined, it was found that 45% of the physical education teachers did not do regular physical activity, 42.8% exercised once a week, and in physical activity, there was no change, 59% of them did their physical activities in the gym, it was also determined that 36.7% of them think their physical activities are beneficial, 37.4% were partially affected by the stay at home project, and 53.2% had increased body weight. As a result, it is thought that there are changes in nutritional knowledge levels and physical activity levels, that it negatively affects human health during the pandemic period, and that adequate/balanced nutrition and physical activity during the COVID-19 process will positively affect people's health. Copyright © 2022 Ubiquity Press. All rights reserved.

Viral exanthems Unravelling viral rashes

Common causes of viral exanthems in Australia include herpesviruses, enteroviruses, parvovirus B19, varicella, measles and rubella viruses and mosquito-borne alphaviruses. The cause can often be diagnosed clinically from the rash distribution and morphology, confirmed only when necessary with serological or PCR tests. Most viral exanthems are self-limiting, requiring supportive care alone.

Prompt Diagnosis and Intervention of Oxalate Nephropathy to Salvage Kidney Function

Hyperoxaluria can be primary due to defective glyoxylate metabolism leading to hepatic oxalate overproduction or secondary due to increased intestinal oxalate absorption. Oxalate nephropathy is the deposition of calcium oxalate crystals leading to tubular injury, interstitial fibrosis, and AKI or CKD. This describes three cases of renal oxalosis. First is a 60 year old male with stroke, hypertension, diabetes who presented with AKI of 4.5 mg/dL from 1.6 that rose to 11 mg/dL. Serologies for glomerulonephritis and paraproteinemia were negative. Biopsy showed tubular oxalate crystal deposition with tubular injury and interstitial nephritis. His renal failure required dialysis. Second is a 58 year old female with gastric bypass surgery who presented for edema and AKI from 1.3 to 3.6 mg/dL. Serologies were also negative. Biopsy showed interstitial nephritis with tubular calcium oxalate deposition. She was started on prednisone 60 mg. Creatinine stabilized to 2.2 mg/dL, not requiring dialysis. Third is a 82 year old male with obesity and sarcoma of the scalp treated with pembrolizumab who presented with dyspnea, edema and an AKI from 1 to 8.6 mg/dL. Urine sediment was bland with negative serologies. Differential included AIN due to pembrolizumab. Patient was started on high dose prednisone and biopsy showed interstitial nephritis and calcium oxalate crystal deposition. Patient endorsed taking frequent vitamin C as prophylaxis for Covid. Creatinine stabilized to 2.9 mg/dL not on dialysis. Classic etiologies of hyperoxaluria include dietary oxalate from ascorbic acid and fat malabsorption from gastric bypass surgery. Treatment includes increased fluid intake, oral calcium supplements and low oxalate diet. Oxalate nephropathy remains an under recognized cause of kidney failure, as such, early biopsy and intervention are necessary. (Figure Presented)

Stress and Adherence During the COVID-19 Pandemic in an Inner-City Population of Dialysis Patients: Relationship to Age

It has been reported that older pts adapt better to dialysis than younger pts. We investigated in response by age to various stressors encountered during the COVID-19 pandemic in a population of inner-city dialysis patients. A survey was conducted in a random sample of 32 dialysis patients. Patients were asked about their fluid intake, general attitudes towards medical recommendations, and changes in their wellbeing due to COVID19. The PSS (Perceived Stress Scale) and KAS-R (Kim Alliance Scale Revised) were also used. Mean age was 56.8 ± 18.2 years. 15 pts (46.9%) were <60 yrs (younger) and 17 (53.1%) were ≥60 yrs (older). Mean dialysis time was 88.0 ± 104.0 months. There were 20 (62.5%) male, 29 (90.6%) identified as black, 18 (56%) had a high school diploma or less, and 14 (44%) completed some college or more. 7% (1) of older and 46% (6) of younger pts reported “some of the time” or “never” rather than "most of the time" when asked how often they followed the fluid restriction recommendations (p=0.034). 29% (4) of younger pts reported fluid restrictions were difficult to follow, vs. none of the older pts (p=0.037). 33% (5) of younger pts reported “poor” or “average” when asked about wellbeing prior to the pandemic and 100% (15) of older patients reported “good” (p=0.05). When asked to rate their stress level over the last year, 64% (9) of younger pts reported being somewhat or very stressed and 79% (11) of older pts reported not at all or a little stressed (p=0.015). 29% (4) of younger pts stated they sometimes work well with their provider and 100% (15) of older patients stated always (p=0.026). There were no statistically significant differences between the groups for sex, race, or education. In our population during the pandemic: 1. Younger pts were less adherent to fluid restriction and found them more difficult to follow. 2. Older pts were more likely to report feeling good prior to the pandemic and were less stressed following it. 3. Older pts were more likely to report a good relationship with their provider. 4. Younger pts may need more support through the pandemic as they appear to be coping less well, feel less connected, and are less able to follow important dietary restrictions. (Table Presented) This case highlights the uncommon sequelae of untreated primary hyperparathyroidism which is rare since the introduction of automated chemistry analyzers [2]. Pancreatitis is reported in < 3% of patients with hyperparathyroidism and is seldom seen in current practice. Nephrocalcinosis and pancreatitis are rare complications of untreated hyperparathyroidism and could have been averted with the definitive treatment of parathyroidectomy.

SIGNIFICANT CK ELEVATION IN HEAT-EXPOSURE ADULT RHABDOMYOLYSIS WITH CONCURRENT ASYMPTOMATIC SARS-COV2 INFECTION

CASE: A 59 years old male with past medical history of type 2 diabetes presented in August of 2020 after 2 weeks of leg cramps, nausea, and dark urine that followed several weeks of poor fluid intake during his job as a construction worker. Patient reported that he had a similar episode in 2011, and was diagnosed with rhabdomyolysis with a CK value of 3442. Physical examination revealed a blood pressure of 138/79 mmHg, a pulse of 99 beats/min, respiratory rate of 16 breaths/min, temperature of 36.9 °C, and oxygen saturation of 96% on room air. He was alert and oriented, able to ambulate with pain, and no other significant cardiovascular, pulmonary, neurologic, and gastrointestinal findings. Notable elevation of plasma creatinine of 10.23 mg/dL, BUN of 90mg/dL, sodium of 123 mmol/L, potassium of 5.4 mmol/L, bicarbonate of 15 mmol/L, CRP of 115.4, D-dimer of 4305, Ferritin of 7927, Serum myoglobin of 5320 mcg/L, and total CK of 365148 U/L were noted. Nasopharyngeal swab at presentation was positive for Sars-CoV-2. Patient's urine drug/toxicology screen were negative. The patient was placed on intermittent hemodialysis, and IV fluids were administered. Given his unusually high CK level and COVID-19 positive status, viral myositis associated with COVID-19 was initially suspected. Muscle biopsy showed necrotizing myositis, and ANA titer and myositis specific antibodies were negative. Patient's sole complaint continued to be bilateral lower extremity spasm that gradually improved. The patient was discharged 13 days later with improving kidney functions and total CK of 1683. Patient did not follow up until January of 2021 when he presented to our emergency department for a gunshot wound. His kidney function was back to his baseline at the time. IMPACT/DISCUSSION: Multiple reports in the past 2 years have noted some relationship between rhabdomyolysis and SARS-CoV2 infection, including cases of rhabdomyolysis as a presenting and late complication of severe and mild COVID-19 pneumonia (Valente-Acosta et al, Min et al, and Suwanwongse et a). This case shows both an non- respiratory COVID-19 patient presenting with rhabdomyolysis as well as extremely high presenting CK of 365148 in a non-exercise associated adult rhabdomyolysis. While there are studies that suggests SARS-CoV2 can cause a direct viral injury on muscles, patient's muscle biopsy showing necrotizing myositis rather than direct viral injury suggests that this is not the likely mechanism that aggravated the disease. Rather, given that patient had significantly elevated d-dimer, ferritin, and CRP at presentation, the mechanism may be due to the significant inflammatory responses seen in COVID-19 patients. CONCLUSION: COVID-19 infection, regardless of severity, can significantly exacerbate rhabdomyolysis. Proper inpatient management in such cases can lead to no lasting musculoskeletal or renal complications despite severity. The relationship between COVID-19 infection and severe rhabdomyolysis may be based on the inflammatory responses.

THE BIG IMPACT OF SMALL CHANGES IN NARROW THERAPEUTIC INDEX DRUGS

CASE: An 84-year-old woman with atrial fibrillation on Digoxin presented with acute onset of confusion associated with a week history of abdominal pain, vomiting, and poor fluid intake. A few days prior, Amiodarone was added to her drug regimen which included Lasix. Additionally, she received the COVID-19 booster vaccine which led to a viral-like syndrome resulting in dehydration. The patient was afebrile, normotensive, but bradycardic. EKG showed a prolonged PR interval and scooped ST segments. Labs showed hyperkalemia, pre-renal acute kidney injury (AKI), and a Digoxin level of 4.3 ng/mL (therapeutic range: 0.8-2.0 ng/mL). Digoxin and Lasix were held and Digoxin antidote, Digibind, was administered with normalizing heart rate, potassium, and clinical improvement. IMPACT/DISCUSSION: Digoxin is used to slow conduction in atrial fibrillation and increase cardiac contractility in heart failure. It inhibits the membrane sodium-potassium-adenosine triphosphatase pump (Na/K ATPase), resulting in increased cytosolic calcium and subsequent cardiac contractility and automaticity. In turn, this can also cause premature ventricular contractions and tachycardia. In the carotid sinus, increased baroreceptor firing and subsequent increased vagal tone occurs which can cause bradycardia, atrioventricular blocks, hypotension, and GI symptoms. In skeletal muscle, hyperkalemia can result due to the abundance of Na/K ATPase pumps. Digoxin has a narrow therapeutic index with serum levels easily affected by many commonly prescribed drugs by way of decreasing renal clearance, inhibiting P-glycoprotein, and inducing secondary electrolyte disturbances. That said, drug dosing should be individualized with close monitoring to avoid potentially life-threatening effects that may result with even mildly increased digoxin levels. Acute toxicity manifests as non-specific GI, and neurologic symptoms (confusion, lethargy, visual changes), hyperkalemia, and brady or tachy-arrhythmias. Treatment is with digoxin specific fragment antigen binding (Fab) antibody, Digibind, which binds digoxin, inactivating it within 6-8 hours. Postadministration, digoxin serum testing cannot distinguish free verse bound drug;therefore, drug levels remain elevated for days to weeks until the FabDigoxin complex is excreted. In the case above, the viral-like-syndrome after the booster vaccine with subsequent AKI secondary to dehydration likely precipitated Digoxin toxicity. Accompanying drug interactions of diuretics causing dehydration and hypokalemia, P-glycoprotein inhibitors (Amiodarone, Verapamil, Diltiazem, Quinidine), and ACE inhibitors can further worsen renal clearance and culminate in Digoxin toxicity. CONCLUSION: Given Digoxin's narrow therapeutic index, small clinical changes such as post COVID-19 vaccine flu-like symptoms, dehydration, and medication changes can manifest drug toxicity. Therefore, attentive monitoring of accompanying comorbidities and drug interactions is imperative at preventing catastrophic toxic effects.

From Other Journals

The article highlights that balanced multielectrolyte solution (BMES) has been touted as superior to 0.9% saline because of concerns about iatrogenic acute kidney injury and hyperchloraemic metabolic acidosis. It also discusses that patients who have suffered out- of-hospital cardiac arrest frequently have cardiogenic shock.

Updated principles of prevention, diagnosis and treatment of COVID-19 in children in Poland - recommendations for paediatricians and family medicine doctors

Since late 2021, we have observed a significant increase in the proportion of children infected with SARS-CoV-2. The course of the disease in children is usually sparsely symptomatic or asymptomatic. However, the predominance of new virus variants makes children more likely to become symptomatically ill and require hospitalisation. This paper aims to update recommendations for managing a child with COVID-19 in out- and inpatient settings. Current options for prevention and antiviral treatment are discussed, noting the limited availability of therapy for children. In most children with COVID-19, the basis for treatment remains symptomatic and supportive therapy and measures to reduce SARS-CoV-2 infection spread.

Impact of COVID-19 on monthly water consumption on a tropical tourism island: case study of Phuket (Thailand)

Phuket is a tropical island in Thailand that is famous for tourism. The COVID-19 pandemic resulted in the number of tourists reducing to almost zero. Since tourism contributes around one-half of the gross provincial product of Phuket, the impact was so severe that even the numbers of people employed and registered as locals decreased. Analysing the data from January 2015 to March 2021, we found that the total, residential and non-residential monthly consumptions dropped significantly after Thailand’s State of Emergency was declared in March 2020. Unlike other studies that reported residential consumption increasing when people were required to stay home for a prolonged period, Phuket’s residential consumption decreased by more than 10% from the pre-COVID-19 level, possibly due to the drop in peer-to-peer accommodation bookings. To study the impact on consumption in detail, we modelled using cascade regression analysis by dividing the predictors into three groups, namely socioeconomics, weather and calendar period. The results showed that the number of guest arrivals was the most statistically significant in all types of consumption and should be used as a predictor for water demand forecasting models in tourism areas.