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Autoantibodies against melanoma differentiation-associated protein 5 (MDA5) associated with dermatomyositis have recently been described in Asians with rapidly progressive respiratory disease. Here we report the case of a middle-aged white woman with anti-MDA5 antibody-associated amyopathic dermatomyositis with interstitial lung disease (ILD), which is stable with minimal immune suppression. A 55-year-old woman was referred to a virtual dermatology clinic during the COVID-19 pandemic suspected of having widespread eczema involving the chest, face, arm and hands on the background of atopy. On direct questioning, she admitted to having constitutional symptoms, exertional dyspnoea, joint pain and symptoms of proximal muscle weakness. On clinical suspicion of possible connective tissue disorder, she was urgently reviewed in the hospital, where she was found to have a photodistributed rash involving cutaneous ulceration and violaceous plaques. Hand examination showed mechanic's hand mimicking hand eczema, ragged nail cuticles and acute tenosynovitis in the left index finger. Her upper and lower limb muscle power was normal and respiratory examination revealed bi-basal fine end-expiratory crepitation. Her repeated biochemical, haematological and muscle enzymes remained normal. Skin biopsy taken from photosensitive rash over the wrist showed hypergranulosis, Civatte body formation, colloid bodies and dyskeratotic keratinocytes, in keeping with severe lichenoid eruption. Superficial dermis showed patchy red-cell extravasation, perivascular chronic infiltration, dermal oedema and serum on the surface, in keeping with ulceration secondary to severe inflammatory processes. There were no eosinophils and eccrine coils were free of inflammation, raising the suspicion of a drug eruption. Her antinuclear antibody and double-stranded DNA were repeatedly negative. Myositisspecific antibody panel was performed owing to a high clinical suspicion of photosensitive dermatoses, both clinically and histologically. Histology revealed positive anti-MDA5 antibodies;repeated positive testing confirmed this. Although lung function was normal, computed tomography revealed evidence of ILD. We made a diagnosis of anti-MDA5 antibodyassociated amyopathic dermatomyositis with ILD. Her malignancy screening was negative. The patient was started on lowdose prednisolone and hydroxychloroquine 200 mg twice daily, with topical steroid applications, which resulted in remarkable clinical improvement. Anti-MDA5 associated dermatomyositis has characteristic cutaneous lesions consisting of skin ulceration and tender palmar papules, mechanic's hands, inflammatory arthritis and rapidly progressive ILD, which is frequently fatal. Although our patient had ILD, she was relatively stable on minimal immunosuppression. It is important for clinicians to have an increased awareness of this disease as it could have a highly variable clinical presentation in the white population.
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The purpose of this paper is to enhance the performance of the virtual assistant. So, what exactly is a virtual assistant. Application software, often called virtual assistants, also known as AI assistants or digital assistants, is software that understands natural language voice commands and can perform tasks on your behalf. What does a virtual assistant do. Virtual assistants can complete practically any specific smartphone or PC activity that you can complete on your own, and the list is continually expanding. Virtual assistants typically do an impressive variety of tasks, including scheduling meetings, delivering messages, and monitoring the weather. Previous virtual assistants, like Google Assistant and Cortana, had limits in that they could only perform searches and were not entirely automated. For instance, these engines do not have the ability to forward and rewind the song in order to maintain the control function of the song;they can only have the module to search for songs and play them. Currently, we are working on a project where we are automating Google, YouTube, and many other new things to improve the functionality of this project. Now, in order to simplify the process, we've added a virtual mouse that can only be used for cursor control and clicking. It receives input from the camera, and our index finger acts as the mouse tip, our middle finger as the right click, and so forth.Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.
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Case Diagnosis: A 71-year-old female developed C7-C8 radiculitis with left hand weakness 4 days after receiving her booster dose of SARS-CoV-2 vaccine. Case Description or Program Description: Patient with a significant past medical history of cervical fusion and bilateral carpal tunnel releases over 20 years ago presented to outpatient office because of decreased hand grip strength 4 days after receiving her booster dose of Pfizer-BioNTech SARS-CoV-2 vaccine. Her left hand weakness was spontaneous in onset, making her unable to flex her index finger and type. No pain or paresthesia. No trauma, swelling, color or temperature change in her left hand. Nerve conduction study and electromyography performed 19 days after the onset of her symptoms revealed acute greater than chronic changes mainly in distal muscles innervated by C7-C8 nerve roots, compatible with left C7-8 radiculopathy. MRI findings were chronic and compatible with her history of cervical fusion. Her clinical presentation was thought to be an inflammatory rather than mechanical etiology associated with the booster. Patient was referred to outpatient occupational therapy to help her restore hand function. Setting(s): Outpatient office of acute rehabilitation hospital Assessment/Results: Patient underwent occupational therapy and reported mild improvement in hand strength and function after 3 months of therapy. Discussion (relevance): The clinical course of this patient suggested an association between her symptoms and the booster dose of SARS-Cov-2 vaccine. It is possible that some component of the booster might have triggered an immune response and cross-reacted to the peripheral nerve system, leading to acute neuritis and the weakness of her hand. Conclusion(s): Neurologic complications after SARSCov- 2 vaccination is usually mild and self-limiting. We present a rare case of acute radiculitis that was associated with SARS-Cov-2 vaccination with residual impairment in function. Although the causality cannot be confirmed due to the lack of a biological marker, this case may help guide further research into a potential pathogenic mechanism.
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Background: Cardiac Rehabilitation (CR) is a supervised exercise and risk factor modification program for patients with cardiac conditions. Endothelial dysfunction is often present and is associated with worsening cardiac prognosis, and several studies have indicated that standard onsite CR has improved endothelial function in heart disease patients. However, during the COVID-19 pandemic, many CR programs transitioned to a virtual or hybrid model of care to increase safety of CR programs. Objective(s): The objective of this study was to determine vascular function of patients with coronary artery disease (CAD) measured before and after 4 months of outpatient CR using a virtual model of care. Method(s): Virtual CR included 1 virtual group session/week by videoconferencing and hybrid CR included 1 session/week (4 on-site and 12 virtual group sessions) for a total of 16 weeks. CAD patients (6 females, 4 males) mean age 68.1+/-7.5 years rested in a supine position to measure 1) brachial artery flow-mediated dilation (FMD), 2) microvascular function, and 3) augmentation index (AI) using ultrasound sonography (n=8) and an EndoPAT 2000 (n=9). Two patients completed virtual CR and the rest underwent hybrid CR. These measurements were obtained concurrently using an ultrasound transducer at the brachial artery proximal to a blood pressure cuff on the forearm with EndoPAT cuffs on the index fingers during 5-minute intervals of baseline, occlusion, and recovery. FMD results were analyzed using automated Cardiovascular Suite software. AI and Reactive Hyperemia Index (LnRHI) were determined using automatic analysis via the EndoPAT 2000. Anthropometrics, blood pressure, and food intake were recorded at each visit. Patients were advised to refrain from strenuous exercise, alcohol, caffeine, and highly saturated foods at least 12 hours prior to the study appointment. One tailed paired t-tests were conducted between baseline and completion. Result(s): Adherence to CR averaged 10.3+/-3.2 out of 16 sessions. FMD improved from (2.75+/-1.71% to 5.63+/-4.37%, p=0.048) while there was no improvement in AI (14.2+/-18.8 to 13.2+/-19.6, p=0.45) or LnRHI (0.56+/-0.12 to 0.52+/-0.20, p=0.24). Conclusion(s): While there was no improvement in LnRHI or AI after CR, FMD improved in CAD patients after 4 months of adapted CR. Our results indicate that while virtual and hybrid models of CR may not be sufficient for improving microvascular function and aortic stiffness in CAD, there is an improvement of endothelial function. Future studies should examine the effects of adherence, duration and exercise intensity within these alternative models of CR on aortic and microvascular improvements.
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SESSION TITLE: Critical Diffuse Lung Disease Cases 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Acute eosinophilic pneumonia (AEP) is dramatic in presentation mimicking infectious pneumonia or acute respiratory distress syndrome in previously healthy individuals. Medications are a commonly recognized cause of AEP. Daptomycin, has been strongly linked to AEP. Herein, we present a case of a patient with a septic joint treated with Daptomycin who went on to develop AEP. CASE PRESENTATION: Patient is an 80 year old man with history of hypertension, hypothyroidism, atrial flutter, complete heart block status post pacemaker, who had a hx of a mucinous cyst on his left index finger, requiring hospitalization. Blood cultures were positive for MRSA s/p debridement of the joint. He was discharged on 4 weeks of intravenous daptomycin. Two weeks after being discharged he presented back to the hospital with fevers, fatigue and worsening shortness of breath. His temperature was 103.8 and O2 saturation of 90% on 2L NC. Laboratory findings included WBC count of 8.6 with no eosinophilia on differential, ESR 110, negative blood cultures, sputum cultures with commensal flora, negative urine legionella, PCR for SARS COV-2 was negative. Chest radiograph showed mild interstitial airspace disease in the left mid and lower thorax, along with small bilateral pleural effusions. CT chest showed scattered bilateral consolidations and ground glass opacities and trace bilateral effusions. Daptomycin was switched to Vancomycin. Patients oxygen requirements had increased to 6l NC. Patient underwent airway exam with bronchoscopy and broncheoalveolar lavage in superior segment of the lingula, which showed inflamed bronchial mucosa with copious secretions. Cell count of the BAL showed increased eosinophil count with negative gram stain and culture. Patient was started on methylprednisolone 60 mg four times per day and then tapered. Vancomycin was switched to oral linezolid. Patient's hypoxia improved and was discharged home on 3l NC. At four week follow up, he no longer required oxygen on ambulation and chest radiograph showed complete resolution of infiltrates. DISCUSSION: Over 140 drugs have been recognized as a cause of drug induced eosinophilic pneumonia (DIEP). The diagnosis of DIEP requires febrile illness <5 days, diffuse bilateral infiltrates, hypoxemia and BAL showing 25% eosinophils or eosinophilic pneumonitis on lung biopsy. Additionally, a diagnosis of DIEP requires exposure to a candidate drug in the appropriate time frame, exclusion of infectious causes of eosinophilic pulmonary opacities. It also requires clinical improvement after cessation of medication. Daptomycin has been strongly linked to DIEP. In 2010 US FDA issued a warning about the risk of developing eosinophilic pneumonia during treatment with Daptomycin. CONCLUSIONS: Daptomycin is strongly linked with DIEP. Clinicians should maintain a high index of suspicion for DIEP in patient treated with daptomycin who develop respiratory distress. Reference #1: Uppal, P., LaPlante, K.L., Gaitanis, M.M. et al. Daptomycin-induced eosinophilic pneumonia - a systematic review. Antimicrob Resist Infect Control 5, 55 (2016). https://doi.org/10.1186/s13756-016-0158-8 Reference #2: Cottin V. Eosinophilic Lung Diseases. Clin Chest Med. 2016 Sep;37(3):535-56. doi: 10.1016/j.ccm.2016.04.015. Epub 2016 Jun 25. PMID: 27514599. Reference #3: Rosenberg CE, Khoury P. Approach to Eosinophilia Presenting With Pulmonary Symptoms. Chest. 2021 Feb;159(2):507-516. doi: 10.1016/j.chest.2020.09.247. Epub 2020 Sep 28. PMID: 33002503;PMCID: PMC8039005. DISCLOSURES: No relevant relationships by Kamelia Albujoq No relevant relationships by Rajaninder Sharma
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Introduction: A possible side-effect of various medical drugs is prolongation of the electric repolarization of the heart, measured as the corrected QT-interval (QTc). Patients treated with these drugs should be monitored frequently via an ECG to screen for early changes indicating possible life-threating arrythmias. Especially during the Covid-19 pandemic, remote patient monitoring gained importance. The Withings Scanwatch offers automated analysis of the QTc remotely, thereby obviating the need for in-person visits. We aimed to compare automated QTc-measurements using a single lead ECG (SL-ECG) of a novel smartwatch (Withings Scanwatch, SW-ECG) with manual-measured QTc from a nearly simultaneously recorded standard 12-lead ECG. Methods: We enrolled consecutive patients referred to a tertiary hospital for cardiac workup in a prospective, observational study. To obtain a SW-ECG, patients were instructed to keep their index finger on the stainless steel ring on the top case of the smartwatch continuously for 30 seconds The QT-interval was manually interpreted by two blinded, independent cardiologists through the tangent-method, using lead II or V5/ V6. Bazett's formula was used to calculate QTc. Results: We prospectively enrolled 317 patients (48% female, mean age 63.3 ± 17.2 years). The smartwatch was able to automatically measure QTc-intervals in 177 patients (56%). The diagnostic accuracy of SW-ECG for detection of a QTc-interval ≥ 460ms as quantified by the area under the curve (AUC) was 0.91 (95%CI 86.4-95.9). The Bland-Altman analysis resulted in a bias of 6.6ms (95% limit of agreement (LoA) - 58.6ms to 71.9ms) comparing automated QTc measurements via SW-ECG with manual QTc-measurement via 12-lead ECG (Figure 1). In 12 patients (6.9%) the difference between the two measurements was greater than the LoA. Premature ventricular complexes, noise or differences in heart rate were responsible in 8.3%, 83.0% and 8.3%, respectively, for observed outliers. Conclusion: In this clinical validation of a direct-to-consumer smartwatch we found fair to good agreement between automated-SW-ECG QTc-measurements and manual 12-lead-QTc measurements. The SW-ECG, however, was only able to automatically calculate QTc-intervals in one half of all assessed patients. Our work shows, that the automated algorithm of the SW-ECG needs to be improved to be useful in a clinical setting. (Figure Presented).
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Background: Vascular injury has been implicated as a major cause of clinical complications in patients with coronavirus disease 2019 (COVID-19). Autopsy studies have revealed destruction of the endothelial cell lining, which might explain cardiovascular alterations arising from the infection. However, data demonstrating endothelial dysfunction during ongoing infection are sparse, and the underlying mechanisms are still largely unknown. Red blood cells (RBCs) are affected by COVID-19 with alterations in their structure and function, possibly contributing to vascular injury via increased oxidative stress. Purpose: To determine the presence of endothelial dysfunction in patients with COVID-19 and to explore the RBC as a possible mediator of such dysfunction. Methods: The study was performed on 17 patients hospitalized for moderate COVID-19 infection and age-and sex-matched healthy subjects. Inclusion criteria of the COVID-19 patients were PCR-verified SARS-CoV2 infection, pulmonary infiltrates on x-ray, oxygen demand during hospital stay and ≤ one cardiovascular co-morbidity. Microvascular endothelial function in vivo was assessed with a pulse amplitude tonometry device on each index finger at baseline and during reactive hyperemia and expressed as reactive hyperemia index (RHI). RBCs from COVID-19 patients (C19-RBCs) and healthy subjects (H-RBCs) were incubated with isolated rat aortic segments for evaluation of endothelium-dependent and -independent relaxation. Results: COVID-19 patients displayed profound impairment in endothelial function in vivo with RHI 1.56 (1.30-1.81, median and interquartile range) compared to healthy subjects 2.36 (1.97-2.79, p<0.001). C19-RBCs induced severe impairment in both endothelium-dependent (27% maximal relaxation) and -independent relaxations (54%) compared to H-RBCs (67% and 95% relaxation, respectively). Further, C19-RBCs induced upregulation of vascular arginase 1 (∼2 fold increase compared to H-RBCs) and markers of oxidative stress (∼6 fold). Consequently, inhibition of vascular arginase or superoxide attenuated the impairment in endothelial function induced by C19-RBCs. C19-RBCs were characterized by increased production of reactive oxygen species (∼1.4 fold) and reduced export of the nitric oxide metabolite nitrate. Following pre-incubation with interferon-γ, but not interleukin-6 or tumor necrosis factor-α, H-RBCs induced impairment in endothelial function. Conclusions: This study demonstrates the presence of marked endothelial dysfunction in an otherwise mainly healthy patient group hospitalized for COVID-19, and clearly implicates a central role of the RBC as a mediator of endothelial injury through enhancement of reactive oxygen species and arginase. These data shed light on a new pathological mechanism underlying vascular dysfunction in COVID-19 patients and may lay the foundation for future therapeutic developments.