COVID-19: comparison lung CT signs and biochemical parameters in the groups of patients with three-time positive RT-PCR and with triple negative RT-PCR test during the period of hospitalization.

Research goal. Comparative characteristics of the dynamics of CT semiotics and biochemical parameters of two groups of patients: with positive RT-PCR and with triple negative RT-PCR. Reflection of the results by comparing them with the data already available in the literature. The aim of the study is to compare the dynamics of CT semiotics and biochemical parameters of blood tests in two groups of patients: with positive RT-PCR and with triple negative RT-PCR. We also reflect the results by comparing them with the data already available in the literature. Materials and methods. We have performed a retrospective analysis of CT images of 66 patients: group I (n1 = 33) consists of patients who had three- time negative RT-PCR (nasopharyngeal swab for SARS-CoV-2 RNA) during hospitalization, and group II (n2 = 33) includes patients with triple positive RT-PCR. An important selection criterion is the presence of three CT examinations (primary, 1st CT and two dynamic examinations - 2nd CT and 3rd CT) and at least two results of biochemistry (C-reactive protein (CRP), fibrinogen, prothrombin time, procalcitonin) performed in a single time interval of +/- 5 days from 1st CT, upon admission, and +/- 5 days from 3st CT. A total of 198 CT examinations of the lungs were analyzed (3 examinations per patient). Results. The average age of patients in the first group was 58 +/- 14.4 years, in the second - 64.9 +/- 15.7 years. The number of days from the moment of illness to the primary CT scan 6.21 +/- 3.74 in group I, 7.0 (5.0-8.0) in group II, until the 2nd CT scan - 12.5 +/- 4, 87 and 12.0 (10.0-15.0), before the 3rd CT scan - 22.0 (19.0-26.0) and 22.0 (16.0-26.0), respectively. In both groups, all 66 patients (100%), the primary study identified the double-sided ground-glass opacity symptom and 36 of 66 (55%) patients showed consolidation of the lung tissue. Later on, a first follow-up CT defined GGO not in all the cases: it was presented in 22 of 33 (67%) patients with negative RT-PCR (group I) and in 28 of 33 (85%) patients with the positive one (group II). The percentage of studies showing consolidation increased significantly: up to 30 of 33 (91%) patients in group I, and up to 32 of 33 (97%) patients in group II. For the first time, radiological symptoms of "involutional changes" appeared: in 17 (52%) patients of the first group and in 5 (15%) patients of the second one. On second follow-up CT, GGO and consolidations were detected less often than on previous CT: in 1 and 27 patients of group I (3% and 82%, respectively) and in 6 and 30 patients of group II (18% and 91%, respectively), although the consolidation symptom still prevailed significantly . The peak of "involutional changes" occurred on last CT: 31 (94%) and 25 (76%) patients of groups I and II, respectively.So, in the groups studied, the dynamics of changes in lung CT were almost equal. After analyzing the biochemistry parameters, we found out that CRP significantly decreased in 93% of patients (p < 0.001) in group I;in group II, there was a statistically significant decrease in the values of C-reactive protein in 81% of patients (p = 0.005). With an increase in CT severity of coronavirus infection by one degree, an increase in CRP by 41.8 mg/ml should be expected. In group I, a statistically significant (p = 0.001) decrease in fibrinogen was recorded in 77% of patients;and a similar dynamic of this indicator was observed in group II: fibrinogen values decreased in 66% of patients (p = 0.002). Such parameters as procalcitonin and prothrombin time did not significantly change during inpatient treatment of the patients of the studied groups (p = 0.879 and p = 0.135), which may indicate that it is inappropriate to use these parameters in assessing dynamics of patients with a similar course of the disease. When comparing the outcomes of the studied groups, there was a statistically significant higher mortality in group II - 30.3%, in group I - 21.2% (p = 0.043). Conclusion. According to our data, a course of the disease does not significantly differ in the groups o patients with positive RT-PCR and three-time negative RT-PCR. A negative RT-PCR analysis may be associated with an individual peculiarity of a patient such as a low viral load of SARS-CoV-2 in the upper respiratory tract. Therefore, with repeated negative results on the RNA of the virus in the oro- and nasopharynx, one should take into account the clinic, the X-ray picture and biochemical indicators in dynamics and not be afraid to make a diagnosis of COVID-19.Copyright © 2021 ALIES. All rights reserved.

COVID-19 pneumonia - increased incidence of pneumothorax/mediastinal emphysema after invasive mechanical and non-invasive ventilation.

Introduction: COVID pneumonia can lead to pneumomediastinum or pneumothorax during non-invasive or invasive mechanical ventilation. This affects the prognosis. Methodology: During the study period, 121 patients with SARS-CoV-2 infections and invasive or non-invasive ventilation therapy were recorded in our hospital. All patients with a pneumothorax or pneumomediastinum were analyzed in more detail. Result(s): Pneumothorax and pneumomediastinum occurred in 12 patients and resulted in 7 deaths. Discussion(s): The incidence of pneumothorax with COVID infection ranges from 0.56 to 1%, reaching 3.5% in our own studies and 4.2% under invasive mechanical ventilation. The incidence of pneumomediastinum was 10% and 9.2% in our own patients. Overall mortality was 58.3% and similar to that reported in the literature, up to 60%.Copyright © 2023 Dustri-Verlag Dr. K. Feistle.

Bilateral Spontaneous Pneumothorax in a Child with Multisystem Inflammatory Syndrome Associated with COVID-19

Introduction: Spontaneous pneumothorax is a rare complication of coronavirus disease 2019 (COVID-19), primarily reported in adults. Pediatric cases with bilateral pneumothorax are much less reported. Case Presentation: We presented the case of a five-year-old previously healthy boy who developed persistent fever, abdominal pain, generalized maculopapular rash, and dyspnea before admission. His chest computed tomography (CT) showed a viral involvement pattern of pneumonia suggestive of COVID-19. Subsequently, he was confirmed with multisystem inflammatory syndrome in children (MIS-C). While he responded well to the therapies, on the fifth day of admission, he developed respiratory distress again. A chest roentgenogram showed bilateral spontaneous pneumothorax. Bilateral chest tubes were inserted, and his condition improved sig-nificantly after five days of admission to the intensive care unit. Two weeks later, he was discharged in good condition. Conclusion(s): Children with MIS-C associated with COVID-19 may develop primary spontaneous pneumothorax. Owing to the clinical picture overlapping with MIS-C associated with COVID-19, the timely diagnosis of pneumothorax may be challenging in such patients.Copyright © 2022, Author(s).

Spontaneous pneumomediastinum, pneumothorax, pneumoperitoneum and soft tissue emphysema as complication in patients with COVID-19, series of cases.

Spontaneous pneumomediastinum, pneumothorax, pneumoperitoneum, and soft tissue emphysema have been recently described in several sources as possible complications in patients with severe COVID-19 and lung damage. This clinical case is dedicated to demonstrarte the development of these lesions in 3 male patients with comorbid conditions. The putative pathophysiological mechanism of these complications is air leakage due to extensive diffuse alveolar damage followed by rupture of the alveoli. All presented patients had a favorable outcome of the disease without lethal cases, their laboratory data and clinical dynamics were described. It should be noted that such conditions are not rare complications of COVID-19, and are observed mainly in male patients with severe form of the disease and the presence of comorbid conditions. Such complications are associated with long hospitalization and a severe prognosis. In some cases, with a mild course of the disease and positive dynamics in a decrease of the percentage of pulmonary lesions, the outcome is favorable, not requiring additional invasive interventions.Copyright © 2022 Medical Visualization. All rights reserved.

Pneumomediastinum as a complication of SARS-CoV-2 pneumonia

The incidence of pneumomediastinum in hospitalised patients diagnosed with SARS-CoV-2 pneumonia is by no means negligible, much higher compared to the general population. The pathophysiology of pneumomediastinum in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia is explained by the increase in alveolar-interstitial pressure gradient (dry coughing spells, respiratory work, barotrauma from ventilatory support) in the context of particularly "fragile" lungs due to diffuse alveolar-interstitial damage from infectious-inflammatory origin, all of which significantly increases the risk of alveolar wall rupture. The more severe the SARS-CoV-2 pneumonia, the more likely it is that pneumomediastinum will occur. The development of pneumomediastinum in patients with SARS-CoV-2 pneumonia is associated with higher frequencies of death, intensive care unit (ICU) admission and tracheostomy and longer hospital and ICU lengths of stay. In most cases, pneumomediastinum in SARS-CoV-2 pneumonia is a benign and self-limiting process that resolves with conservative treatment. © 2022 Sociedad Madrinela de Neumologia y Cirugia Toracica. All rights reserved.

Unexpected Severe Bocavirus Infections among Hospitalized Children during the COVID-19 Pandemic

Objective: Acute respiratory tract infections are one of the leading causes of morbidity and mortality in children. Although human bocavirus (HBoV) infections are not as common as other seasonal respiratory viruses, children who are infected with HBoV are more likely to suffer from a variety of respiratory conditions, including the common cold, acute otitis media, asthma exacerbations, bronchiolitis pneumonia, some of the affected children require pediatric intensive care unit stay. Here, we aimed to evaluate pediatric bocavirus (HBoV) cases presenting with severe respiratory tract symptoms during the coronavirus disease 2019 (COVID-19) pandemic. Method(s): This retrospective study evaluated the medical records of children diagnosed with respiratory infections, followed up at the Faculty of Medicine, Eskisehir Osmangazi University between September 2021 and March 2022. In this study, patients with HBoV identified using nasopharyngeal polymerase chain reaction (PCR) were considered positive. Cases were analyzed retrospectively for their clinical characteristics. Result(s): This study included 54 children (29 girls and 25 boys) with HBoV in nasopharyngeal PCR samples. The cases ranged in age from 1 month to 72 months (median 25 months). At the time of presentation, cough, fever, and respiratory distress were the most prevalent symptoms. Hyperinflation (48%), pneumonic consolidation (42%), and pneumothorax-pneumomediastinum (7%) were observed on the chest X-ray;54% of the children required intensive care unit stay. The median length of hospitalization was 6 days. Bacterial coinfection was detected in 7 (17%) children, while HBoV and other viruses were present in 20 (37%) children;57% of children received supplemental oxygen by mask, 24% high-flow nasal oxygen, 7% continuous positive airway pressure, and 9% invasive mechanical ventilation support. Antibiotics were given to 34 (63%) cases, and systemic steroid treatment was given to 41 (76%) cases. Chest tubes were inserted in three out of the four cases with pneumothorax-pneumomediastinum. All patients were recovered and were discharged from the hospital. Conclusion(s): The COVID-19 pandemic changed the epidemiology of seasonal respiratory viruses and the clinical course of the diseases. Although it usually causes mild symptoms, severe respiratory symptoms can lead to life-threatening illnesses requiring intensive care admission.Copyright © 2023. The Author(s).

The effect of covid-19 vaccines on pneumothorax in geriatric patients hospItalized in intensive care unit due to covid-19

In our study, we examined the effect of COVID-19 vaccination on the incidence of pneumothorax in intensive care patients over age 65. COVID-19 intensive care patients that presented to our department between April 2020 and May 2021 during the COVID-19 pandemic were evaluated retrospectively. Patients were divided into two main groups, i.e., before and after the vaccination period. Patients were evaluated retrospectively for the following parameters: Gender, age, side of pneumothorax, mortality, discharge, comorbidity, and additional pleural complications. The total number of patients was 87, i.e., 66 patients before vaccination and 21 patients after vaccination. When patients in the pre- and post-vaccination period were compared, there was a significant difference in the incidence of pneumothorax between the two groups (p<0.05). Pneumothorax was less common after vaccination. When patients with pneumothorax and tube thoracostomy were evaluated according to pre- and post-vaccination mortality, mortality was significantly higher (89%) in the pre-vaccination period (p<0.05). We consider that COVID-19 vaccines used in patients aged over 65 reduced the incidence of pleural complications, especially pneumothorax. We think that mortality due to pneumothorax in patients over 65 years of age was lower during the vaccination period. In addition, we think that bilateral pneumothorax was more common in the non-vaccinated period. As a result, we think that life-threatening pneumothorax and similar complications could be reduced by increasing the number of vaccines made in the COVID-19 pandemic and spreading it around the world.Copyright © 2022, Dr. Mladen Stojanovic University Hospital. All rights reserved.

Successful ECMO course in an Acquired Immune Deficiency Syndrome (AIDS) patient with ARDS complicated by pneumocystis jirovecii pneumonia and COVID-19: A unique case

Objectives: Reviewing current literature and case reports of patients placed on Venous-Venous ECMO support for HIV and AIDS, with confection with Pneumocystis pneumonia and covid-19 pneumonia. The use of extracorporeal membrane oxygenation (ECMO) in patients who have acute respiratory distress syndrome has been shown to have very good outcomes. However, there is limited data to support the initiation of ECMO in patients who have human immunodeficiency virus infection with or without acquired immune deficiency syndrome. Method(s): We present a unique and challenging case of a 30 year old male, with no known past medical history, unvaccinated against covid-19, who presented with one week of progressive shortness of breath. On admission he was found with moderate bilateral infiltrates and was diagnosed with covid-19 pneumonia. Despite appropriate medical therapy, patient developed worsening hypoxic respiratory failure. Found to have elevated (1- 3)-7beta;-d-glucan and tested positive for HIV. CD4 count 11, HIV viral load 70,000. The patient remained severely hypoxemic despite mechanical ventilation, sedation, paralytics and proning. Venous venous extracorporeal membrane oxygenation was initiated. Considering his non improvement with variety of antivirals and antibiotics and with elevated (1-3)-7beta;-d-glucan in the setting of AIDS he was treated for presumed Pneumocystis pneumonia. The patient tolerated proning while on VV ECMO and his course was complicated with bilateral pneumothorax necessitating chest tube placement. Result(s): The patient successfully completed 64 days on VV ECMO, where he was treated for PCP pneumonia, covid pneumonia, CMV viremia and tolerated initiation of anti-retroviral therapy. Patient was successfully decannulated, and ultimately discharged from the hospital. Conclusion(s): VV-ECMO can be a beneficial intervention with successful outcomes in severely immunocomprimised patients with AIDS. This case highlights the importance of minimizing sedation and early mobilization on ECMO support. (Figure Presented).

Clinical characteristics and risk factors of patients with COVID-19 developing barotrauma

Background: At our hospital, people with COVID-19 (coronavirus disease 2019) had a high rate of pulmonary barotrauma. Therefore, the current study looked at barotrauma in COVID-19 patients getting invasive and non-invasive positive pressure ventilation to assess its prevalence, clinical results, and features. Methodology: Our retrospective cohort study comprised of adult COVID-19 pneumonia patients who visited our tertiary care hospital between April 2020 and September 2021 and developed barotrauma. Result(s): Sixty-eight patients were included in this study. Subcutaneous emphysema was the most frequent type of barotrauma, reported at 67.6%;pneumomediastinum, reported at 61.8%;pneumothorax, reported at 47.1%. The most frequent device associated with barotrauma was CPAP (51.5%). Among the 68 patients, 27.9% were discharged without supplemental oxygen, while 4.4% were discharged on oxygen. 76.5% of the patients expired because of COVID pneumonia and its complications. In addition, 38.2% of the patients required invasive mechanical breathing, and 77.9% of the patients were admitted to the ICU. Conclusion(s): Barotrauma in COVID-19 can pose a serious risk factor leading to mortality. Also, using CPAP was linked to a higher risk of barotrauma.Copyright © 2021 Muslim OT et al.

HIGH DOSE INTRAVENOUS ANAKINRA TREATMENT IS SAFE AND EFFECTIVE IN SEVERE AND CRITICAL COVID-19 PATIENTS: A PROPENSITY SCORE MATCHED STUDY IN A SINGLE CENTER

BackgroundIn COVID-19 severe disease course such as need of intensive care unit (ICU) as well as development of mortality is mainly due to cytokine storm.ObjectivesIn this study, we aimed to evaluate the high dose intravenous anakinra treatment response and outcome in patients with severe and critical COVID-19 compared to standard of care.MethodsThis retrospective observational study was carried out at a tertiary referral center. The study population consisted of two groups as follows;the patients receiving high dose intravenous anakinra (anakinra group) between 01.09.2021 and 01.02.2022 and the patients treated with standard of care (SoC, control group) as historical control group who were hospitalized between 01.07.2021 and 01.09.2021.ResultsAfter the propensity score 1:1 matching 79 patients in anakinra and 79 patients in SoC matched and included into the analysis. Mean±SD patient age was 67.4±16.7 and 67.1±16.3 years in anakinra and SoC group, respectively (p=0.9). Male gender was 38 (48.7 %) in anakinra and 36 (46.2 %) SoC (p=0.8). Overall, ICU admission was in 14.1 % (n=11) and 30.8 % (n=24) (p=0.013;OR: 6.2), intubation in 12.8 % (n=10) and 16.7 % (n=13) patients (p=0.5), 14.1 % (n=11) and 32.1 % (n=25) patients died in anakinra and control group, respectively (p=0.008;OR: 7.1)ConclusionIn our study mortality was lower in patients receiving anakinra compared to SoC. Intravenous high dose anakinra is safe and effective treatment in patients with severe and critical COVID-19.Table 1.Baseline clinical and laboratory features of patients receiving standard of care (SoC) and Anakinra before and after propensity score (PS) matchingBefore PS matchingAfter PS matchingVariablesAnakinra (n=148)SoC (n=114)p value (OR)Anakinra (n=78)SoC (n=78)p value (OR)Age (years) (mean±SD)66.8±1763.1±170.0967.4±16.767.1±16.30.9Gender, male (n, %)78 (52.7)45 (39.5)0.033 (4.5)38 (48.7)36 (46.2)0.8Duration of hospitalization (days) (median, IQR)11 (12)9 (7.3)0.027.5 (9)11 (8)0.01Comorbidities (n, %) Diabetes mellitus41/146 (28.1)39 (34.2)0.318 (23)31 (39.7)0.025 (5) Hypertension84/143 (58.7)64 (56)0.730 (61.5)50 (64)0.7 Coronary heart disease27/143 (19)24 (21)0.718 (23)20 (25.6)0.7 Heart failure18/143 (12.6)23 (20)0.114 (18)20 (25.6)0.24 Chronic renal failure31 (21)6 (5.3)<0.001 (13.06)15 (19)6 (7.7)0.035 (4.5) Chronic obstructive lung disease23/144 (16)19 (16.7)0.914 (18)15 (19)0.8 Dementia15/117 (12.8)2 (1.8)0.001 (10.4)3/61 (5)2 (2.6)0.5 Malignancy16/146 (11)8 (7)0.39 (11.5)6 (7.7)0.4 Immunosuppressive usage18/146 (12.3)2 (1.8)0.001 (10.08)5 (6.5)2 (2.6)0.2Disease severity (n, %) NIH score 3 (severe)57 (38.5)68 (59.6)0.001 (11.5)48 (61.5)44 (56.4)0.5 NIH score 4 (critical)91 (61.5)46 (40.4)30 (38.5)34 (43.6) mcHIS score (mean±SD)3.4±1.22.64±1.5<0.0012.9±13.1±1.30.2PS: Propensity score, SoC: Standard of care, OR: Odds ratio, SD: Standard deviation, IQR: Interquartile range, mcHIS: Modified Covid hyperinflammatory syndrome score, NIH: National Institute Health, ALT: Alanin aminotransferase, AST: Aspartate aminotransferaseTable 2.Outcomes of patients receiving SoC and Anakinra before and after PS matchingBefore PS matchingAfter PS matchingVariables (n, %)Anakinra (n=148)SoC (n=114)p value (OR)Anakinra (n=78)SoC (n=78)p value (OR)Pneumothorax3/134 (2.2)00.25*2/73 (2.7)00.5*Myocardial infarction3/132 (2.3)6 (5.3)0.32/72 (2.8)2/56 (3.6)1Pulmonary embolism4/134 (3)11 (9.6)0.034 (4.8)*3/73 (4.1)7 (9)0.3*Intensive care unit60 (40.5)25 (22)0.001 (10.2)11 (14.1)24 (30.8)0.013 (6.2)Intubation54 (36.5)13 (11.4)<0.001 (21.3)10 (12.8)13 (16.7)0.5Mortality56 (37.8)27 (23.7)0.015 (5.96)11 (14.1)25 (32.1)0.008 (7.1)PS: Propensity score, SoC: Standard of care, OR: Odds ratioREFERENCES:NIL.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

Treating pneumothorax . . . and other stories

[...]a longitudinal study from Australia finds little convincing evidence that there are any long term implications for mental health (Arch Dis Child doi:10.1136/archdischild-2019-318014). At the age of 10, children who had persisting severe sleep problems in their first year were no more likely to meet diagnostic criteria for a psychiatric disorder than a comparison group of children who slept well as infants. A retrospective analysis of electronic health records from the US identified several features of viral pharyngitis, which the investigators believe are reliable enough to identify children in whom testing for streptococcal infection can be avoided (J Pediatr doi:10.1016/j.jpeds.2020.01.030).

Barotrauma during Noninvasive Respiratory Support in COVID-19 Pneumonia Outside ICU: The Ancillary COVIMIX-2 Study.

BACKGROUND: Noninvasive respiratory support (NIRS) has been extensively used during the COVID-19 surge for patients with acute respiratory failure. However, little data are available about barotrauma during NIRS in patients treated outside the intensive care unit (ICU) setting. METHODS: COVIMIX-2 was an ancillary analysis of the previous COVIMIX study, a large multicenter observational work investigating the frequencies of barotrauma (i.e., pneumothorax and pneumomediastinum) in adult patients with COVID-19 interstitial pneumonia. Only patients treated with NIRS outside the ICU were considered. Baseline characteristics, clinical and radiological disease severity, type of ventilatory support used, blood tests and mortality were recorded. RESULTS: In all, 179 patients were included, 60 of them with barotrauma. They were older and had lower BMI than controls (p < 0.001 and p = 0.045, respectively). Cases had higher respiratory rates and lower PaO2/FiO2 (p = 0.009 and p < 0.001). The frequency of barotrauma was 0.3% [0.1-1.3%], with older age being a risk factor for barotrauma (OR 1.06, p = 0.015). Alveolar-arterial gradient (A-a) DO2 was protective against barotrauma (OR 0.92 [0.87-0.99], p = 0.026). Barotrauma required active treatment, with drainage, in only a minority of cases. The type of NIRS was not explicitly related to the development of barotrauma. Still, an escalation of respiratory support from conventional oxygen therapy, high flow nasal cannula to noninvasive respiratory mask was predictive for in-hospital death (OR 15.51, p = 0.001). CONCLUSIONS: COVIMIX-2 showed a low frequency for barotrauma, around 0.3%. The type of NIRS used seems not to increase this risk. Patients with barotrauma were older, with more severe systemic disease, and showed increased mortality.

COVID-19-associated lung weakness (CALW): Systematic review and meta-analysis.

OBJECTIVES: To assess mortality and different clinical factors derived from the development of atraumatic pneumothorax (PNX) and/or pneumomediastinum (PNMD) in critically ill patients as a consequence of COVID-19-associated lung weakness (CALW). DESIGN: Systematic review with meta-analysis. SETTING: Intensive Care Unit (ICU). PARTICIPANTS: Original research evaluating patients, with or without the need for protective invasive mechanical ventilation (IMV), with a diagnosis of COVID-19, who developed atraumatic PNX or PNMD on admission or during hospital stay. INTERVENTIONS: Data of interest were obtained from each article and analyzed and assessed by the Newcastle-Ottawa Scale. The risk of the variables of interest was assessed with data derived from studies including patients who developed atraumatic PNX or PNMD. MAIN VARIABLES OF INTEREST: Mortality, mean ICU stay and mean PaO2/FiO2 at diagnosis. RESULTS: Information was collected from 12 longitudinal studies. Data from a total of 4901 patients were included in the meta-analysis. A total of 1629 patients had an episode of atraumatic PNX and 253 patients had an episode of atraumatic PNMD. Despite the finding of significantly strong associations, the great heterogeneity between studies implies that the interpretation of results should be made with caution. CONCLUSIONS: Mortality among COVID-19 patients was higher in those who developed atraumatic PNX and/or PNMD compared to those who did not. The mean PaO2/FiO2 index was lower in patients who developed atraumatic PNX and/or PNMD. We propose grouping these cases under the term COVID-19-associated lung weakness (CALW).

Bilateral spontaneous pneumothorax as a late complication of COVID-19, a clinical case report.

Key Clinical Message: Bilateral spontaneous pneumothorax and sudden dyspnea can occur as late complication in patients with COVID-19 even without any history of mechanical ventilation usage. Abstract: Bilateral spontaneous pneumothorax can occur as a late complication in patients with COVID-19, even without any history of mechanical ventilation. Here, we present a patient with mild COVID-19 pneumonia with a left massive pneumothorax in the third week of hospitalization and the addition of a right pneumothorax.

Severe SARS-CoV-2 Pneumonia and Pneumomediastinum/Pneumothorax: A Prospective Observational Study in an Intermediate Respiratory Care Unit.

INTRODUCTION: The occurrence of pneumomediastinum (PM) and/or pneumothorax (PTX) in patients with severe pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was evaluated. METHODS: This was a prospective observational study conducted in patients admitted to the intermediate respiratory care unit (IRCU) of a COVID-19 monographic hospital in Madrid (Spain) between December 14, 2020 and September 28, 2021. All patients had a diagnosis of severe SARS-CoV-2 pneumonia and required noninvasive respiratory support (NIRS): high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP). The incidences of PM and/or PTX, overall and by NIRS, and their impact on the probabilities of invasive mechanical ventilation (IMV) and death were studied. RESULTS: A total of 1306 patients were included. 4.3% (56/1306) developed PM/PTX, 3.8% (50/1306) PM, 1.6% (21/1306) PTX, and 1.1% (15/1306) PM + PTX. 16.1% (9/56) of patients with PM/PTX had HFNC alone, while 83.9% (47/56) had HFNC + CPAP/BiPAP. In comparison, 41.7% (521/1250) of patients without PM and PTX had HFNC alone (odds ratio [OR] 0.27; 95% confidence interval [95% CI] 0.13-0.55; p < .001), while 58.3% (729/1250) had HFNC + CPAP/BiPAP (OR 3.73; 95% CI 1.81-7.68; p < .001). The probability of needing IMV among patients with PM/PTX was 67.9% (36/53) (OR 7.46; 95% CI 4.12-13.50; p < .001), while it was 22.1% (262/1185) among patients without PM and PTX. Mortality among patients with PM/PTX was 33.9% (19/56) (OR 4.39; 95% CI 2.45-7.85; p < .001), while it was 10.5% (131/1250) among patients without PM and PTX. CONCLUSIONS: In patients admitted to the IRCU for severe SARS-CoV-2 pneumonia requiring NIRS, incidences of PM/PTX, PM, PTX, and PM + PTX were observed to be 4.3%, 3.8%, 1.6%, and 1.1%, respectively. Most patients with PM/PTX had HFNC + CPAP/BiPAP as the NIRS device, much more frequently than patients without PM and PTX. The probabilities of IMV and death among patients with PM/PTX were 64.3% and 33.9%, respectively, higher than those observed in patients without PM and PTX, which were 21.0% and 10.5%, respectively.

Predictors of Pneumothorax in People With COVID-19 Pneumonia: A Multicenter Retrospective Investigation.

This multicenter retrospective investigation aimed to identify predictors of pneumothorax (PTX), pneumomediastinum (PM), and subcutaneous emphysema (SE) in patients with COVID-19 pneumonia admitted to the ICU. A total of 256 patients were included, with 128 in the case group and 128 in the control group. The study sample consisted of predominantly male patients with a mean age of around 53 years and a high prevalence of comorbidities. Significant predictors of PTX, PM, and SE included the presence of coronary artery disease, non-rebreather mask usage, high-flow oxygen therapy, mechanical ventilation, pressor usage, inpatient dialysis, steroid usage, sedative usage, narcotic usage, paralytic usage, elevated C-reactive protein levels, increased lung infiltration, the presence of PM and SE, mode of ventilation, duration of various respiratory support interventions, and severity of illness as indicated by APACHE and SOFA scores. These findings have important implications for the clinical management of patients with COVID-19 pneumonia, as they may help identify and closely monitor at-risk individuals, allowing for timely intervention and potentially improving clinical outcomes. Future research should focus on validating these predictors in larger cohorts and investigating the underlying mechanisms to develop targeted preventive and therapeutic strategies.

Effect of the capsid assembly modulator (CAM) ALG-000184 on HBsAg Levels in subjects with HBeAg positive chronic hepatitis B (CHB)

Background: ALG-000184 is a prodrug of ALG-001075, a novel, potent, pan-genotypic Class II CAM. CAMs are thought to have two mechanisms of action (MoA). The primary MoA affects pgRNA encapsidation resulting in inhibition of HBV DNA/RNA replication, as confirmed in CHB subjects receiving ALG-000184. The secondary MoA, which occurs at higher concentrations, regulates the establishment and replenishment of cccDNA, resulting in lowering of HBsAg, an effect that has not been reported to date with ALG- 000184. Method(s): ALG-000184-201 is a multi-part, multicenter, doubleblind, randomized, placebo-controlled study. In healthy volunteers (HVs), single doses up to 500 mg and multiple doses up to 250 mg were well tolerated with linear PK (Gane E., HBV TAG and APASL 2021). In treatment naive (TN) subjects with CHB, daily oral doses of 10-100 mg ALG-000184 for 28 days were well tolerated with linear PK and were associated with profound reductions of DNA/RNA regardless of HBeAg status or dose (Yuen MF, EASL 2022). Plasma exposures required to engage the secondary MoA are expected to be achieved at the 300 mg dose level. Data from a 300 mg cohort treated for 28 days are described here. Data from another ongoing cohort treated with 300 mg for 12 weeks will be presented at the conference. Result(s): Ten subjects were randomized to 300 mg ALG-000184 for 28 days and two to placebo. Two subjects randomized to ALG- 000184 were replaced due to missing data due to Covid-19 lockdown. Subjects were Asian, HBeAg positive, and genotype B or C. Mean baseline HBV DNA and RNA levels were 8.4 log10 IU/mL and 7.3 log10 copies/mL, respectively. One subject experienced a serious adverse event (AE) of pneumothorax>8 weeks after last dose which was considered unlikely related to study drug. No subjects prematurely discontinued study drug. All treatment emergent AEs were Grade <= 2 except for 4 Grade >= 3 alanine aminotransferase (ALT) elevations, which an independent ALT Flare Committee assessed as not related to study drug toxicity. PK was similar to HBeAg negative and HV cohorts following body weight adjustment. Subjects dosed with 300 mg ALG-000184 experienced mean declines of 4.0 log10 IU/mL and 2.6 log10 copies/mL in HBV DNA and RNA levels, respectively, at Day 28. Three of 7 evaluable subjects who received ALG-000184 had HBsAg declines>0.2 log10 IU/mL (0.23-0.78 log10 IU/mL). One subject receiving ALG-000184 had unquantifiable HBsAg throughout the study. Additionally, one HBeAg positive subject in a prior 100 mg cohort had plasma exposures equivalent to the 300 mg dose level and experienced a 0.5 log10 IU/mL HBsAg decline. Conclusion(s): In TN HBeAg positive CHB subjects, 300 mg ALG- 000184 for 28 days was well tolerated, exhibited predictable PK and resulted in rapid and substantial declines in HBV DNA and RNA. Notably, 3 of 7 evaluable subjects from this cohort experienced HBsAg declines of up to 0.78 log10 IU/mL. These data suggest that ALG-000184 can engage the secondary MoA of CAM II. Cohorts evaluating 300 mg over longer durations are planned or ongoing.

A Case Report of Iatrogenic Esophageal Perforation: Complication of Orogastric Tube Placement

Introduction: Orogastric tube insertion is a routine procedure in medical care. However, misplacement of the tube can cause a variety of complications, which can be life threatening in some instances. Case Description/Methods: 71-year-old male presented with dyspnea, fever, chills, cough, and myalgia for 2 weeks. He had tachycardia, tachypnea, and was hypoxic to 66% in room air. He was found to have acute hypoxic respiratory failure secondary to COVID-19 Pneumonia and was admitted to ICU. But, he continued to be hypoxic and was started on BiPAP. He eventually became altered, and was intubated. Post intubation orogastric tube (OGT) placement was unsuccessful on the first attempt due to resistance. On the second attempt, the nurse was able to advance partially (Figure). But, a chest XR showed OGT in the mediastinum, and OGT was removed. CT of neck and chest revealed pneumomediastinum with possible mid-thoracic esophageal perforation. The patient was started on broad-spectrum antibiotics and thoracic surgery was consulted. Given his mechanical ventilation requirement, surgery deemed him unfit to tolerate thoracotomy and the endoscopic procedure was not available in the hospital. So, recommendation was to manage conservatively. His hospital course was complicated by hypotension requiring vasopressors and metabolic acidosis in setting of acute renal failure requiring CRRT. Code status was changed by the family to Do Not Resuscitate due to his deteriorating condition. Eventually, he had a PEA arrest and was expired. Discussion(s): OGT intubation is performed at hospitals for feeding, medication administration or gastric decompression. Although it is considered a safe procedure, complications can arise due to OGT misplacement or trauma caused by the OGT itself or the intubation process. OGT misplacement is typically endotracheal or intracranial. Misplacement within the upper GI lumen is usually detected by a kink in the oropharynx or esophagus. The subsequent complications are identified by the structure that is perforated (e.g., mediastinitis or pneumothorax). Regardless of whether counteraction is perceived, the physician must be careful not to apply excessive force. The location of the OGT tip should be determined by a chest radiograph;visualization of the tip below the diaphragm verifies appropriate placement. Complications of OGT insertion are uncommon;however, the consequences are potentially serious, and the anatomy of the upper GI tract should be understood by all who are involved in the care.

Lung Ultrasound in Critical Care and Emergency Medicine: Clinical Review.

Lung ultrasound has become a part of the daily examination of physicians working in intensive, sub-intensive, and general medical wards. The easy access to hand-held ultrasound machines in wards where they were not available in the past facilitated the widespread use of ultrasound, both for clinical examination and as a guide to procedures; among point-of-care ultrasound techniques, the lung ultrasound saw the greatest spread in the last decade. The COVID-19 pandemic has given a boost to the use of ultrasound since it allows to obtain a wide range of clinical information with a bedside, not harmful, repeatable examination that is reliable. This led to the remarkable growth of publications on lung ultrasounds. The first part of this narrative review aims to discuss basic aspects of lung ultrasounds, from the machine setting, probe choice, and standard examination to signs and semiotics for qualitative and quantitative lung ultrasound interpretation. The second part focuses on how to use lung ultrasound to answer specific clinical questions in critical care units and in emergency departments.