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Introduction: Croatian National Cancer Registry of Croatian Institute for Public Health reported that in year 2020 lung cancer was the second most common cancer site diagnosed in men with 16% and the third most common in women with 10% incidence among all cancer sites. Unfortunatelly lung cancer has the highest mortality in both men and women. Haematological malignancies had 7% share in all malignancies in both male and female cances cases. In 2020 190 newly diagnosed cases of lymphatic leukemia in men and 128 cases in women were reporeted, meaning 1.5 and 1.2% of all malignancies, respectively. Chronic lymphatic leukemia (CLL) is an advanced age disease and incidence increases with age. Impaired immunity, T and B cell dysfunction in CLL, chromosomal aberations, long-term immunosuppressive therapy and genetic factors can all cause secondary malignancies. Co- occurence of solid tumors and CLL is very rare. Although patiens with CLL have an increased risk of developing second primary malignancies including lung carcinoma, the data about their clinical outcomes are lacking. Parekh et al. retrospectively analyzed patients with simultaneous CLL and lung carcinoma over a 20-year period, and they found that ~2% of patients with CLL actually developed lung carcinoma. The authors claimed that up to 38% of patients will also develop a third neoplasm more likely of the skin (melanoma and basal cell carcinoma), larynx (laryngeal carcinoma) or colon. Currently there are no specific guidelines for concurrent CLL and non-small cell lung carcinoma (NSCLC) treatment. Usually, when the tumors are diagnosed simultaneously, treatment is based to target the most aggressive malignancy, as the clinical outcomes depend on the response of the tumor with the poorest prognosis. For this reason, a multidisciplinary approach is mandatory. Case report: A patient with history of coronary heart disease, myocardial infarction and paroxysmal atrial fibrillation was diagnosed in 2019 (at the age of 71) with B chronic lymphocytic leukemia with bulky tumor (inguinal lymph nodes 8x5 cm), stage B according to Binet, intermediate risk. He was treated with 6 cycles of chemoimmunotherapy (rituximab/cyclofosfamid/fludarabine). In 10/2019 remission was confirmed, but MSCT described tumor in the posterior segment of upper right lung lobe measuring 20x17 mm and bilateral metastases up to 11 mm. Bronchoscopy and biopsy were performed, and EGFR neg, ALK neg, ROS 1 neg, PD-L1>50% adenocarcinoma was confirmed. He was referred to Clinical Hospital Center Osijek where monotherapy with pembrolizumab in a standard dose of 200 mg intravenously was started in 01/2020. Partial remission was confirmed in October 2020. Immunotherapy was discontinued due to development of pneumonitis, dysphagia and severe weight loss (20kg), but without radiologically confirmed disease progression. At that time he was referred to our hospital for further treatment. Gastroscopy has shown erosive gastritis with active duodenal ulcus, Forrest III. Supportive therapy and proton pump inhibitor were introduced. After complete regression of pneumonitis, improvement of general condition and resolution of dysphagia, no signs of lung cancer progression were found and pembrolizumab was reintroduced in 12/2021. Hypothyroidism was diagnosed in 01/2021 and levothyroxine replacement ther apy was started. In 03/2021 he underwent surgical removal of basal cell carcinoma of skin on the right temporal region with lobe reconstruction. From 02/2021, when pembrolizumab was reintroduced, regression in tumor size was continously confirmed with complete recovery of general condition. He was hospitalized for COVID 19 infection in 09/2021, and due to complications pembrolizumab was discontinued till 11/2021. Lung cancer immunotherapy proceeded till 11/2022, when Multidisciplinary team decided to finish pembrolizumab because of CLL relapse. CLL was in remission till August 2022 when due to B symptoms, lymphcytosis, anemia and generalized lymphadenopathy, hematological workup including biopsy of cervical lymph node was performed and CLL/SLL relapse was confirmed. Initially chlorambucil was introduced, but disease was refractory. Based on cytogenetic test results (IGHV unmutated, negative TP53) and due to cardiovascular comorbidity (contraindication for BTK inhibitors) venetoclax and rituximab were started in 01/2023. After just 1 cycle of treatment normal blood count as well as regression of B symptoms and peripheral lymphadenopathy occured, indicating the probability of complete disease remission. In our patient with metastatic lung adenocarcinoma excellent disease control is achieved during 41 month of treatment in first line setting. Furthermore, relapsed/refractory CLL/SLL is currently in confirmed remission. Conclusion(s): Successful treatment of patients with multiple primary malignancies is based on multidisciplinarity, early recognition and management of side effects, treatment of comorbidities with the aim of prolonging life, controlling symptoms of disease and preserving quality of life.
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Hepatitis A is a common viral infection worldwide that is transmitted via the fecal-oral route. Since the introduction of an efficient vaccine, the incidence of infection has decreased but the number of cases has risen due to widespread community outbreaks among unimmunized individuals. Classic symptoms include fever, malaise, dark urine, and jaundice, and are more common in older children and adults. People are often most infectious 14 days prior to and 7 days following the onset of jaundice. We will discuss the case of a young male patient, diagnosed with acute hepatitis A, leading to fulminant hepatitis refractory to conventional therapy and the development of subsequent kidney injury. The medical treatment through the course of hospitalization was challenging and included the use of L-ornithine-L-aspartate and prolonged intermittent hemodialysis, leading to a remarkable outcome. Hepatitis A is usually self-limited and vaccine-preventable;supportive care is often sufficient for treatment, and chronic infection or chronic liver disease rarely develops. However, fulminant hepatitis, although rare, can be very challenging to manage as in the case of our patient.Copyright © 2023 The Author(s).
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The proceedings contain 78 papers. The topics discussed include: work disability, indirect costs and risk factors in patients with Crohn's disease in a Rio De Janeiro tertiary care center;proton pump inhibitors are associated with less severe periodontal disease: considerations for IBD patients;impact of COVID-19 pandemic in treatment adherence in inflammatory bowel disease patients;impact of COVID-19 in a cohort of patients with inflammatory intestinal disease;utilization of biologic therapy in patients with microscopic colitis not responding to standard therapy;restrictive eating symptoms may persist in children adolescents with treated IBD: case series;power calculations in randomized controlled trials of inflammatory bowel disease;measuring patient-reported outcomes in Crohn's disease patients during the outbreak of COVID-19;Tofacitinib and ileal pouch anal anastomosis. a single-center case series;corticosteroids, aminosalicylates and gastrointestinal symptoms are associated with the need of hospitalization in patients with inflammatory bowel diseases and COVID-19;and manometric study and the role of the perianal disease and the clinical activity in anorectal dysfunction in Crohn's disease.
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Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the coronavirus-19 disease (COVID-19) pandemic. The H-2 blocker famotidine has been suggested as an FDA-approved drug that could potentially be repurposed for treatment of COVID-19. Famotidine has since been shown to improve patient outcomes and reduce symptom severity in patients acutely ill with COVID-19. Other studies have suggested that proton pump inhibitors (PPIs) might have an association with COVID-19. OBJECTIVE: The purpose of the present study was to determine whether famotidine or any other antireflux medications have a prophylactic or detrimental effect for SARS-CoV-2 infection when taken regularly for the management of acid reflux. METHODS: An anonymous, web-based survey was distributed via email to adult otolaryngology patients to collect demographic data, past medical history, medication history, incidence of symptoms associated with COVID-19, potential exposure to SARS-CoV-2, and results of any PCR or serological testing. Associations between reflux medications and incidence of COVID-19 cases were analyzed. Statistical analysis was performed using SPSS. Chi-square with Fisher's exact test, Point-Biserial correlation, Kendall's-tau-b, independent samples t test, and the Mann-Whitney U test were used as appropriate. A binary logistic regression model was fit to determine probability of COVID-19 cases after adjustment for other risk factors. RESULTS: There were 307 patients who responded to the survey. The average age of respondents was 52.63 ± 17.03. Famotidine use was not associated with incidence of laboratory-confirmed (P= 0.717) or symptomatically suspected (P= 0.876) COVID-19. No other reflux medications were found to be significant predictors for laboratory-confirmed or suspected COVID-19 (P> 0.05). Younger age (odds ratio [OR] = 1.043, 95% CI: 1.020-1.065, P< 0.001), high risk obesity (OR = 4.005, 95% CI: 1.449-11.069, P= 0.007), and use of a corticosteroid nasal spray (OR = 3.529, 95% CI: 1.352-9.211, P= 0.010) were significant predictors for symptomatically suspected COVID-19 cases. CONCLUSIONS: There was no association between incidence of COVID-19 and use of reflux medications, including famotidine at doses used orally to manage reflux and high dose PPIs. Reflux medications did not protect against or increase the risk of COVID-19.
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Background and aim: The long-term consequences of COVID- 19 infection on the gastrointestinal tract remain unclear. Here we aimed to evaluate the prevalence of gastrointestinal symptoms and post-COVID-19 disorders of gut-brain interaction (DGBI) after hospitalization for SARS-CoV-2 infection. Material(s) and Method(s): GI-COVID19 is a prospective, multicenter, controlled study. Patients with and without COVID-19 diagnosis were evaluated upon hospital admission and after 1, 6, and 12 months post-hospitalization. Gastrointestinal symptoms, anxiety, and depression were assessed using validated questionnaires, namely the Gastrointestinal Symptoms Rating Scale (GSRS), the Hanxiety and Depression Scale (HADS) and the Rome IV Diagnostic Questionnaire for Functional Gastrointestinal Disorders in Adults. Result(s): The study included 2183 hospitalized patients. The primary analysis included a total of 883 patients (614 COVID-19 patients and 269 controls) due to the exclusion of patients with pre-existing gastrointestinal symptoms and/or surgery. At enrollment, gastrointestinal symptoms were more frequent among COVID-19 patients than in the control group (59.3% vs. 39.7%, P<0.001). At the 12-month follow- up, constipation and hard stools were significantly more prevalent in controls than in COVID-19 patients (16% vs. 9.6%, P=0.019 and 17.7% vs. 10.9%, P=0.011, respectively). Compared to controls, COVID- 19 patients reported higher rates of irritable bowel syndrome (IBS) according to Rome IV criteria: 0.5% vs. 3.2%, P=0.045. Factors significantly associated with IBS diagnosis included history of allergies, chronic intake of proton pump inhibitors, and presence of dyspnea. [Table presented] At the 6-month follow-up, the rate of COVID-19 patients fulfilling the criteria for depression was higher than among controls. Conclusion(s): Compared to controls, hospitalized COVID-19 patients had fewer complaints of constipation and hard stools at 12 months after acute infection. COVID-19 patients had significantly higher rates of IBS than controls. ClinicalTrials.gov number, NCT04691895.Copyright © 2023. Editrice Gastroenterologica Italiana S.r.l.
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Background: The importance of vaccination in today's world is extremely important given the COVID-19 epidemic. About 30% of the world's population suffers from allergies. Among them, 25% of patients according to the WHO, had an episode of urticaria at least once in their life. Urticaria is one of the most common allergic diseases, which is the highest in-patient admission toll at Dnipro Allergy Center. During the year 2021, 600 patients with urticaria were treated in the hospital. Patients with chronic recurrent urticaria do not want to be vaccinated because of the fear of complications such as anaphylaxis.Vaccination of urticaria patients without complications. Method(s): The study involved 45 patients aged 18 to 65 years, with a mean age of 34.3 +/- 1.0 (13 males and 32 females). The average experience of the disease is 3.6 +/- 0.8 years. Patients with chronic recurrent urticaria were admitted to the in-patient unit. Prior to vaccination, they were tested for tryptase levels, a detailed platelet blood test, coagulogram, D-dimer, and ECG. Result(s): Many patients had concominant gastrointestinal pathology in the form of gastro-esophageal reflux disease (GERD) -20 patients (44.4%), peptic ulcer disease disease -17 patients (37.7%), or stomach pathology in 45 patients (100%), which required proton pump inhibitors (PPI). Given that PPIs are a risk factor for anaphylaxis, according to EAACI documents, PPIs were discontinued three days before vaccination. Serum tryptase levels were elevated in 3 patients (13 mug/l, 16 mug/l, 32 mug/l). All patients underwent premedication. At normal serum tryptase levels, patients received 1-fold dose of desloratadine, and at high serum tryptase levels: 13 mug/l, 16 mug/l and 32 mug/l, patients received 4-fold dose of desloratadine. After 30 minutes vaccination shot was carried out without side effects and without complications of allergic nature. The second vaccination shot was also protected by antihistamines, so all the patients we observed had received 2 shots of the vaccine not complicated by side effects such as fever or allergic reactions. Conclusion(s): All patients were vaccinated without complications. In urticaria patients, serum tryptase levels should be determined prior to vaccination. Depending on the level of tryptase, appropriate premedication is prescribed: with a high level of tryptase -4- fold dose of desloratodine, with a normal level -1- fold dose. All patients with urticaria should be diagnosed with concomitant pathology in order to correct the basic therapy before vaccination.
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Aim: In our study, the effects of methylprednisolone and anakinra drugs in the treatment of hyperinflammation in severe COVID-19 patients were investigated. Material(s) and Method(s): In this single-center retrospective study, severe COVID-19 patients followed up with signs of hyperinflammation were examined. The patients were examined in the Sequential Treatment Group receiving high-dose methylprednisolone followed by Anakinra, and the concomitant treatment group receiving both at the same time. Inflammatory parameters, imaging findings, and way of leaving the intensive care unit of the patients were compared. Result(s): A total of 87 patients were included in the present study. In both treatment groups, an increase in lymphocyte levels and a decrease in CRP, lactate dehydrogenase (LDH) and ferritin levels were detected at the end of treatment values compared to the initial treatment values. (p<0.001 and p<0.001). Also, LDH values after the treatment were significantly lower in the concomitant treatment group than in the sequential treatment group (p=0.049). In the present study, 53 of the patients were discharged with good recovery and 34 died. The mortality rate was 31% in the concomitant treatment group and 43% in the sequential treatment group. In terms of mortality, numerical findings in favor of the concurrent treatment group were determined. Discussion(s): In addition to the studies in the literature, it was found that the concomitant use of Methylprednisolone and Anakinra can be an effective treatment option that reduces mortality and improves inflammatory parameters.Copyright © 2022, Derman Medical Publishing. All rights reserved.
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Over the last few years, we have seen 11 patients presenting with proton pump inhibitor (PPI) photosensitivity at our tertiary referral photodiagnostic service and in our local dermatology department. Many adverse effects, including the discovery in 2020 of an almost twofold increased risk of severe COVID-19, of this widely used group of drugs have been noted (Lee SW, Ha EK, Yeniova AO et al. Severe clinical outcomes of COVID-19 associated with proton pump inhibitors: a nationwide cohort study with propensity score matching. Gut 2020;DOI: 10.1136/gutjnl-2020-322248). Although PPIinduced phototoxicity has been described, phototest results have not been reported and all clinical presentations have not been described. We aimed to identify all patients with PPI photosensitivity who presented to our unit. We sought to better understand their clinical characteristics, blood test results and photodiagnostic results. We retrospectively reviewed all case notes and investigation results of patients who were diagnosed with PPI photosensitivity. Eleven patients were identified to have been seen between 2014 and 2019. Two patients were male and nine were female. Mean duration of disease was 3 6 years and mean duration of PPI ingestion was 5 years. Five patients presented with a drug-induced lupus pattern [subcutaneous lupus erythematosus (SCLE;n = 2), papulosquamous SCLE and discoid (n = 1), tumid (n = 1) and acute cutaneous (n = 1)], four with drug-induced phototoxicity (sunburn-like) and two with a drug-induced solar urticaria relating to a lupus mechanism. The majority of patients reported symptoms on sun-exposed sites. The most common indication for PPI prescription was gastroesophageal reflux disease with omeprazole being the most commonly prescribed PPI. All patients underwent phototesting. Three patients were not on an PPI while undergoing phototesting and did not demonstrate photosensitivity. Of the remaining patients who underwent phototesting the most common finding was delayed sensitivity to ultraviolet A and to visible light. Druginduced photosensitivity can be a challenging diagnostic entity owing to the varied clinical presentation and heterogeneous time to onset. We present this case series to further help clinicians in recognizing the clinical and diagnostic pattern of photosensitivity present with PPI use.
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Background & Aims: Bacterial infections affect survival of patients with cirrhosis. Hospital-acquired bacterial infections present a growing healthcare problem because of the increasing prevalence of multidrug-resistant organisms. This study aimed to investigate the impact of an infection prevention and control programme and coronavirus disease 2019 (COVID-19) measures on the incidence of hospital-acquired infections and a set of secondary outcomes, including the prevalence of multidrug-resistant organisms, empiric antibiotic treatment failure, and development of septic states in patients with cirrhosis. Methods: The infection prevention and control programme was a complex strategy based on antimicrobial stewardship and the reduction of patient's exposure to risk factors. The COVID-19 measures presented further behavioural and hygiene restrictions imposed by the Hospital and Health Italian Sanitary System recommendations. We performed a combined retrospective and prospective study in which we compared the impact of extra measures against the hospital standard. Results: We analysed data from 941 patients. The infection prevention and control programme was associated with a reduction in the incidence of hospital-acquired infections (17 vs. 8.9%, p <0.01). No further reduction was present after the COVID-19 measures had been imposed. The impact of the infection prevention and control programme remained significant even after controlling for the effects of confounding variables (odds ratio 0.44, 95% CI 0.26-0.73, p = 0.002). Furthermore, the adoption of the programme reduced the prevalence of multidrug-resistant organisms and decreased rates of empiric antibiotic treatment failure and the development of septic states. Conclusions: The infection prevention and control programme decreased the incidence of hospital-acquired infections by nearly 50%. Furthermore, the programme also reduced the prevalence of most of the secondary outcomes. Based on the results of this study, we encourage other liver centres to adopt infection prevention and control programmes. Impact and implications: Infections are a life-threatening problem for patients with liver cirrhosis. Moreover, hospital-acquired infections are even more alarming owing to the high prevalence of multidrug-resistant bacteria. This study analysed a large cohort of hospitalised patients with cirrhosis from three different periods. Unlike in the first period, an infection prevention programme was applied in the second period, reducing the number of hospital-acquired infections and containing multidrug-resistant bacteria. In the third period, we imposed even more stringent measures to minimise the impact of the COVID-19 outbreak. However, these measures did not result in a further reduction in hospital-acquired infections.
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EGID is a recently described condition with an unknown etiology and pathogenesis. There are three case reports of duodenal stricture associated with EGID: one in an adult requiring pancreaticoduodenectomy due to the suspicion of malignancy and 2 cases in a child and a young adult, who responded to oral steroids. We report the case of a 10-year-old who presented to A&E with a 9-month history of epigastric abdominal pain and 1 episode of haematemesis, on a background of asthma. He was treated for Helicobacter pylori, based on a positive stool antigen. Abdominal pain and vomiting persisted, therefore an oesophago-gastro-duodenoscopy (OGD) was performed. This identified widespread white plaques throughout the oesophagus, erythema and nodularity of the gastric antrum and white nodules in the first part of the duodenum. Histology revealed changes of EGID and eosinophilic oesophagitis (EOE) and patient was commenced on Montelukast, oral viscous Budesonide (OVB), Cetirizine and continued proton pump inhibitor (PPI). After the allergy workup identified house dust mites, cat sensitisation and fish allergy, a 6-food elimination diet was initiated. During the next 2 years, symptoms subsided, and endoscopy changes improved, with only mild signs of active EOE while on OVB, PPI and diary/egg/fish free diet. However, the patient relapsed due to poor compliance to treatment. He became more unwell during the Covid pandemic with recurrent vomiting and static weight. A trial of dupilumab was considered, however his reassessment OGD had to be delayed due to restricted access to theatre. He was treated empirically with a reducing course of oral prednisolone, with temporary response. The endoscopic assessment performed subsequently showed erythema, erosions and white plaques in the distal oesophagus and gastric antrum with narrowing between the first and the second part of the duodenum (D2), that could not be entered. Histology identified mild upper oesophagitis (4 eosinophils (eos)/HPF), active middle and lower oesophagitis (20 eos/HPF and 12 eos/HPF, respectively), chronic gastritis (80 eos/HPF) and nonspecific reactive changes of the proximal duodenum. A barium meal confirmed a duodenal stricture. At this stage, we recommended a sloppy diet and a second weaning course of oral prednisolone, along with Montelukast. He was subsequently commenced on azathioprine for maintenance of remission. A repeat barium study and small bowel MRI performed post course of steroids and on azathioprine revealed stable appearances of the proximal duodenal stricture, excluding the presence of further strictures. While the patient has responded to the course of oral steroids and azathioprine, a repeat upper GI endoscopy is currently planned to dilate the duodenal stricture. The challenges posed by this case were the rarity of the condition, limited treatment options and access to endoscopy during the Covid pandemic and the fact that unlike previous case reports a sustained remission could not be obtained on steroids, and a maintenance immunosuppressive medication was required. We can conclude that this subgroup of patients should be monitored closely for signs of bowel obstruction and will require more intense treatment, including immunomodulators, endoscopic dilatation and or surgery.
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Histamine-2-receptor antagonist (H2RA) has shown beneficial effects on the kidney, heart, and sepsis in animal models and on the heart and COVID-19 infection in clinical studies. However, H2RAshave been used as a reference in most epidemiological studies examining the association of proton pump inhibitors (PPI) with outcomes. Therefore, we aimed to evaluate the effect of H2RA on renal and survival outcomes in chronic kidney disease (CKD) patients. We used a Taiwanese nationalhealth insurance database from 2001 to 2016 to screen 45,767 CKD patients for eligibility. We identified new users of PPI (n = 7121), H2RA (n = 48,609), and users of neither PPI nor H2RA (as controls) (n = 47,072) during follow-up, and finally created 1:1:1 propensityscore-matchedcohorts; each cohort contained 4361 patients. Participants were followed up after receivingacid-suppression agents or on the corresponding date until the occurrence of end-stage renal disease (ESRD) in the presence of competing mortality, death, or through the end of 2016. Compared toneither users, H2RAand PPI users demonstrated adjusted hazard ratios of 0.40 (95% confidence interval, 0.30-0.53) for ESRDand 0.64 (0.57-0.72) for death and 1.15 (0.91-1.45) for ESRD and 1.83 (1.65-2.03) for death, respectively. A dose-response relationship betweenH2RA use with ESRD and overall, cardiovascular, and non-cardiovascular mortality was detected. H2RA consistently provided renal and survival benefits on multivariable stratified analyses and multiple sensitivity analyses. In conclusion, dose-dependent H2RA use was associated with a reduced risk of ESRD and overall mortality in CKD patients, whereas PPI use was associated with an increased risk of overall mortality, not in a dose-dependent manner.
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The safety of proton pump inhibitors (PPIs) use in coronavirus infection (COVID-19) is not well understood. PPIs are potent suppressors of gastric secretion and become one of the ten most widely used drugs in the world. They are expected to influence virus susceptibility, severity, and outcomes in patients diagnosed with COVID-19. This concern is based on their mechanism of action — suppression of gastric acidity, which is considered the first line of defense against infections. Taken together, the results of most studies and meta-analyses support that PPIs use has been associated with increased risk of COVID-19 and severe outcomes. However, taking into account all potential risk factors for disease severity seems impossible in the real world in the context of COVID-19, so conclusions about causal relationships between PPI use and COVID-19 should be treated with great caution. An additional interesting point about the use of PPIs in the pandemic is that it reduced absorption of certain vitamins. On the other hand, several studies have appeared in the literature regarding the protective therapeutic effects of PPIs. There is growing evidence of an immunomodulatory and antifibrotic role of PPIs that could be used in the treatment of COVID-19. In addition, their ability to alkalize the contents of endosomes and lysosomes serves as an obstacle to the penetration of the virus into host cells. This review analyzes the possible effects of PPIs in patients with COVID-19.
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Background & Aims Gastrointestinal (GI) symptoms are present in 20% of patients with COVID-19. We studied the association of GI symptoms (in COVID-19 patients) with adverse outcomes and factors associated with poor outcomes in these patients. Methods The study cohort included 100,902 patients from the Cerner Real World Data (CRWD) COVID-19 Database of hospital encounters and emergency department (ER) visits with COVID-19 infection from December 1, 2019, to November 30, 2020. Multivariate analysis was used to study the effect of GI symptoms on adverse outcomes, and the factors associated with acute respiratory distress syndrome (ARDS), sepsis, and ventilator requirement or oxygen dependence in COVID-19 patients with GI symptoms. Results Patients with COVID-19 and GI symptoms were significantly more likely to have ARDS (OR 1.20, 95% CI 1.11, 1.29), sepsis (OR 1.19, 95% CI 1.14, 1.24), acute kidney injury (OR 1.30, 95% CI 1.24, 1.36), venous thromboembolism (OR 1.36, 95% CI 1.22, 1.52) or GI bleed (OR 1.62, 95% CI 1.47, 1.79);and less likely to experience cardiomyopathy (OR 0.87, 95% CI 0.77, 0.99) or death (OR 0.71, 95% CI 0.67, 0.75). Among those with GI symptoms, older age, higher Charlson comorbidity index scores, and use of proton pump inhibitors (PPI)/ H2 receptor antagonists (H2RA) were associated with higher mortality, ARDS, sepsis, and ventilator or oxygen requirement. Conclusion Patients with COVID-19 who have GI symptoms have overall worse in-hospital complications, but less cardiomyopathy and mortality. Older age, higher comorbidity scores, and the use of PPI and H2RA are associated with poor outcomes in these patients.
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BACKGROUND: Medication reconciliation is a important part of primary care, yet good prescribing practices are not often a focus of residency training. This study aims to raise awareness among resident physicians around polypharmacy and deprescribing by targeting a common class of medications, proton pump inhibitors (PPIs). PPIs are often continued longer than appropriate and can have side effects when used long-term. We present a quality improvement (QI) project aimed at deprescribing non-indicated PPIs in a resident clinic. As residency education has increasingly relied on teleconferencing to adapt to the COVID-19 pandemic, this study is the first to describe the use of virtual education sessions to reduce rates of inappropriate PPI use. METHODS: We implemented an IRB-approved QI project at a federally qualified health center that serves as the continuity clinic site for 46 internal medicine residents. From 9/2021 to 10/2021, residents participated in a 10-minute virtual education presentation on an evidence-based PPI deprescribing algorithmat the beginning of a clinic “huddle” session. Pre-and post-education surveys were administered to assess resident knowledge of and comfort level around deprescribing PPIs. Data were collected from our electronic medical record from 7/1/21 (start of academic year) through 1/1/22. RESULTS: Comparison of pre-and post-education surveys showed improvement in resident knowledge of PPI side effects (27% correct on pre-education survey vs 98% post), indications for long-term PPI use (7% vs 62%) and guidelines around re-assessment of PPI use in patients with GERD (49% vs 78%). After the education session, residents reported increased comfort with deprescribing PPIs (5.8 out of 10 pre-education vs 7.9 post). PPI utilization decreased by 13% across all ages from 9/1/21 to 1/1/22. Residents deprescribed PPIs for 56 patiens;there were 14 new PPI prescriptions. Rates of PPI deprescribing were higher in adults under 65-years-old (14%) compared to adults 65-years-old and older (11%). CONCLUSIONS: Deprescribing can be effectively incorporated into the residency curriculum during the COVID-19 pandemic through brief, virtual teaching sessions. The sessions increased resident knowledge and comfort around deprescribing PPIs, as demonstrated by a reduction in PPI utilization over a short period of time.
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Background: Optimizing management of gastroesophageal reflux disease (GERD) is important to preserve graft function after lung transplantation as patients with GERD are at higher risk of rejection. Patients with COVID-19 associated respiratory failure undergoing lung transplantation is an emerging subset of patients in which GERD pre- or post-transplant is not well characterized. Aim: To evaluate the prevalence and adverse effects of GERD both pre- and post-transplant in patients undergoing lung transplantation for severe COVID-19 infection. Methods: A retrospective review was conducted at a single academic medical center with a large multi-organ transplant program. All patients undergoing lung transplant due to COVID-19 from 2020-2021 were included in the study, with attention to pre- and post-operative physiological testing for GERD. Results: Seventeen patients were identified who had undergone lung transplant for COVID-19. All patients were male;52.9% (9/17) were Hispanic, 35.3% (6/17) Caucasian and 11.8% (2/17) Black. Median age was 50 (24- 70 years) with median time to transplant from documented infection of 131 days. A prehospitalization GERD diagnosis was found in 29.4% (5/17) patients, and two patients (11.8%) were taking prescribed proton-pump inhibitor (PPI) prior to their COVID-19 associated hospitalization. No patient underwent pre-transplant GERD testing, although three patients did undergo upper endoscopy for GI bleeding prior to transplant. Post-transplant, all patients were immediately treated with PPI per institutional protocol. 70.5% (12/17) patients reported post-transplant foregut symptoms including heartburn, regurgitation, dysphagia, early satiety, abdominal bloating/cramping, nausea and vomiting. All 17 patients had at least one symptomdriven foregut study such as a gastric emptying study, barium esophagram, upper endoscopy, esophageal manometry or pH testing. Three patients were referred for anti-reflux surgery (ARS) based on results of testing, including delayed gastric emptying, abnormal pH testing and bronchoscopy findings concerning for aspiration pneumonia. All three underwent Toupet fundoplication with or without hiatal hernia repair;one was performed early (< 3 mo) posttransplant, two occurred late (> 6 mo), and none had complications or symptom-based recurrence of reflux. Discussion: In this large single-center series of COVID-19 associated respiratory failure and lung transplant, pre-operative reflux testing could not be performed;however, post-transplant GERD symptoms were still routinely assessed and evaluated, prompting management with ARS in a small subset of patients, both early and late posttransplant, with resolution of GERD symptoms. Long-term outcomes of this unique group and comparison with others requiring transplant will necessitate further investigation to assess impact of GERD on allograft dysfunction.
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Background: Gastrointestinal (GI) bleeding is one of the impactful complications in patients hospitalized from Covid-19 infection. The previous study showed the risk factors of overall (upper and lower) GI bleeding in patients with Covid-19 infection but no study focused on patients with upper GI bleeding (UGIB). This study aimed to identify the risk factors and outcomes of patients who were hospitalized from Covid-19 infection and developed UGIB. Methods: This is a retrospective in university-hospital which enrolled patients who were admitted due to Covid-19 infection and developed UGIB between April and October 2021. The primary outcome was the associated factors of high risk UGIB defined by having hematemesis or fresh blood from NG tube or hematochezia plus hemodynamic instability. The secondary outcomes were etiologies of high risk UGIB and mortality in those patients. Results: Of 7,214 patients hospitalized though the period, 49 patients (0.7%) had evidence of UGIB. The majority were male (63.3%) with mean ages of 70+12 years. Twenty-seven from 49 patients (55.1%) had mechanical ventilator, 40 patients (81.6%) received systemic corticosteroids, and 13 patients (26.5%) received anticoagulants for venous thromboembolic prophylaxis. Seven from 49 patients (14%) had high risk UGIB;5 hematemesis (71.4%), 1 fresh blood from NG tube (14.3%), and 1 hematochezia (14.3%). There was no significant difference in term of number of patient taking antiplatelets, anticoagulants, or steroids and severity of COVID-19 infection (e.g. Mechanical ventilator needed) between two groups. The emergency endoscopy was performed in 6/7 (85.7%) patients and showed 5 peptic ulcer with non-bleeding visible vessel and 1 gastric lymphoma with blood oozing (Table 1). All 6 patients underwent endoscopic hemostasis including adrenaline injection, bipolar coaptation, clipping, Hemospray®, and over-the-scope clip. There was a robust result when conducting uni- (p=0.005) and multi-variate analysis (OR 6.38;95%CI 1.04-38.92;p= 0.045) that an absence of proton-pump inhibitor (PPI) use was the significant risk factor of high risk UGIB in targeted patients (Table 2). The overall mortality rate in patients with UGIB was 20/49 (40.8%) and 1 from 20 patients (5.0%) expired from UGIB due to moribund condition and unsuitable for endoscopy. None of patients with high risk UGIB and underwent therapeutic endoscopy expired during admission. Conclusion: Our study demonstrated that the absence of PPI use was a sole significant risk factor for high risk UGIB which required therapeutic endoscopy in patients with COVID-19 infection. We suggest that PPI prophylaxis should be prescribed in those patients once they need hospitalization regardless of the severity of COVID-19 infection and anticoagulant usage to minimize the severity of UGIB.(Table Presented)
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BACKGROUND: No gold standard therapy was approved globally for COVID-19 pneumonia to the date of this study. The pathophysiology of SARS-CoV-2 infection displayed the predominance of hyperinflammation and immune dysregulation in inducing multiorgan damage. Therefore, the potential benefits of both immune modulation and suppression in COVID-19 have been extensively discussed as a modality to control cytokine release syndrome (CRS). Abnormally high levels of interleukin-6 (IL-6) are a common finding in COVID-19 patients with pneumonia and acute respiratory distress syndrome, so the use of IL-6 antagonist was tested as a therapeutic option in controlling the disease. Tocilizumab is a recombinant humanized anti-human IL-6 receptor monoclonal antibody that can specifically bind the membrane-bound IL-6 receptor and soluble IL-6 receptor, thereby inhibiting signal transduction. Tocilizumab is currently FDA approved for the management of rheumatoid arthritis, giant cell arthritis, polyarticular juvenile idiopathic arthritis, and systemic juvenile idiopathic arthritis. This study is a retrospective analysis of data polled during Phase I of COVID pandemic, adopted by the isolation hospital of Kasr Al-Ainy Medical School, Cairo University, during the period from May to September 2020. AIM: The aim of this study is to evaluate tocilizumab influence in the outcome;in terms of reducing the hospital stay, risk and duration of mechanical ventilation (invasive and noninvasive), mortality, and the incidence of complications related to drugs use (secondary bacterial infection and GIT bleeding) in patients with moderate-to-severe COVID-19. METHODS: This retrospective, observational cohort study included adults (between 18 and 80 years) with moderate-to-severe COVID-19 pneumonia, who were admitted to isolation hospital of Kasr Al-Ainy Medical School, Cairo University, between May and September 2020. We segregated the patients into two groups: Group A: In addition to the standard care protocol according to the local guidelines of the Egyptian Ministry of Health and Population in that period (supplemental oxygen, steroids in a dose of 1–2 mg/kg methylprednisolone for 5–10 days, broad-spectrum antibiotics, vitamins, and prophylactic dose of anticoagulation with low-molecular-weight heparin, proton-pump inhibitor, and poly-vitamins), they received tocilizumab intravenously in a dose of 8 mg/kg bodyweight (up to a maximum of 800 mg per dose), divided in two shots 12–24 h apart. Group B: Those received the standard care protocol alone, noting that guidelines were adjusted later on according to the updated scientific publications and WHO recommendations. The primary endpoint was to evaluate the effect of different regimens in controlling the disease, the need for mechanical ventilation and its duration (either invasive or non-invasive), length of ICU stay, hospital stay, and in-hospital mortality. Comparisons between quantitative variables were done using the non-parametric Mann–Whitney U-test. For comparison of serial measurements within each patient, the non-parametric Wilcoxon signed-rank test was used. For comparing categorical data, Chi-square (2) test was performed. Exact test was used instead when the expected frequency was <5. Correlations between quantitative variables were done using Spearman correlation coefficient. RESULTS: During this period, 166 patients were admitted to ICU, suffering from severe hypoxemia with moderate to severe COVID-19 pneumonia, 10 of them were excluded (three were over 80 years old, other three had advanced stages of malignancy, two were on steroids therapy and non-invasive home ventilation due to chronic chest condition, and two were presented with MODs and deceased in <48 h from admission), thus, 156 were included in the study. Group A: Seventy-six patients (49%) received tocilizumab in addition to standard therapy, Group B: Eighty patients (51%) received standard therapy only. In Group A, the mean length of ICU stay was 8.96 days with mean length of hospital stay 13.76, compared to mean length f ICU stay 9 days in Group B (p = 0.57) and mean length of hospital stay 12.46 days (p = 0.117). In Group A, 35 patients (46%) needed non-invasive mechanical ventilation (MV),12 patients of the 35 needed invasive MV in later stage, compared to 26 patients (32%) in Group B, 14 patients of the 26 needed invasive MV in later stage (p = 0.16). In Group A, 14 patients (18.4%) needed invasive mechanical ventilation, compared to 19 patients (23.7%) in Group B (p = 0.213). In Group A, 6 (7.9%) of 76 patients died, compared to 13 (16.3%) of 80 in Group B p = 0.11. The incidence of secondary bacterial infection in Group A was 16 patients (21%) compared to 21 (26%) in Group B (p = 0.44). CONCLUSION: In this study, we did not detect statistical difference in both groups of patients coming during CRS-associated COVID-19 pneumonia, regarding (ICU stay, need for and length of MV, the incidence of secondary bacterial infection, and in-hospital mortality) for COVID-19 moderate-to-severe pneumonia.
ABSTRACT
Fungal infection of vocal cord in immunocompetent host is rare and may be missed as the lesion may mimic granulomatous disease, carcinoma, leukoplakia etc. Here we present a case of a healthy male patient. A 77 years old male patient presented to ENT specialist with complaints of hoarseness of voice for last 3 months. The patient was a non-smoker, not immunocompromised or taking immunosuppressive drugs. He was prone to seasonal bouts of cough & cold with sneezing. Video laryngoscopy showed inflamed tonsils and congested vallecula & epiglottis. Both vocal cords showed proliferative mass, white keratotic patch in anterior & middle third portion with restricted movement. Tissue samples from both vocal cords was sent for histopathology (HP). Slide examination revealed necrotic exudate containing broad based aseptate fungal hyphae and a provisional diagnosis of vocal cord fungal infection favoring Mucor mycosis was made. Patient was started on Itraconazole 100 mg twice daily along with treatment for patient's allergic condition. The slides and tissue sample obtained by direct laryngoscopy were sent to a different lab for reconfirmation. Further HP examination showed necrotic exudate and fibrin deposits with abundant fungal spores & hyphae. Grocott methenamine silver (GMS) stain & Periodic acid-Schiff (PAS) staining showed fungal spores and branching septate fungal hyphae confirming a diagnosis of vocal cord aspergillosis. His routine blood tests, serology, ECG reports were normal. RTPCR (Reverse Transcriptase Polymerase Chain Reaction) for SARS-CoV-2 was negative. After final diagnosis, patient was referred to pulmonologist to exclude pulmonary aspergillosis. Medication was changed to Voriconazole 200 mg twice daily along with antileukotrienes & antihistamines for his seasonal allergies. Patient was asked to follow up with CT chest to exclude pulmonary aspergillosis. The CT chest did not show any chest pathology. His voice was normal and other physical examinations were within normal limit. He was prescribed Voriconazole 200 mg twice daily for 3 months along with antihistamines, antileukotrienes, proton pump inhibitors & cough syrup. He was advised to come for follow up with liver function test after 4 weeks. Primary fungal infection of vocal cords is rare. Fungal infection is common in immunocompromised host but to detect such cases in healthy immunocompetent patient requires high level of suspicion and usually oral antifungal therapy for 3-4 weeks results in complete resolution of symptoms & lesion as per the current literature. (Figure Presented).
ABSTRACT
The proceedings contain 66 papers. The topics discussed include: exploring elderly patients? perspectives on deprescribing: a qualitative study interim analysis;supporting safe and gradual reduction of long-term benzodiazepine receptor agonist use: development of the safeguarding-BZRAs toolkit using a co-design approach;a feasibility study of a pharmacist led proton pump inhibitor deprescribing intervention in older patients in an Irish hospital;using risk prediction to case-find frail older people at risk of anticholinergic burden for structured medication reviews: a qualitative study exploring the views and perspectives of primary care professionals;routinely implementing safe deprescribing in primary care: a scoping review;and antimicrobial consumption in hospitalized COVID-19 patients: a systematic review and meta-analysis.