ABSTRACT
Purpose of Study: Previous Osteopathic manipulative treatment (OMT) research has shown evidence of increased lymphatic movement resulting in increased leukocyte and cytokine flow. One study even showed increased antibody titer response in patients when used in conjunction with the Hepatitis B vaccine. Given previous studies, our group conducted a year-long longitudinal randomized controlled clinical trial to evaluate the ability of OMT to improve the COVID-19 vaccine immune response. Methods Used: Subjects were randomized into either the control arm or OMT intervention arm. OMT consisted of myofascial release of the thoracic inlet, pectoral traction, diaphragm release with MFR, splenic pump, and thoracic pump applied the day of and the day following each vaccination session. All subjects in each group received the Pfizer mRNA COVID-19 vaccine. All subjects had blood drawn on day 0 (1st vaccine), day 7, day 21 (2nd vaccine), days 28, 90, 210, and 365. Anti-spike IgG immunoglobulin titers (AS IgG) were measured at all time points for all subjects. Side effects, adverse events, and medication usage in response to the vaccines or OMT was documented. Breakthrough cases with symptomology and medication usage was documented for both groups. The study was approved by the WesternU IRB committee, protocol #FB21/IRB026. Summary of Results: Data for 91 subjects were analyzed with 41 male (45.1%) and 50 female (54.9%). Age distribution was comparable between the two groups. Side effects and medication usage reported by the subjects was similar between groups (p>0.1). AS IgG measured at baseline distinguished between previously infected individuals and those naive to COVID-19, regardless of OMT treatment. For all time points measured, the average AS IgG in subjects trended higher in OMT group than control group. Two-way ANOVA analysis showed statistical significance at 1 week after 2nd injection (p<0.001) in the COVID-19 naive population. 13 symptomatic breakthrough infections were reported in the control group and 12 in the OMT group. Length of symptoms were reported as 8.36 +/- 4.60 days (control) and 4.62 +/- 2.60 days (OMT) (p<0.05). Length of medication usage was 3.64 +/- 3.58 days (control) and 1.23 +/- 1.24 days (OMT) (p<0.1). Conclusion(s): Both groups had comparable side effects after COVID-19 vaccination with no adverse events linked to OMT, indicating that OMT is a safe adjunct that can be used with COVID-19 vaccination. The data showed an enhanced immune response by OMT, as evidenced by increased levels of AS IgG in previously naive subjects. Although both control and OMT groups had similar rates of symptomatic breakthrough infection, the OMT data shows reduced length of symptoms and medication duration in this population when compared to control breakthrough infections. This study is underpowered for statistical significance at each time point and future vaccination studies should recruit more patients to confirm the trends seen here.
ABSTRACT
Outcomes: 1. Assess baseline knowledge, attitudes, and practices on EOL non-pain symptom management among internal medicine residents in a teaching hospital using a cross-sectional survey. 2. Develop a standardized inpatient EOL non-pain symptom management educational toolkit for internal medicine residents. Introduction: With palliative care gaining traction as a vital specialty to help patients living with serious illnesses comes the need for further training of healthcare professionals. Frontline providers such as medical residents can benefit from end-of-life (EOL) care training in symptom management. Method(s): There are three phases (over a period of 4 years) to this study: (1) administration of a needs assessment survey of baseline knowledge, attitudes, and practices on EOL non-pain symptom management;(2) development and implementation of a standardized inpatient EOL symptom management toolkit;and (3) a comparison of pre-and postassessment after the educational intervention. Result(s): The baseline survey had 66 participants. There were six non-pain symptoms that were elicited as important for further education and training. These were anorexia, nausea/vomiting, dyspnea, oral secretions, myoclonus, and delirium. Competency-based comfort and confidence levels were assessed using a Likert scale (1-5), with the highest number as the most comfortable. The residents were noted to be more comfortable with EOL communication compared to symptom management. Furthermore, residents who had had previous EOL care experiences with patients were more comfortable in symptom management. The educational intervention implemented at a later time revealed that there was an improvement in posttest scores for EOL symptom management. Discussion(s): This study highlights the needs and gaps in EOL symptom management training for medical residents. The implementation of a standardized inpatient EOL symptom management toolkit might serve as a potential intervention to address the needs and narrow gaps in medical training. This can serve as a possible template for other institutions to integrate an EOL care curriculum in medical residency. Limitations of the study include a small sample size, implementation during the COVID-19 pandemic, variable participant response rate, and interrupted timelines. The next steps include ongoing training for all residents, long-term follow-up postintervention, and institutional buy-in.Copyright © 2023
ABSTRACT
Introduction: Patients who were affected by severe SARS-CoV2 pneumonia are now presenting respiratory sequelae. High resolution CT (HRCT) offers information about the evolution of the disease and its possible progression in form of pulmonary fibrosis. Aim(s): To assess the radiological findings during 1-year follow-up in patients affected by severe SARS-CoV-2 pneumonia, to determine the incidence of pulmonary fibrosis and its possible risk factors. Method(s): A prospective cohort study was conducted at Dr. Josep Trueta Hospital and Santa Caterina Hospital, including patients with severe SARS-CoV-2 pneumonia hospitalized at the Pulmonology service between March and June 2020. A 1-year follow-up was done, with controls in the 3rd and 6th months. We analysed clinical data, radiological findings, quality of life, grade of dyspnoea, pulmonary function testing and exercise capacity. Pulmonary fibrosis was defined by traction bronchiectasis/bronchiolectasis, pulmonary distortion or honeycomb pattern. Result(s): 94 patients were analysed. In a year span, 47.9% of HRCT were pathological, showing pulmonary fibrosis in 25.8% of them. Ground-glass opacities (GGO) were found in 66.5% of HRCT at the 3rd month, showing an improvement at the 6th month and a practical resolution at the 12th month. However, the fibrotic disease remained stable from the 6th month. The multivariant analysis showed a significant major incidence of pulmonary fibrosis among elderly patients. Conclusion(s): A practical resolution of the GGO is seen in most patients at the 6th month. Up to a quarter of patients develop fibrotic changes at the 1-year follow-up, however it remains stable from the 6th month onwards. Old age would be considered as a risk factor.
ABSTRACT
Introduction: Since its emergence in December 2019, coronavirus disease 2019 has impacted healthcare resources causing a global public threat. His long-term complications are still being evaluated and little is known about the longterm pulmonary sequelae. Method(s): We conducted a prospective observational study at the University Hospital of Gabes. Eighty-nine patients were included. Radiological evolution was assessed at 3 and 6 months from acute presentation by chest CT. Result(s): A total of 89 patients (52% women versus 48% men ;mean age 58 years +/- 13) were studied prospectively. The extension in the initial chest CT was severe to critical in 48%. They had repeat imaging after 3 months. Among those (88,5%) had persistent parenchymal changes residual ground-glass opacification (42%) or interstitial thickening (27%), and 23 (52%) patients developed post COVID-19 fibrosis with CT evidence of fibrotic-like changes : traction bronchiectasis (29%), parenchymal bands (32%), and honeycombing (2%). Six-month follow-up CT was performed in 27 patients and showed fibrotic-like changes in the lung in 30% : traction bronchiectasis (22%), parenchymal bands (26%). These persistent radiological abnormalities in the lung at 6 months were associated with an older age > 65 years (p = 0,03), longer hospital stays > 15 days (p=0,001), and higher initial chest CT score (p=0,026). Conclusion(s): Age, initial CT scan scoring and duration of hospital care were the main predictors of fibrosis-like changes at 6 months found in our study ;further research with prolonged follow-up is needed to provide a better understanding of outcomes for COVID-19 patients.
ABSTRACT
Hesperidin has gained major interest recently due to the outbreak of COVID-19. The traction has led to more research being conducted on the compound hesperidin. Recent studies have shown its anti-inflammatory and anti-viral attributes, which have beneficial effects on severe acute respiratory syndrome (SARS-CoV-2). Hesperidin has also shown unique effects on the protein of SARS-CoV-2, which lead to a good preventative measure for SARS-CoV-2. Hesperidin also causes a suppression of appetite, which helps to combat obesity through the release of cholecystokinin. Furthermore, hesperidin has shown cardioprotective properties, which cause an increase in plasma high-density lipoprotein levels and a decrease in plasma low-density lipoprotein levels. Hesperidin is also used in combination with the Japanese herb Rikkunshito, which has shown potential in a discovery of a new drug for gastrointestinal motility as hesperidin can depolarize pacemaker potential in interstitial cells of Cajal (ICC). The chemo-preventive effects of hesperidin are caused by its antioxidant effect, which may prevent tissue necrosis due to oxidative stress. The photo-protective effect of hesperidin can reduce the damage to the skin caused by UV rays. Hesperidin also possesses wound-healing properties.Copyright © 2023 Bentham Science Publishers.
ABSTRACT
Case Report: Tsukamurella species are aerobic, partially acid fast saprophytes commonly isolated from soil and water. They are opportunistic pathogens known to infect multiple organs and can contribute to significant pathologies such as bacteremia, peritonitis, and respiratory tract infections. Moreover, Tsukamurella shares certain characteristic properties to Mycobacterium tuberculosis and Actinomyces species, including the acid fast stain, which can contribute to misdiagnosis of patients. A 68 year old female patient presented to the ED for shortness of breath, fatigue, and weight loss for 6 months. The patient's past medical history includes pulmonary fibrosis, type 2 diabetes, coronary artery disease with stent, hyperlipidemia, hypertension, and M. tuberculosis infection when she was 3 years old in Finland. On admission, labs revealed thrombocytosis (reactive 555 000/microL), leukocytosis (14 450/microL), and microcytic anemia (9.4 microg/dl). Moreover, C reactive protein was elevated and procalcitonin was normal (0.06 microg/l);a COVID-19 PCR was negative. An X-ray revealed severe patchy and interstitial infiltrates throughout both lungs with parenchymal scarring and pleural thickening in the periphery of the left mid-lung zone with multifocal pneumonia. Blood and sputum cultures were performed under the impression of pneumonia, and treatment with azithromycin and ceftriaxone was started. A M. tuberculosis infection was suspected due to a positive AFS. Further chest CT suggested multifocal pneumonia within the left lung in addition to apparent cavitary lesions versus bulla, a chronic interstitial lung disease with traction bronchiectasis, calcified right lower lung nodule, and calcified hilar lymph nodes suggesting a history of granulomatosis diseases. A bronchoscopy with Bronchoalveolar lavage was performed. The initial sputum specimen direct smear showed acid-fast stain positive with Actinomyces growth, and Penicillin G was added to the treatment. Samples were sent to the state department lab, and biopsy revealed granulomatous inflammation negative for malignant cells. One month later, the patient's sputum culture showed Tsukamurella for High-performance liquid chromatography (HPLC). Moreover, a rifampicin sensible M. tuberculosis complex by NAA was also positive six weeks later. The patient was started on a complete TB regimen and continued in the outpatient pulmonology clinic with the addition of levofloxacin for three months and rifampicin substituted for rifabutin. As demonstrated in the case above, a Tsukamurella infection can present similarly to a Mycobacterium infection. Patients may be misdiagnosed or potentially be co-infected. Our patient was further tested and appropriately treated for Tsukamurella after further extensive diagnostic screenings. Due to a high rate of missed cases, it is important to keep Tsukamurella infection on the differential diagnosis as the patient presentation may initially appear to be a Mycobacterium or other pulmonary infection. Copyright © 2023 Southern Society for Clinical Investigation.
ABSTRACT
SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Common variable immunodeficiency (CVID) is a primary immunodeficiency disorder characterized by low serum IgG, IgA and/or IgM, and poor specific antibody production. CVID is estimated to affect as many as 1 in 25,000 individuals. Chronic lung disease is a common problem in patients with CVID. About 10-20% of patients have lymphocytic infiltrates and/or sarcoid-like granulomas, with several histological findings, termed granulomatous and lymphocytic interstitial lung disease (GLILD). CASE PRESENTATION: Patient is a 61-year-old Caucasian woman with a history significant for CVID in remission who presented to the Pulmonary Clinic with a chief compliant of dyspnea of exertion (DOE). Patient was not suffering from any respiratory complaints until the diagnosis of severe COVID-19 pneumonia 4 months prior. For the following months, patient was slowly improving but was still suffering from severe DOE that has negatively impacted her quality of life. Patient has a remote history of smoking, having quit 10 years ago. Patient denied any joint pain, stiffness, swelling, skin rash, muscle ache, or weakness. No known history of SLE, Rheumatoid Arthritis, or other collagen vascular disorders had been reported. Patient denied any exposure to birds. Physical exam was significant only for bilateral basal rales with no wheezing or crackles. No skin rash, joints deformities, or clubbing was noticed. Laboratory studies revealed ESR was 17 with a CRP of 10.6. Negative ANA, SM, RNP, and SSA/SSB antibodies. Her Immunoglobulins levels were low with IgG 382 (nl > 610) and IgA < 2 (nl > 85). Her PFT revealed severe restrictive process with TLC 46% of predicted and severe reduction in DLCO at 35%. CT chest revealed diffuse central groundglass opacities, and interstitial thickening with traction bronchiectasis. Lung biopsy via VATS revealed lung parenchymal with focal, noncaseating granulomas, foci of focal interstitial lymphocytic infiltration and fibrosis;features consistent with Granulomatosis-Lymphocytic Interstitial Lung Disease (GLILD). Systemic steroid initiated and for the following weeks patient reports significant improvement in DOE. Her PFT at 3 month follow up showed significant improvement in FVC (5% increase), TLC (11% increase), and DLCO (5% increase). DISCUSSION: The respiratory manifestations of CVID follow two main mechanisms: injury due to acute or recurrent infections and damage due to poorly understood immune-mediated processes. Severe COVID-19 results in dysregulated immune and inflammatory response that can worsen an underlying lung disease. Previous cases have been reported about CVID with GLILD complicated with COVID-19 infection but not vice versa. CONCLUSIONS: To our knowledge, this is a rare case of CVID complicated by GLILD triggered by recent COVID-19 infection. However, little is known about the association between COVID-19 infection and GLILD and further investigation is needed. Reference #1: Ho HE, Mathew S, Peluso MJ, Cunningham-Rundles C. Clinical outcomes and features of COVID-19 in patients with primary immunodeficiencies in New York City. J Allergy Clin Immunol Pract. 2020;S2213–2198(20):31102–8. Reference #2: Prasse A, Kayser G, Warnatz K. Common variable immunodeficiency-associated granulomatous and interstitial lung disease. Curr Opin Pulm Med. 2013;19:503–9. Reference #3: Cunningham-Rundles C, Bodian C. Common variable immunodeficiency: clinical and immunological features of 248 patients. Clin Immunol. 1999;92:34–48. DISCLOSURES: No relevant relationships by husam nayef No relevant relationships by Arshia Vahabzadeh No relevant relationships by Zaid Yaqoob No relevant relationships by Mohammad Zalt
ABSTRACT
SESSION TITLE: Systemic Disease with Diffuse Lung Symptoms Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Rapidly progressive interstitial lung disease (RP-ILD) is a rare and potentially fatal manifestation of dermatomyositis (DM) and has considerable impact in terms of the prognosis. CASE PRESENTATION: A 52-year-old male demonstrated DM-typical rash, fever, mialgias, and mild muscle weakness 3 months after asymptomatic COVID-19 infection. Two weeks later dysphonia and progressive dyspnea appeared. Lung CT scan showed the picture of organizing pneumonia. His COVID-19 PCR test was negative multiple times. Laboratory tests revealed the following numbers: ALT 210 IU/L, AST 748 IU/L, LDH 613 IU/L, CPK 1165 IU/L, ferritin 1145ϻg/l, CRB 11 mg/l. The patient was tested positive for anti-Ro52 antibodies, while anti-synthetase and scleroderma-associated antibodies were not discovered. Anti-melanoma differentiation-associated gene 5 (MDA5) test was not available due to the lack of the necessary test systems in the country. The patient was diagnosed with DM. Combined immunosuppressive therapy was administered, including: oral prednisolone 60 mg per day and 720 mg intravenously, dexamethasone 64-24 mg intravenously per diem, ciclosporin 200 mg и cyclophosphamide 600 mg, and 3 plasmapheresis sessions followed by an intravenous immunoglobulin. As a result of the therapy, muscle weakness disappeared and CPK levels returned to normal limits, however dyspnea progressed and ferritin levels hit 3500ϻg/l. After the following 3 weeks of intensive combined immunosuppressive therapy, the patient demonstrated symptoms of severe respiratory failure (RF). CT scan showed multiple traction bronchiectasis, wide areas of ground glass opacity, pneumomediastinum and subcutaneous emphysema of a neck and supraclavicular regions. Ciclosporin was replaced with tofacitinib with the dose of 10 mg per diem, IL-6 inhibitor (olokizumab 256 mg) was injected intravenously, massive broad-spectrum antibiotic therapy was administered. RF progressed and the patient was put on mechanical ventilation. The patient died of acute RF and sepsis a week later. DISCUSSION: RP-ILD is a common manifestation of severe MDA5+ DM, which is also associated with necrotizing vasculitis and amyopathic/hypomyopathic muscle involvement. In this case acute ILD in a patient with typical DM could also have been provoked by previous COVID-19 infection. CONCLUSIONS: The courses of disease for COVID-19 and MDA5+ DM have several similarities, which means it can be the same for their pathogenesis and clinical manifestations. In spite of early screening and intensive immunosuppressive therapy in such cases, the prognosis of patients with DM and RP-ILD is still poor and is associated with high mortality. Reference #1: Wang G, Wang Q, Wang Y, et al. Presence of Anti-MDA5 Antibody and Its Value for the Clinical Assessment in Patients With COVID-19: A Retrospective Cohort Study. Front Immunol. 2021 Dec 20;12:791348. doi: 10.3389/fimmu.2021.791348. PMID: 34987516;PMCID: PMC8720853. DISCLOSURES: No relevant relationships by Lidia Ananyeva No relevant relationships by Maria Aristova No relevant relationships by Liudmila Garzanova No relevant relationships by Anna Khelkovskaya-Sergeeva No relevant relationships by Dmitry Kulikovsky
ABSTRACT
SESSION TITLE: Pneumothorax, Chylothorax, and Pleural Effusion Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Chest tube placement is generally done to drain air (Pneumothorax) or fluid (Effusion or Hemothorax) from the pleural cavity. The incidence of complications related to such intervention varies between 1 to 6 percent (1), and includes but not limited to malposition, injuring chest wall structures, injuring intrathoracic structures, bleeding, and infection. In this case we present an unusual complication to surgical chest tube placement. CASE PRESENTATION: Our patient is a 59-year-old male, long term resident of a nursing facility with past medical history of alcohol use disorder in remission, alcoholic cirrhosis, seizure disorder, protein-calorie malnutrition and a recent COVID-19 infection. He presented with worsening shortness of breath and was admitted with acute hypoxemic respiratory failure. Initial CT scan showed fibrotic, reticular and cystic changes, traction bronchiectasis and diffuse bilateral ground glass opacities. He was admitted to the medical ICU;he was treated initially with broad spectrum antibiotics and diuresis with minimal response. Eventually steroid therapy was started for Covid related organizing pneumonia, and he improved. Later in his hospital state he developed bilateral small pneumothoraxes that enlarged overtime and a surgical chest tube was placed on the right side. Post procedure chest x ray showed that the tube was kinked, and the pneumothorax was still present. A follow up CT chest confirmed the presence of an extra-pleural hematoma with the tube kinked inside it. CT angiography of the chest was done and showed active extravasation of contrast into the extra-pleural space likely from the intercostal arterial branches. Interventional radiology took the patient to see if they could cauterize the bleeding vessel but they were unable to identify the source of bleeding. Thoracic surgery was also consulted and was planning to take the patient to the OR, remove the tube, evacuate the hematoma and control the bleeding. However, the patient opted against this. DISCUSSION: Extra-pleural hematoma is a rare complication of surgical chest tube placement. It is usually seen after blunt trauma or rib fracture, but can still occur after subclavian vein central line placement or chest tube placement. Bleeding is usually arterial in origin and treatment is often surgical. Radiological characteristics include biconvex shape and the extra-pleural fat sign (2,3,);hypodense rim medial to the hematoma due to the inward displacement of the extra-pleural fat by the hematoma. CONCLUSIONS: Chest tube placement remains a routine procedure that is done in emergency departments and hospital wards. Generally, a safe intervention but clinicians should be aware of the possible complications and their management including extra-pleural hematomas. Reference #1: Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010 Tom Havelock1, Richard Teoh2, Diane Laws3, Fergus Gleeson4 on behalf of the BTS Pleural Disease Guideline Group. Correspondence to Dr Tom Havelock, Wellcome Trust Clinical Research Facility, Southampton General Hospital, Southampton SO16 6YD, UK;t.havelock@soton.ac.uk Reference #2: Journal of Trauma and Injury 2017;30(4): 202-205. Published online: December 30, 2017 DOI: https://doi.org/10.20408/jti.2017.30.4.202 Traumatic Extrapleural Hematoma Mimicking Hemothorax Yong Seon Choi, M.D., Soon Jin Kim, M.D., Sang Woo Ryu, Seung Ku Kang Department of Thoracic and Cardiovascular Surgery, Mokpo Hankook Hospital, Mokpo, Korea Correspondence to: Soon Jin Kim, M.D., Department of Thoracic and Cardiovascular Surgery, Mokpo Hankook Hospital, 483 Yeongsan-ro, Mokpo 58643, Korea, Tel: +82-61-270-5574, Fax: +82-61-277-0199, E-mail : innocent-blood@hanmail.net Reference #3: The Journal of Emergency Medicine Volume 51, Issue 2, August 2016, Pages 159-163 Nonoperative Management of a Large Extrapleural Hematom after Blunt Chest Trauma LuisGorospe MD, María Ángeles Fernández-Méndez MD, AnaAyala-Carbonero MD, AlbertoCabañero-Sánchez MD, Gemma MaríaMuñoz-Molina MD, PhD DISCLOSURES: No relevant relationships by Ahmad Allaham No relevant relationships by Elyce Sheehan
ABSTRACT
SESSION TITLE: Occupational and Environmental Lung Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Hypersensitivity Pneumonitis (HP) one of the most common interstitial lung diseases (ILD) and is caused by an allergic reaction to an inciting agent in the airway of a susceptible individual1. The diagnosis is challenging as many of the classic symptoms, dyspnea and fatigue, are nonspecific. An accurate diagnosis involves careful history taking, physical exam, pulmonary function tests (PFTs), chest computed tomography (CT) imaging, and lung biopsy. CASE PRESENTATION: Patient is a 51 year old female with no PMH presents to clinic with worsening dyspnea and nonproductive cough. Symptoms began 6 months ago. She could not identify any triggers and was prescribed steroids and antibiotics with minimal relief. The patient has never smoked, denies drug use but had two pigeons. During the COVID pandemic she admitted to staying indoors more often and was not nearly as active outdoors as before. She denied fevers, chills, night sweats and weight loss. CXR showed no focal infiltrates, sharp costophrenic angels with no evidence of acute pathology. PFT's showed FVC pre 1.78, FVE1 pre 1.35, FVE1 % predicted pre 48%, FEV1/FVC pre 76%, TLC pre 3.23, VC pre 2.06 and a DLCO pre 10.98 with her LLN of 16.59. FVC post 1.91, FEV1 post 1.57, FVE1 % predicted post 58%, FEV1/FVC post 82% (Fig 1). She had positive pigeon serum antibodies. CT chest showed faint diffuse ground glass opacities bilaterally with mild mosaic attenuation reflecting HP (Figs 2, 3). The patient was diagnosed with HP, started on steroids and surrendered her pigeons with resolution of her symptoms. DISCUSSION: Diagnosis of HP is challenging as the classic symptoms of dyspnea and fatigue can be nonspecific. Physicians should be aware about increasing exposures to home antigens during the COVID pandemic in patients who have been indoors for prolonged periods of time. PFTs show a restrictive pattern and DLCO impairment. CT show the presence of centrilobular nodules, ground-glass opacities, mosaic attenuation/perfusion and air trapping and in longstanding disease there can be honeycombing and traction bronchiectasis2. Mainstay treatment is antigen avoidance and corticosteroids. Identification and complete avoidance of the antigen is the mainstay of treatment. Antigen avoidance is critically stressed as repeated exposures can result in HP progression and avoidance of the antigen is associated with improved lung function1. Corticosteroid initiation in progressive patients resulted in a reversal with an improvement of lung function3. Corticosteroids are often used in non-fibrotic HP however its efficacy remains unclear as long term prognosis has never been studied1. CONCLUSIONS: Physicians should recognize that prolonged time indoors, that have been exacerbated during the COVID19 pandemic, can increase the time patients are exposed to home antigens thus a prompt diagnosis and strict avoidance of the antigen is required to prevent irreversible damage. Reference #1: Maria Laura Alberti, "Hypersensitivity Pneumonitis: Diagnostic and Therapeutic Challenges". Frontiers in Medicine, Front. Med., 23 September 2021 ;https://doi.org/10.3389/fmed.2021.718299 Reference #2: Zompatori M, Calabrò E, Chetta A, Chiari G, Marangio E, Olivieri D. Chronic hypersensitivity pneumonitis or idiopathic pulmonary fibrosis? Diagnostic role of high resolution Computed Tomography (HRCT). Radiol Med. 2003 Sep;106(3):135-46. English, Italian. PMID: 14612834 Reference #3: De Sadeleer LJ, Hermans F, De Dycker E, Yserbyt J, Verschakelen JA, Verbeken EK, Verleden GM, Wuyts WA. Effects of Corticosteroid Treatment and Antigen Avoidance in a Large Hypersensitivity Pneumonitis Cohort: A Single-Centre Cohort Study. J Clin Med. 2018 Dec 21;8(1):14. doi: 10.3390/jcm8010014. PMID: 30577667;PMCID: PMC6352061. DISCLOSURES: No relevant relationships by Aryeh Bernstein No relevant relationships by Thai Donenfeld No relevant relationships by Lourdes Marie F aminiano
ABSTRACT
SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Biological disease modifying anti-rheumatic drugs (bDMARDs) are commonly used to treat interstitial lung disease (ILD) in patients with connective tissue disease (CTD). These patients often develop concurrent COVID-19 disease and existing data is scarce to guide treatment. We describe a case with a rare anti-Pl-7 Anti-Synthetase Syndrome (ASS) receiving Rituximab treatment for ILD who developed acute respiratory distress syndrome (ARDS) secondary to COVID-19 disease. CASE PRESENTATION: A 58-year-old female presented with worsening shortness of breath, loss of taste and smell, cough and headaches for 1 week. She had pre-existing severe chronic ILD secondary to ASS on Rituximab therapy. She tested positive on SARS-CoV-2 PCR testing, CT chest showed bilateral lung honeycombing, reticulations, traction bronchiectasis along with ground glass opacities consistent with active inflammatory interstitial process superimposed on ILD. She was diagnosed with COVID-19 pneumonia. She was initially started on high-dose Dexamethasone, Remdesivir and supplemental oxygen via high flow nasal cannula and supportive care for ARDS, however level of care was escalated due to worsening respiratory distress. Rituximab was discontinued due to active COVID-19 infection, the decision was made to start Baricitinib at 4 mg daily. She received treatment for 14 days, that led to a significant improvement in her respiratory status. DISCUSSION: ASS is a rare autoimmune condition involving multiple organs, with ILD being the major cause of morbidity. bDMARDS, especially Rituximab, have shown promising results in management of severe and refractory ILD in ASS. However, the role of bDMARDs as protective or risk factor for developing severe COVID-19 disease in these patients is unclear. ARDS in COVID-19 disease involves a vigorous inflammatory response and cytokine production leading to diffuse alveolar damage. Literature supports that use of corticosteroids, IL-1 and IL-6 receptor blockers and Janus Kinase (JAK) inhibitors for severe COVID-19 pneumonia is associated with decreased morbidity. Baricitinib is a JAK1 and JAK2 with anti-cytokine and anti-viral properties and has been associated with reduction in morbidity and mortality in patients with COVID-19 as demonstrated in our case. Generally, use of bDMARDs does not contribute to worse outcomes in COVID-19 disease in patients receiving these agents for rheumatological conditions. However, use of Rituximab and high dose glucocorticoids have been associated with worse outcomes, while Baricitinib may have a protective effect. Therefore, holding Rituximab in those with active COVID-19 infection is recommended. CONCLUSIONS: Management of COVID-19 in patients with CTD is a challenge due to the novel nature of the disease and scarcity of available data. The association of use of bDMARDs in rheumatological disease with outcomes in SARS-CoV-2 infection is yet to be elucidated. Reference #1: Barbosa AN, Silvinato A, Bacha H, Floriano I, Tanni S, Bernardo W. Use of disease-modifying drugs (tocilizumab, tofacitinib, and baricitinib-a biological or synthetic target specific) in patients hospitalized with COVID-19. Rev Assoc Med Bras (1992). 2022;68(1):3-8. Reference #2: Santos CS, Férnandez XC, Moriano Morales C, Álvarez ED, Álvarez Castro C, López Robles A, Pérez Sandoval T. Biological agents for rheumatic diseases in the outbreak of COVID-19: friend or foe? RMD Open. 2021 Jan;7(1):e001439. doi: 10.1136/rmdopen-2020-001439. PMID: 33455920;PMCID: PMC7813407. Reference #3: Galarza-Delgado DÁ, Serna-Peña G, Compeán-Villegas JE, Cardenas-de la Garza JA, Pineda-Sic RA, Colunga-Pedraza IJ, Vega-Morales D, Pérez-Barbosa L, Skinner-Taylor CM, Flores-Alvarado DE. Characteristics and evolution of 38 patients with rheumatic diseases and COVID-19 under DMARD therapy. Clin Rheumatol. 2021 Mar;40(3):1197-1199. doi: 10.1007/s10067-020-05510-9. Epub 2020 Nov 24. PMID: 33231774;PM
ABSTRACT
SESSION TITLE: Drug-Induced Lung Injury and Disease SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Lomustine, a nitrosurea, inhibits DNA, RNA, and protein synthesis by carbamylation and alkylation, leading to cytotoxic effects 1, 3. Its concentration is high in the central nervous system (CNS) and therefore is commonly used for the management of CNS tumors including recurrent glioblastoma. While known side effects include pancytopenia, few pulmonary toxicities have been reported. This case is a rare example of lomustine induced pneumonitis. CASE PRESENTATION: A 54-year-old female with a history of glioblastoma, treated with a combination of surgical resection, radiation therapy, and temozolomide followed by stereotactic surgery and bevacizumab after disease recurrence, developed progressive dyspnea after initiating lomustine. She had received one dose of lomustine 90 mg/m2 two months prior to developing dyspnea upon exertion. At baseline, she was an active individual who played sports. A chest computed tomography (CT) scan preformed ten months prior was without any parenchymal abnormalities, and pulmonary function tests (PFTs) two months prior were normal with an adjusted DLCO of 15.4 mL/mmHg/min (88%). Repeat chest CT revealed diffuse ground glass opacities, and repeat PFTs showed a moderately impaired adjusted DLCO of 10.4 mL/mmHg/min (60%). Other lab evaluation, CBC, BNP, troponin, and COVID PCR, were negative. After receiving six weeks of steroids, there was resolution of CT findings, improvement of DLCO, and relief from symptoms. DISCUSSION: More common adverse effects of lomustine are GI discomfort and pancytopenia. It is less widely documented to cause pulmonary toxicity compared to its chemical relative carmustine 1, 3. This is perhaps due to decreased alkylation ability and penetration into the lung tissue by lomustine7. There have been few case reports revealing pneumonitis and pulmonary fibrosis. Lomustine induced pneumonitis induces acute parenchymal changes of the lung demonstrated by characteristic symptoms and imaging/biopsies abnormalities after initiation of a drug. 2 Findings include breathlessness, dyspnea upon exertion, cough, hypoxia, crackles upon lung auscultation. PFT's may show a restrictive pattern with decreased FEV1/FVC ratio and DLCO. Imaging may reveal diffuse groundglass opacities, traction bronchiectasis, interlobular septal thickening, and honeycombing. Bronchoscopy with lavage would rule out infection. Management involves discontinuation of culprit medication, immunosuppression, and supportive therapies to alleviate respiratory discomfort. Lack of treatment may produce complications of acute respiratory distress syndrome and fibrosis. CONCLUSIONS: Lomustine is an essential treatment drug for recurrent CNS tumors. Toxicities such as pneumonitis have been rarely demonstrated. Timely recognition of pneumonitis features is key to treat this complication, improve quality of life, and prevent permanent lung compromise. Reference #1: Dent RG. Fatal pulmonary toxic effects of lomustine. British medical journal. 1982;DOI:10.1136/thx.37.8.627 Reference #2: Skeoch S, Weatherley N, Swift AJ, Oldroyd A, Johns C, Hayton, C, et al. Drug-Induced Interstitial Lung Disease: A Systemic Review. Journal of Clinical Medicine. 2018;doi 10.3390/jcm7100356 Reference #3: Weiss RB, Issell BF. The nitrosureas: carmustine and lomustine. Cancer treatment reviews. 1982;https://doi.org/10.1016/S0305-7372(82)80043-1 DISCLOSURES: No relevant relationships by Sukhdeep Kaur No relevant relationships by Chelsea Kennedy-Snodgrass No relevant relationships by Sarun Thomas
ABSTRACT
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: Polymyositis (PM) and dermatomyositis (DM) are inflammatory syndromes that have been shown to be associated with interstitial lung disease in up to 64% of cases. Current management strategies for PM/DM-ILD are mostly derived from treatment of PM/DM and rely on the immunomodulatory effects of steroids and steroid sparing medications. Literature supports the use of intravenous immunoglobulins for the management of PM/DM-ILD. However, this stems from isolated case reports. CASE PRESENTATION: Our patient is a 43-year-old female, previously healthy, who was referred to our ILD clinic for evaluation of possible diffuse interstitial lung disease. Her symptoms began May of 2019 with dyspnea, cough, and muscle aches. Her initial workup was significant for reticular opacities in the mid to lower lung fields on x-ray, moderate restriction, and severe diffusion impairment on pulmonary function tests. High resolution CT scan (HRCT) of the lungs showed a radiological pattern suggestive of nonspecific interstitial pneumonitis (NSIP) with mid to lower lung predominant ground glass opacities, mild subpleural reticulation, traction bronchiectasis with no evidence of honeycombing or air trapping. Further workup showed a positive antinuclear antibody (ANA) in a speckled pattern with a titer of 1:320. Her other rheumatological workup was initially largely unremarkable and she denied significant drug/toxin exposure. She was treated with steroids with initial improvement, however had significant clinical deterioration requiring hospitalization and oxygen supplementation and was eventually started on Mycophenolate Mofetil in Aug 2020. Her pulmonary disease remained stable until she was admitted again in Jan 2021 with new hypoxemic respiratory failure requiring 6 L supplemental oxygen. During that admission, she was diagnosed with polymyositis and referred for a lung transplant evaluation, she also started on IVIG for the treatment of active myositis to wean her off steroids prior to transplant listing. She was discharged home and underwent a full transplant workup. She required readmission for worsening hypoxemia now requiring 12 L supplemental oxygen in May 2021, HRCT showed worsening ground glass opacities. She was again treated with IVIG and a steroid course and had near complete resolution of her hypoxia with a 2 L oxygen requirement only on ambulation. She continues to follow up with our interstitial lung disease team and the pulmonary transplant team. Her course has been complicated by multiple admissions with bacterial pneumonia as well as COVID-19 infection. DISCUSSION: Treatment of PM/DM associated ILD relies heavily on the use of steroids as well as steroids sparing agents such as Mycophenolate or Rituximab. IVIG has been implicated in improving underlying lung disease with data derived from case reports. CONCLUSIONS: Our case highlights the importance of further advanced research in this field. Reference #1: Peshbahar, S., & Bendstrup, E. (2020). Remarkable benefits of intravenous immunoglobulin (IVIG) in a patient with polymyositis-associated acute interstitial lung disease. European Clinical Respiratory Journal, 7(1), 1840706. Reference #2: Fathi, M. (2006). Interstitial lung disease in polymyositis and dermatomyositis. Karolinska Institutet (Sweden). DISCLOSURES: No relevant relationships by Hafsa Abdulla No relevant relationships by ALAA ABU SAYF
ABSTRACT
SESSION TITLE: Global Pulmonary Cases SESSION TYPE: Global Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Progressive fibrosing interstitial lung diseases (PF-ILD) consist of a group of interstitial lung diseases (ILD) showing similar clinical phenotype of accelerated respiratory failure, frequent disease exacerbation with earlier mortality. CASE PRESENTATION: 48 year old male patient, smoker for 20 years (smoking index 20),presented with severe COVID pneumonia 9 months back where he has been admitted to ICU for 7 days. CTPA excluded PE but revealed severe covid pneumonia. inflammatory markers were consistent with cytokine storm. he has been commenced ono2 therapy with HNNC, steroid therapy(dexamethasone 6 mg for 15 days ), tocilizumab & remdisivir. he discharged from hospital after 15 days with o2 sat around 90 % on RA but still he has dyspnea on mild exertion. discharged on 40 mg steroid and tapered according to his repsonce.3 months later during his FU FVC was 55% of predicted with o2 sat on RA 84, 90 % on 2 L/M.HRCT chest showed diffuse reticulation with starting traction bronchiectasis more in both upper lobes occupying more than 10 % of lung parenchyma. he continued on CS 30 MG and with consideration of antifibrotic medications.after 2 months he developed pneumothorax on the right side where ICT was inserted for 7 days.4 months later he presented with gradual progressive SOB and gradual increase o2 requirement up to 6 L/M to maintain o2 sat around 90%.he became wheelchair bound during all his daily activities. FVC BECAME 40 %.ABG showed PO2 around 54 mmHg. evidence of irreversible lung disease, such as severe bullous destruction or evidence of established fibrosis.HRCT chest showed extensive reticulation with fibrotic changes, interstitial thickening associated with lung architecture distortion, with multiple bilateral bullous destruction on left and right upper lobe.(figure 1-2).MDT decide to start nintadanibe with discussion with lung transplantation team for possible listing. DISCUSSION: we reported a case of post covid lung fibrosis who is fulfilling criteria for being progressive and being fibrotic, as he showed decrease in FCV over 6 months more than 10%, progressive of respiratory symptoms and progression of lung fibrosis with development of bullous changes in both upper lobes. initially we know that it is too Early to address the POST COVID ILD in full details but there are many cases have been progressed and developed end sage fibrotic lung diseases.(1-2). then, the 2nd question that should be there, is "there any role of smoking for this rapid progression with development of this pattern".as there some reports about this risk but no clear evidence on large patient population CONCLUSIONS: is post covid lung fibrosis will be one of causes for progressive fibrosing lung pathology& what are the risk factors?the answer of these questions should be addressed as it may affect morbidity and mortality especially with increasing number of COVID cases. Reference #1: 1-Udwadia ZF, Pokhariyal PK, Tripathi AK, Kohli A. Fibrotic interstitial lung disease occurring as sequelae of COVID-19 pneumonia despite concomitant steroids. Lung India 2021;38:S61-3. Reference #2: 2-Kayhan S, Kocakoç E. Pulmonary fibrosis due to COVID-19 pneumonia. Korean J Radiol 2020;21:1273. Reference #3: 3-Vardavas CI, Nikitara K (2020) COVID-19 and smoking: a systematic review of the evidence. Tob Induc Dis. 18:20, DISCLOSURES: No relevant relationships by Usama Abu Elhassan No relevant relationships by Safwat Ali Mohammed Eldaaboo
ABSTRACT
SESSION TITLE: Acute COVID-19 and Beyond: from Hospital to Homebound SESSION TYPE: Original Investigations PRESENTED ON: 10/18/2022 02:45 pm - 03:45 pm PURPOSE: The aim of this study was to determine risk factors for residual pulmonary radiological and functional abnormalities and assessment of possible treatment approaches for reducing such complications in survivors with post-ARDS related to COVID-19. METHODS: There were 97 survivors enrolled, 12 weeks after severe ARDS who were intubated in COVID-19. All survivors admitted to pulmonary and critical care departments of university hospital from 30 August to 30 November 2021. 39 patients with lung radiographic abnormalities between 50-75%;58 patients with lung abnormalities more than 75%. RESULTS: At 12 weeks after discharge all patients reported persistent symptoms: dyspnea 100.0%, cough 42.3%, chest pain 51.1%, fever 29.0%, and hemoptysis 18.5%. More severe dyspnea (increased by exertion and at rest) was found with lung involvement more than 75%(OR 4.25[0.94-10.34]95%CI;p<0.0001).Pulmonary function tests were abnormal in all patients, however,more severe functional abnormalities were with lung involvement more than 75% and median FVC predicted was (46.3+_11.9 vs 64.7+_10.6;p<0.001),DLCO also was significantly lower (54.6+_9.3 vs 70.4+_8.4;p<0.01).Comorbidities such as diabetes milletus (DM) (OR 2.87[0.86-7.34]95%CI;p<0.002), obesity(OR2.44[0.79-6.98]95%CI;p=0.003), older age (OR 2.12[0.72-5.88]95%CI;p<0.004), and kidney failure (OR2.01[0.70-5.22]95%CI;p=0.005) were common in lung involvement more than 75%. Lack of dexamethasone at ICU admission with ARDS was significantly associated with more severe residual pulmonary abnormaliries: organizing pneumonia (OR 4.82[0.99-12.32]95%CI;p<0.0001),usual interstitial pneumonia(UIP)(OR 3.22[0.85-9.23]95%CI;p<0.0004),traction bronchiectasis(OR2.38[0.74-6.12]95%CI;p<0.001),and cystic changes (p<0.001) were commonest. In contrast, ground galss opacity (GGO) was commonest in use of dexamethasone (OR 2.95[0.79-7.54]95%CI;p<0.001). Multi-drug-resistant (MDR) pahtogen caused ventilator associated pneumonia (VAP) at the time intubation was significantly associated with residual OP (OR 4.76[0.91-11.66]95%CI;p<0.0001). CONCLUSIONS: There were several risk factors found for development of more severe residual pulmonary functional and radiological abnormalities: older age, and comorbidities such as DM, obesity, and kidney failure. Lack of use of dexamethasone was associated with development OP,UIP,traction bronchiectasis,and cystic changes.OP was common in patients with history of MDR-pathogen-caused VAP at intubation.The use of dexamethasone was associated with non-severe residual pulmonary functional and radiological abnormalities. CLINICAL IMPLICATIONS: The result of our investigation might be helpful for clinicians in COVID-19 practice.Our findings also may be helpful for pulmonologists, respiratory therapist, and nurses. Also our discussion may aid in correct management of ARDS and minimalizing of residual pulmonary functional and radiological abnormalities. DISCLOSURES: No relevant relationships by Alizamin Sadigov
ABSTRACT
SESSION TITLE: Imaging, ECMO, and other Procedures in the ICU Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Central Venous Catheter placement is a common procedure in the ICU setting and provides a valuable route for medication delivery and venous access. The Seldinger method is the most commonly used method for placement of the catheter, and is the standard of care [1] with current recommendations. However, central line placement is still associated with complications including infection, thrombotic events, and mechanical malfunctions. Guidewire related complications are less common, but can occur [2]. Wire retention is a known, but avoidable complication of central venous catheter placement. Guidewire errors have been associated with operator fatigue, inexperience, and inadequate supervision of trainees. CASE PRESENTATION: An immunocompromised 40 year old female who presenting with hypoxia secondary to COVID-19, ultimately requiring intubation. She required initiation of continuous sedatives, analgesics, and vasopressors, for which a CVC was placed. The procedure proceeded in usual fashion with ultrasound and sterilization. Standard seldinger technique with US guidance was utilized. However, during advancement of the catheter, the wire was also advanced and lost within the catheter. DISCUSSION: Using ultrasound the wire could be seen within the lumen of the catheter and approximately 1-2 cm deep. A chest plain film was obtained and displayed above (Figure 1). Given the superficial location of the wire, bedside removal was attempted. Counter-traction was applied anterior to the catheter entry site with a second operator while suction was applied to the terminal catheter port using a 30 cc syringe. A debakey hemostat was utilized to clamp the catheter as it penetrated the dermis. The catheter was removed 2 cm and then the hemostat was released while still applying suction and then again replaced at the same site. This process was repeated three subsequent times and then the catheter was completely removed revealing the guidewire protruding from the initial entry site. The wire was safely removed. The patient was otherwise unharmed and would later discharge to rehab facility. CONCLUSIONS: Central venous catheter placement is a common ICU procedure than can be associated with complications. The above case reflects one complication that occurs per few thousands [3]. Fortunately, bedside retrieval was possible and further invasive procedures were avoided. The above method represents one possible method for removal of a guidewire that is only superficially buried. Finally, this case demonstrates that a thoughtful approach to procedural complications and use of available resources can avoid more invasive procedures, increased risk of further complications, and increased costs to the patient and healthcare system. Reference #1: Thaut L, Weymouth W, Hunsaker B, Reschke D. Evaluation of Central Venous Access with Accelerated Seldinger Technique Versus Modified Seldinger Technique. J Emerg Med. 2019 Jan;56(1):23-28. doi: 10.1016/j.jemermed.2018.10.021. Epub 2018 Nov 30. PMID: 30503723. Reference #2: Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. Int J Crit Illn Inj Sci. 2015;5(3):170-178. doi:10.4103/2229-5151.164940 Reference #3: Bessoud B, de Baere T, Kuoch V, Desruennes E, Cosset MF, Lassau N, Roche A. Experience at a single institution with endovascular treatment of mechanical complications caused by implanted central venous access devices in pediatric and adult patients. AJR Am J Roentgenol. 2003 Feb;180(2):527-32. doi: 10.2214/ajr.180.2.1800527. PMID: 12540466. DISCLOSURES: No relevant relationships by John Craver Scientific Medical Advisor relationship with Synspira Please note: 3 years Added 03/29/2022 by Bryan Garcia, value=Salary Speaker/Speaker's Bureau relationship with Insmed Please note: 3 years Added 03/29/2022 by Bryan Garcia, value=Honoraria Advisory Committee Member relationship with Zambon Pharmaceuticals Please note: 2 ears Added 03/29/2022 by Bryan Garcia, value=Honoraria No relevant relationships by John Murphy
ABSTRACT
This article traces the development of vaccines from the early attempts to combat a fatal disease caused by variola (smallpox) virus in antiquity, through to the highly technical advances which have led to the efficacious vaccines targeting COVID-19. As vaccine preparation has advanced, so has the understanding of the immune response to immunisation and the realisation that the use of adjuvants is essential to boosting the immune response. Furthermore, coupling polysaccharides to proteins is important in achieving vaccine efficacy in young children and older adults. Successful vaccination programmes have led to marked reductions in mortality associated with the diseases targeted by those vaccines – and to the unintended consequence of cultural amnesia regarding those diseases. The anti-vaccination movement has gained traction by riding on this cultural amnesia to capitalise on spurious associations, infrequent public-health disasters around inadvertent administration of faulty vaccine preparations and rare adverse events to build a case against vaccination. This tension between the advances in vaccine production and the criticism cast at the pro-vaccination agenda should be viewed as an agent for growth in the development of safe and effective vaccines, and in the planning to combat future pandemics.
ABSTRACT
Introduction: Due to the COVID-19 pandemic, and increased use of prone positioning, there has been an increase in observed plexopathies. Objectives: To retrospectively analyse data of all COVID-19 admissions to the ICU of an acute hospital, to identify both the prevalence and risk factors for nerve injuries post prone positioning. As well as reviewing current guidance to facilitate best practice and optimise rehabilitation following nerve injury. Methods: Data from the Norfolk and Norwich University Hospital, a large teaching hospital, was retrospectively collected from the hospitals electronic clinical records system. Data was reviewed for all COVID-19 patients admitted from March-June 2020 and October 2020-March 2021. Patients with nerve injuries were diagnosed from physiotherapy assessment as there were no electrophysiology studies available. Results: 45 patients were admitted during the first wave. Of these, 1 peroneal nerve injury was identified (2.2% of all patients). Throughout the second wave 225 patients were admitted, with 10 isolated nerve injuries identified in 7 patients. These included 6 lower limb injuries (peroneal nerve) and 4 upper limb injuries (brachial plexus or ulnar nerve). This equates to 3.1% of patients. All these patients were nursed prone during their ITU admission, and no nerve injuries were found in patients who were not proned. Characteristics of the patients can be seen in Table 1. In comparison, Miller et al. (2021) found 5.9% of all COVID-19 patients admitted to a large UK hospital suffered an upper limb nerve injury. Malik et al. (2020) found nerve injuries (upper and lower) in 14% of patients. However, both studies took place in rehab settings, not acute. On average, nerve injuries were diagnosed on day 26 of admission. Early diagnosis is difficult due to prolonged sedation, delirium, and ICU-acquired weakness masking nerve injuries. Therefore, it is likely that the incidence of injury is higher than demonstrated in this series. Data was missing for 4 patients who were transferred in from other ICUs in the region. However, number of prone episodes varied from 1 to 6, and total hours spent in prone varied from 15 to 106. Conclusion: This case series demonstrates that nerve injuries are a consequence of prone positioning. Although a very small sample, there seems to be no relation to the frequency of proning or the number of hour's proned. Achieving optimum positioning to avoid complications is imperative. This was likely made more difficult in the pandemic due to the cohort of patients (high BMI, large number of co-morbidities) and undue stress with temporary surge support staff and an extreme number of patients. Guidance has now been published for positioning to avoid brachial plexus injuries (Quick & Brown, 2020). However, there is no guidance published regarding lower limb injuries, which in this case series were more common. In our trust we are in the process of adjusting our proning SOP accordingly to include the above guidelines, as well as an awareness of lower limb positioning to avoid compression or traction. It is important that there is a clear individualised pathway in place.
ABSTRACT
The COVID-19 pandemic has increased the necessity of setting priorities in health and beyond. To set such priorities in health, we need meaningful and consistent health measures. The global burden of disease study plays an important role during the pandemic. Disease burden is largely measured through the lens of disability-adjusted life years (DALYs). Since its conception in the early 1990s, the DALY has gained traction and increased popularity. Several revisions of the value assumptions built into the DALY have followed. Moreover, discussions have been made of the different potential purposes of the DALYs, whether it be monitoring patterns and inequalities in disease burden, aggregating morbidity and mortality, or setting priorities within large health programs. However, much less attention has been on the main assumption of the DALY, that is, that DALYs = YLDs + YLLs. To elaborate, the DALY is the aggregation of years lived with disability (YLDs) and years of life lost (YLLs). However, are YLDs and YLLs entities that can be aggregated? Epicurus famously argued that existence is necessary for anything to matter to you, therefore, death is nothing to you. If Epicurus was right that death (i.e., the incident of death, not the process of dying) is not bad for those who die, then DALY's addition of years lost by death may not give a meaningful result. There are at least three responses to this foundational DALY problem, of which a counterfactual account of harm might be the most viable approach. This counterfactual strategy, however, comes with severe challenges. I argue that Epicurus was correct in claiming that the incident of death is not bad for the dying or the dead. Death, for epicureans, means permanent non-existence, and hence, it remains questionable whether YLD + YLL makes sense.
ABSTRACT
COVID-19 and the resulting lockdowns have forced establishments to rely on food delivery to stay afloat. Food delivery is regarded as a necessary service that is rapidly gaining traction as people become increasingly confined to their homes and order-in. The only relief that the Food industry has received is through delivery operations, as the lockdown has been extended to practically every part of the globe. Food delivery is one of the essential public services that has been allowed to continue. This means that eateries would need to adapt to changing market conditions. Cloud Kitchens are commercial kitchens with no actual dining space that only cater to internet delivery orders. Throughout the restaurant sector, the introduction of no-dine-in restaurant model has grabbed everyone's interest. This one-of-a-kind restaurant concept requires no physical space, no large capital investments, low restaurant rentals, and relies solely on internet delivery orders.