Your browser doesn't support javascript.
Show: 20 | 50 | 100
Results 1 - 20 de 2.359
Filter
Add filters

Year range
1.
Pharmacopsychiatry ; 55(3):172, 2022.
Article in English | EMBASE | ID: covidwho-1967689

ABSTRACT

Introduction Safety studies have shown that COVID-19 vaccinations can provoke inflammatory processes in patients. The subsequent release of cytokines is accompanied by an increased inflammatory marker, C-reactive protein (CRP) [1]. For some antipsychotic drugs, inflammatory processes have been associated with increased drug levels, even above therapeutically approved ranges [2] [3]. It is not clear, whether this holds also true for COVID-19 vaccinations. Methods We present a case series comprising of 10 inpatients at the CIMH treated with an antipsychotic drug. Patients received a first, second or third dose of the COVID-vaccination Comirnaty in the morning. Blood samples were taken directly before the injection and were followed on day 1 and 4 while constant dosing. Blood testing included drug levels, safety laboratory, and CRP. Results CRP levels were elevated in nine patients;four of those also presented an increase in antipsychotic drug levels within a few days after COVID-19 vaccination. Blood level changes were i)+0%,+24%,+125%,+116% in quetiapine-, ii)+0%,+0%,+100% in olanzapine-, iii)+0,+42% in clozapine-treated patients, and iv)+205% in one risperidone-treated patient. As a result, three patients had drug levels above the therapeutically recommended range. Conclusion We present a series of patients with increased antipsychotic drug levels after COVID-19 vaccinations mediated via inflammatory processes. The intensity of inflammatory reactions strongly varies across patients. Hence, COVID-19 vaccinations may constitute an unpredictable risk factor for increased drug levels. Therapeutic drug monitoring can help to prevent safety risks in those patients with supra-therapeutic drug levels.

2.
Laryngo- Rhino- Otologie ; 101:S335, 2022.
Article in English | EMBASE | ID: covidwho-1967686

ABSTRACT

Background Olfactory and gustatory disorders after COVID-19 vaccination have been described in the literature in case reports. These are mainly described after the Comirnaty vaccination. In this case report, the olfactory and gustatory disorders of two patients after Comirnaty vaccination are described. Methods The two affected patients with persistent subjective olfactory and/ or gustatory dysfunction after COVID-19 vaccination were evaluated using olfactory testing with Sniffin Sticks (TDI) and taste testing. Therapy was subsequently initiated and patients were followed up at regular intervals. Results 2 Patients (1 male and 1 female) with an average age of 80 years, who developed olfactory and/or gustatory disorders after the first and second vaccination respectively, were examined and tested. One case exhibited in the subjective and objective tests a functional anosmia (TDI: right 14.3, left 12.8) whilst the second case displayed hyposmia (TDI: right 18.75, left 21.75) and hypogeusia (right 4/16, left 6/16). Antibody testing showed the presence of IgG(S) but no IgG(Nc) was detected. Discussion Olfactory dysfunction in terms of hyp- or anosmia, as well as parosmia, may occur in patients after COVID-19 vaccination without previous COVID- 19-infection and should always be tested objectively. One case even exhibited hypogeusia. Despite laboratory diagnostics, previous COVID-19 infections cannot be ruled out with certainty. Age-related pre-existing disorders cannot be evaluated. Whether the course of olfactory dysfunction is comparable to that of patients after COVID-19 infection needs to be investigated in further studies.

3.
Laryngo- Rhino- Otologie ; 101:S320, 2022.
Article in English | EMBASE | ID: covidwho-1967682

ABSTRACT

Introduction We report on three patients, who presented themselves at our clinic between February and June 2021 with impaired voice, which resulted in an aphonia after having had Covid-19 infection. Material & methods Indirect laryngoscopy and videostroboscopy were performed in all patients. The voice quality was limited in all patients. Voice analysis was performed perceptively (RHB scheme) and objectively by computer-assisted analysis (Göttingen hoarseness diagram, voice field). Self-assessment was performed using the Voice Handicap Index (VHI). Results Laryngoscopically, all patients showed laterally mobile vocal folds, non-irritant mucosal conditions and a wide glottis. All patients showed wide, irregular vibration amplitudes and incomplete glottis closure by videostroboscopy. Objective voice analysis revealed pathological values for the irregularity and noise components as well as the Dysphonia Severity Index (DSI). In the VHI all patients documented a high-grade voice disorder with a mean score > 62. Our patients continued to suffer from dysphonia 6-9 months after initial presentation. Voice therapy did not provide satisfactory voice improvement. Discussion Whether glottic hypofunction is due to sensorimotor dysfunction caused by neurotropic coronavirus remains a conjecture. In addition, the hy-pofunction may be related to the general reduced performance of the patients in post-covid-syndrome. Conclusion According to our literature research, this is the first description of dysphonia as a possible symptom in post-covid-syndrome.

4.
Laryngo- Rhino- Otologie ; 101:S308, 2022.
Article in English | EMBASE | ID: covidwho-1967678

ABSTRACT

Introduction Symptoms and severity of SARS-CoV-2 infection vary greatly. Dizziness is a frequently reported symptom of SARS-CoV-2 viral infection. However, the extent to which this symptom is a result of the effect of SARS-CoV-2 on the vestibular system remains unclear. Material & methods In the present single-centre study, 50 patients with a previous SARS-CoV-2 infection underwent a vestibular assessment consisting of dizziness handicap inventory to assess dizziness during and after infection, clinical examination, video head impulse test and subjective visual vertical test (SVV). When SVV was abnormal, vestibular evoked myogenic potentials were performed. In addition, a retrospective data analysis of patients admitted to hospital presenting with acute symptoms of dizziness who were also diagnosed with acute SARS-CoV-2 infection was performed. Results During and after the SARS-CoV-2 infection, women were significantly more likely to suffer from dizziness than men. A significantly reduced semicircular canal or otolith function was not observed in either women or men. Acute SARS-CoV-2 infection was diagnosed in three patients who presented to with acute vestibular syndrome. One of the patients exhibited acute peripheral unilateral vestibulopathy upon diagnosis. A different patient was diagnosed with vestibular migraine and another with a posterior inferior cerebellar artery infarct. Conclusion Past SARS-CoV-2 infection does not usually lead to a hypofunction of the vestibular organs. However, individual patients with acute infection have been reported to show symptoms of acute vestibular syndrome. Although the underlying pathomechanism has not yet been elucidated, SARS-CoV-2-induced neuropathy or ischemia should be considered in the differential diagnosis.

5.
Laryngo- Rhino- Otologie ; 101:S307, 2022.
Article in English | EMBASE | ID: covidwho-1967677

ABSTRACT

Introduction As part of the immune response to the COVID-19-vaccine a multitude of anti-COVID-antibodies is formed. A part of these antibodies can bind to the body-s own tissue and facilitate autoinflammatory processes. Such autoimmune-inflammatory processes are suspected to be behind various symptoms of the COVID disease and the long-COVID syndrome. So far, numerous reports on neuro-otological symptoms in the context of COVID infection have been published. The present report describes patients who presented in a university ENT outpatient department with vestibulo-cochlear symptoms in connection with a COVID vaccination. Methods All patients who presented with dizziness, tinnitus and hearing impairment for the first time in a direct temporal context (max. 3 days after vaccination) tot he vaccination were examined by an ENT specialist and further examined using subjective and objective audiometry and, depending on the symptoms, using vestibular diagnostics. Results An otitis media was not found in any patient. A cochlear genesis of the vestibulo-cochlear symptoms could be demonstrated in all patients. One patient has isolated symptoms with hearing loss, all others also suffered from tinnitus or dizziness. In all patients, the symptoms resolved after drug therapy was carried out. Discussion Vaccine-associated hearing loss has also been described in the case of influenza vaccination. We were unable to provide direct evidence of the COVID vaccination as the triggering factor for the vestibulo-cochlear symptoms. An association of these symptoms with the vaccination cannot be ruled out though. The most likely mechanism is an immunoglobulin-triggered specific autoimmune response.

6.
Laryngo- Rhino- Otologie ; 101:S198-S199, 2022.
Article in English | EMBASE | ID: covidwho-1967673

ABSTRACT

Objective The objective of this study was to determine if patients with Neurofibromatosis Type 1 (NF1) have an impaired sense of smell or taste. Neurofibromin, the NF1gene protein product is ubiquitous in the body and is especially associated with the development of neurogenetic structures. Lately enlarged olfactory bulbs have been described in patients with NF1. Until now, there is no study to evaluate the sense of smell and taste in patients with NF1. Method This study has been approved by the Hamburg Ethics committee. An evaluation of the sense of smell and taste was undertaken in 26 patients with NF1 using the Burghart Sniffin' Sticks. Three patients were excluded due to a prior infection with the Corona virus. As a control group the same examination was performed in healthy individuals (same sex/ same age as the NF1 patients) by the same examiner. Results Preliminary results show a normal sense of smell in patients with NF1. The morphologic finding of enlarged olfactory bulbs seem to have no functional equivalent. However, 8 out of 23 patients with NF1 had difficulties identifying at least one taste flavor. The data collection of the control group is still ongoing, thus far none of the study participants misidentified a taste flavor. A statistical significance is aimed at by increasing the case numbers.

7.
Laryngo- Rhino- Otologie ; 101:S351-S352, 2022.
Article in English | EMBASE | ID: covidwho-1967657

ABSTRACT

Introduction Telemedicine can reduce poor health care access and improve the diagnosis and treatment of rare diseases. COVID-19 has also helped telemedicine to become more widely used in Germany. Since April 2020, the Facial Nerve Center Jena also offers virtual consultation hours. Material and Methods We analyzed in retrospect all initial encounters of patients with the Facial Nerve Center Jena between April 2020 and October 2021. 33 patients (20 f, 13 m) aged 9 to 69 years (median: 42) were treated. Results In 28 of 33 cases, a diagnosis of facial palsy was made at initial presentation (duration of paresis: 1 - 512 months, median: 11.5 months), 20 of which showed defect healing and synkinesis. In 4 cases, there was no evidence of facial palsy and further diagnostics were recommended. In one patient, a definite diagnosis could not be made due to technical problems with video transmission. Psychoeducation was given to 28 patients. 20 patients were counseled about a possible injection of botulinum toxin to reduce synkinesis. In 10 cases, we gave recommendation and instruction on corneal protection. Day-care treatment was indicated in 16 patients, and telemedicine biofeedback training was indicated in 8. Travel distances would have ranged from 40 to 1570 km (median: 360 km). Discussion Telemedicine is well suited for diagnosis and therapy of facial nerve palsies and subsequent defect healing, in part, because webcams are optimized to display faces. We see potential in video consultations to provide highly specialized care nationwide, to minimize travel distances, and to simplify second opinion consultations.

8.
Laryngo- Rhino- Otologie ; 101:S180, 2022.
Article in English | EMBASE | ID: covidwho-1967655

ABSTRACT

Introduction The use of biologics has been described as an effective therapy in phase 3 studies in severe CRSwNP. Relatively unexplored is the post-covid syndrome in CRSwNP patients. Method Case presentation. Results Presentation of a 75-year-old patient with CRSwNP, asthma, ASA intolerance and eosinophilic granulomatosis with polyangiitis. Drug therapy with daily 1-5 mg prednisolone oral and inhalation therapy with formoterol/ beclomethasone. In February 2021, the patient was diagnosed with SARS-CoV-2 infection. For four days, the patient was admitted to a hospital with pronounced physical weakness without respiratory insufficiency. Anosmia has long been known because of CRSwNP. After Covid-19 illness, the patient reported severe sleep impairment and a severe state of exhaustion compatible with a post-covid syndrome. In addition, the patient was impaired by a severe nasal obstruction. At presentation in the rhinological consultation 7 months after Covid-19 illness, severe nasal polyps (NP overall score 8) and anosmia were detected. Dupilumab therapy (anti IL-4/IL-13 antibody) was initiated for severe CRSwNP. In the course of 2 months, an improved quality of life with less nasal obstruction as well as a reduced NP overall score of 6 were shown. Furthermore, the sleep impairment and exhaustion of the patient did not improve. Conclusion Dupilumab therapy improves quality of life in patients with severe CRSwNP, which may be especially important in post-covid syndrome.

9.
Radiotherapy and Oncology ; 170:S866-S867, 2022.
Article in English | EMBASE | ID: covidwho-1967467

ABSTRACT

Purpose or Objective The Canadian Medical Association recently acknowledged that physician health remains a significant threat to the viability of Canada’s health care system. A 2014 survey reported a 44% prevalence of burnout among American oncologists. The purpose of this survey was to determine the national prevalence of burnout and document work engagement among Canadian radiation oncologists. Materials and Methods Between November 2019 and March 2020 (pre COVID pandemic), online questionnaire was distributed electronically to 333 Canadian radiation oncologists, across 49 centers, through the National Canadian Association of Radiation Oncology office mailing list. The survey included 62 questions determining job engagement, and validated burnout scale The Maslach Burnout Inventory (MBI) (22 questions). Results 241 of the 333 surveyed Canadian radiation oncologists (72%) completed the questionnaire and were included in this analysis. Responses to the MBI showed that 15% of radiation oncologist met the strict criteria for burnout (i.e. negative scores in all 3 domains: exhaustion, depersonalization, and low accomplishment). Another 60% scored negative in at least one of the three burnout domains. Using the more commonly reported definition of burnout (negative scores in either exhaustion and/or depersonalization), 44% of Canadian radiation oncologist were burnt out. Only 25% had positive scores in all 3 domains and were fully engaged in their work. The full burnout syndrome varies with the provinces and was the highest in British Columbia (22% ) and lowest in Quebec (3%). The responses to work engagement questions revealed a significant concerns regarding inefficiency in work flow (50%), heavy workloads (>50%), a poor work life balance (68%), lack of control over the work environment (47%) and lack of recognition from administrators (45%). 48% perceive the atmosphere at their primary work area as “chaotic and hectic”. Within the last 3 years, 41% had considered leaving their institution to work elsewhere and 51% were considering reducing their full-time equivalent (FTE). Reassuringly, 80% reported a sense of overall ability to provide high quality care and a 59% feel they have a supportive network of colleagues, 80% are willing to try something new. The top 4 strategies identified by respondants aimed to improve worklife quality were (1) more support staff at work, (2) more efficient care models, (3) more resources for patients, and (4) lighter workloads for physicians. Conclusion The survey shows that only 25% of the Canadian radiation oncologist is fully engaged in their work, 15 % meet the strict criteria for burnout and 44% meet the more commonly used burnout criteria. With the rising incidence of cancer and complexity of care, there is an urgent need for change, leverage the enthusiasm to “try something new”, and develop appropriate strategies to improve the wellbeing of the oncology work force.

10.
Radiotherapy and Oncology ; 170:S120-S121, 2022.
Article in English | EMBASE | ID: covidwho-1967460

ABSTRACT

Purpose or Objective The role of perioperative treatment in radiation-induced and in-field recurrent sarcomas (RIS/IFRS) is unknown. Reirradiation may be associated with a risk of significant toxicity;thus, it is rarely used. We hypothesized that the combination of preoperative or definitive 12x 3 Gy radiotherapy (RT) with or without integrated 3.5 Gy to 42 Gy boost combined with regional hyperthermia twice a week will enable satisfactory local control without significant late toxicity in patients with RIS/IFRS. Materials and Methods A prospective phase II, single-arm clinical trial was conducted. We included patients with locally advanced RIS/IFRS without distant metastases. Treatment combined three weeks of radiotherapy, four fractions per week, 3 or 3.5 Gy per fraction, with regional hyperthermia, followed by surgery or observation. The choice of the boost or no-boost regimen was based on resectability (Figure 1). The intervention would be deemed tolerable if significant RT-related (grade 3+ CTCAE 5.0) late adverse events occur in less than 20% of patients. We planned to enroll 20 patients based on Wilson’s method for calculation of confidence intervals. (Figure Presented) Results We recruited 20 patients. All patients completed the treatment without interruptions. Eight of them had RIS whereas twenty were diagnosed with IFRS. Patients’ characteristics were provided in Table 1. Twelve patients from planned 15 underwent surgery. Two patients with potentially resectable tumors did not undergo surgery due to COVID-related reasons. One patient preferred not to undergo surgery after the preoperative no-boost regimen. The remaining five patients were deemed unresectable at the enrollment and received the simultaneous boost. In five patients who underwent resection, we observed extensive pathological response according to the European Organization for Research and Treatment of Cancer-Soft Tissue and Bone Sarcoma Group recommendations for pathological examination and reporting, namely grade A in two cases and grade C in three cases. In four patients we observed complete radiological response. The median follow-up was 13 months. In 14 patients we noted mild or moderate radiation dermatitis. One patient experienced grade 2 gastrointestinal toxicities. From the late toxicities, we observed restricted limb mobility (grade 1) in one patient and chronic skin ulceration (grade 2) in one patient. None of the patients who developed grade 3 or higher late toxicity. Two patients who received the no-boost regimen and did not undergo resection developed local progression. One patient experienced borderline local relapse after surgery. None of the patients who received the boost regimen developed local progression. Three patients developed distant metastases. One patient was lost to follow-up. (Figure Presented) Conclusion Preliminary data suggest that the tolerance of the regimen is acceptable;however, data regarding late toxicity may change during the follow-up period. Boost may play a significant role in achieving local control in non-resected tumors.

11.
Gastroenterology ; 162(7):S-1376-S-1377, 2022.
Article in English | EMBASE | ID: covidwho-1967452

ABSTRACT

BACKGROUND: Gastrointestinal (GI) manifestations are the most frequently reported extrapulmonary symptoms of COVID-19 infection with a prevalence of 10%-50%. Most common ones are nausea, vomiting, diarrhea and abdominal pain. GI perforation especially spontaneous colonic perforations are rare in the disease course. METHODS: We report the case of a patient with COVID-19 infection, who developed cecal perforation while recovering from COVID pneumonia, necessitating emergent surgical treatment, and the current literature was reviewed. CASE PRESENTATION: 65-year-old male presented to the hospital with shortness of breath, myalgias and fever. He was admitted to ICU secondary to acute hypoxemic respiratory failure due to COVID 19 pneumonia. He was treated with steroids, tocilizumab and remdesivir. On day-11, he developed severe abdominal pain with worsening leukocytosis. His CXR showed air under diaphragm and abdominal CT showed large pneumoperitoneum, suggestive of a perforated viscus. He underwent emergent laparotomy and was found to have non-obstructive cecal perforation. A colonic de-tension and right colectomy with ileotransverse anastomosis was performed and he was successfully discharged later. The tissue pathology showed distended colon, active colitis, transmural granulocytic inflammation, micro-abscesses, and ulceration suggestive of bowel perforation. DISCUSSIONS: ACE2 protein, a cell receptor for SARS-CoV-2, has been found in glandular cells of gastrointestinal epithelia. Direct viral infection, small vessel thrombosis, or nonocclusive mesenteric ischemia are some possible explanations for the spectrum of bowel findings. SARS-CoV-2 can have direct inflammatory effect on vascular endothelium too. Use of steroids, tocilizumab and systemic coagulopathy seen in severe COVID-19 infection also contributes to these manifestations. In our patient, an acute over-distension of colon, without mechanical distal obstruction, in the setting of COVID-19 infection & tocilizumab led to cecal perforation. Our literature review confirmed only 33 case-reports or series of bowel perforation (either as presenting symptom or during hospital course) in the setting of COVID-19 infection have been reported, with combined 28.5% mortality rate and 5 studies not reporting the outcome. Considering the worldwide incidence of this pandemic, it is a rare complication. CONCLUSIONS: GI perforation is a rare but dangerous complication of COVID19. Treatment with interleukin- 6 inhibitors or steroids is often associated in most cases. As we are gaining more knowledge about clinical spectrum of this novel disease, we are learning more about its possible rare expression, associations, and complications. Our case underlines the need to be vigilant for severe GI symptoms in setting of COVID-19 infection to enrich our understanding of this pandemic and as a result improve patients' outcome. (Figure Presented)

12.
Gastroenterology ; 162(7):S-1112, 2022.
Article in English | EMBASE | ID: covidwho-1967410

ABSTRACT

Background: Vedolizumab (VDZ) is effective in inducing and maintaining remission in patients with Inflammatory bowel disease (IBD), but limited data exists in the youngest patients diagnosed <6, known as very early onset (VEO)-IBD. We aimed to evaluate the efficacy and safety of VDZ in this cohort. Methods: This was a retrospective study of patients with VEO-IBD followed at the Children's Hospital of Philadelphia, treated with VDZ for >6 months. Data collected included demographics, disease characteristics, medications, hospitalizations, growth, surgeries, and labs. Disease activity was measured using the Pediatric Ulcerative Colitis Activity Index (PUCAI) and Pediatric Crohn Disease Activity Index (PCDAI) at baseline and 6 months. Primary outcome was clinical response defined as a decrease in PUCAI>20 or PCDAI>15 at 6 months. Secondary outcomes included improvement in growth, labs, steroid use and hospitalizations. Continuous variables were analyzed using the Friedman test followed by the Wilcoxon signed-rank test. Nominal data was analyzed using McNemar's test. Results: Thirty-three children with VEO-IBD, 66% male, treated with VDZ were included. Median age of diagnosis was 3.7 years (range 1.2-6 years), with a median baseline disease duration of 3 years (range 0.1-18.5 years). IBDU was classified in 61%, and CD in 39%. Disease location was 70% colonic, 27% ileocolonic and 3% small bowel. Seven patients had prior surgeries, including diverting ileostomies (n=6) and subtotal colectomy (n=1). Nineteen (58%) patients were biologic naïve. VDZ was used as combination therapy in 6 (18%) patients (methotrexate n=4, rapamycin n=1, tacrolimus n=1). Bridge therapy was initiated in 78% of patients, with steroids (n=8) and antibiotics (n=18). Clinical response at 6 months was achieved in 19 patients (58%) with improvement in median PUCAI from 25 to 5 (p<0.01) and median PCDAI from 18.75 to 5 (p<0.05). BMI for age Z-score improved from -0.325 to 0.65 (p<0.001). Steroids and antibiotics were tapered off in 6/8 (75%) and 14/18 (78%, p<0.001) respectively. Hospital length of stay decreased significantly during the 12 months after initiating VDZ compared to 3 months prior to initiation (p<0.05). 2 patients underwent surgery including a subtotal colectomy for colonic stricture and diverting ileostomy within 2 months of starting VDZ. Adverse effects included COVID-19 infection (n=2), influenza (n=2), upper respiratory infection (n=2), pneumonia (n=1), tracheitis (n= 1), cellulitis (n=1), molluscum (n=1), and pityriasis rosea (n=1). Conclusion: VDZ is effective at inducing clinical remission in a subset of children with VEO-IBD primarily with colonic disease. It has a favorable safety profile with minimal reported adverse events observed in this study. This study is limited by small sample size and retrospective design. Larger prospective studies are warranted.

13.
Gastroenterology ; 162(7):S-854, 2022.
Article in English | EMBASE | ID: covidwho-1967377

ABSTRACT

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.

14.
Gastroenterology ; 162(7):S-846, 2022.
Article in English | EMBASE | ID: covidwho-1967375

ABSTRACT

The incidence of Eosinophilic Oesophagitis (EoE) is increasing worldwide in the paediatric population. Management of these children is complex, and includes elimination diet (2/4/ 6 food), steroids etc. It is recommendedto perform endoscopies between each reintroduction to assessdisease activity. In our centre dietary exclusion is the standard practice. Since 2019 we follow a step-up approach with regards to elimination diet starting with 2 food exclusion diet (FED) and building up as required. Food is reintroduced gradually with significant dietetic support and proactive monitoring including endoscopy. Objectives: We looked at the outcomes of children with EoE referred to Maidstone and Tunbridge Wells NHS Trust from Kent and East Sussex. Methods: Retrospective review of case notes of paediatric patients diagnosed with EoE between January 2015 and December 2020. Data collected included symptoms, endoscopy findings and histology at diagnosis and compared the same after dietary intervention. Results 21 patients were diagnosed with EoE between January 2015 and December 2020 between 5-16 yrs Median age at diagnosis 11years. Frequently seen in boys (65%). Dysphagiawas the predominant symptom (76%) followed by vomiting (60%), abdominal pain (50%), and choking (20%). Features of EoE were seen during endoscopy in 71% and oesophagus looked endoscopically normal in 29% of patients. Diagnosis was made on eosinophil count as per ESPGHAN guidance. The frequency and timing of repeat endoscopies following dietary intervention varied due to a multitude of factors including COVID-19 restrictions (between 4-9 months median 4 months). Histological remission (Eosinophils <15 pHPF) was achieved in 15/21 (70%) of patients. 7/10 children on 2FED, 3/3 patients on 4FED and 5/5 children on 6FEDachieved histological resolution. The 6FED group took significantly longer to identify the causative food, establish long term dietary management and required more endoscopies. Food was reintroduced gradually on an individual basis with the aim of introducing back all food groups. 13/15 continue to be on milk free diet, 5/15 remain on milk and wheat free diet, 1/15 on soya and egg free diet and the other patient remains on 4FED (parental choice). 2 patients have started steroids due to on-going symptoms findings on surveillance endoscopy and histological following reintroduction. Summary and Conclusion Dysphagia was the predominant symptom in our cohort of patients. Furrowing and oedema was the major finding duringendoscopy. With dietary exclusion endoscopic resolution was seen in 62% and histological resolution seen in 70% of patients at first surveillance endoscopy. Re-introduction continues to remains a major challenge and we have not been able to introduce all the food groups in any of our patients due to either symptoms or recurrence on endoscopy/histology.

15.
Gastroenterology ; 162(7):S-752, 2022.
Article in English | EMBASE | ID: covidwho-1967368

ABSTRACT

Epstein-Barr virus (EBV) hepatitis is well established, and most cases involves asymptomatic liver enzyme abnormalities. Albeit rare, viruses such as EBV have been reported to induce generalized pustular psoriasis (GPP);and exanthems such as GPP have been associated with acute hepatitis. This case describes a unique case of cholestatic hepatitis due to EBV, followed by a diffuse pustular rash suggestive of GPP. After complete resolution of the cholestatic hepatitis, the patient returned over a year later with concurrent hepatitis and diffuse pustular rash. Case: An obese 26 year-old African-American female presented to the hospital on three separate occasions over a 15 month span with slightly varying symptoms. At the index hospitalization she presented with fatigue and jaundice. Liver chemistries revlead a mixed pattern liver injury, see Table 1. Extensive serological evaluation was unremarkable, though antinuclear antibody and anti-smooth muscle antibody were mildly and non-specifically elevated, but IgG was normal. A liver biopsy was performed revealing portal and lobular inflammation with predominantly lymphocytic moderate micro-vesicular steatosis (Figure 1). EBV PCR returned positive at 20,737 IU/mL yielding a diagnoses of EBV-induced hepatitis. She returned to the hospital one week later due to a diffuse pruritic and painful rash. She had scleral icterus and diffuse erythematous plaques with tiny pustules dispersed over the body sparing the palms, soles, and mucosal surfaces. Laboratory values were overall improved as noted in Table 1. Punch biopsy of the right arm was suggestive of EBV induced GPP. She rapidly stabilized and was discharged the following day with triamcinolone 0.1% ointment. The patient had an uneventful convalescence and liver chemistries returned to normal. Approximately 15 months after her initial hospitalization, she presented with both recurrent hepatitis and a pustular, pruritic, erythematous rash with perioral and periorbital swelling. She denied taking any new medications or supplements. Labs revealed recurrent, though now primarily cholestatic liver injury, see Table 1. Results of a repeat thorough serological evaluation were negative, including for EBV-PCR and COVID-19. Abdominal ultrasound revealed a 16 cm hepatic length. Pustules, spongiosis, and edema were found on repeat skin biopsy, suggestive of GPP. She recovered quickly with systemic steroids. Awareness of GPP induced hepatitis can guide a judicious assessment of abnormal liver chemistries. Furthermore, unnecessary healthcare utilization can be avoided by providing appropriate and timely pharmacotherapy (i.e., corticosteroid taper) for on demand flares. (Figure Presented) (Table Presented) (Figure Presented)

16.
Gastroenterology ; 162(7):S-277-S-278, 2022.
Article in English | EMBASE | ID: covidwho-1967263

ABSTRACT

Background: Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the gastrointestinal tract characterized by immune dysregulation and decreased T cell receptor (TCR) repertoire diversity. Patients with immune-mediated disorders such as IBD have attenuated convalescent antibody responses after COVID-19 infection. We sought to understand the immune configuration associated with high versus low convalescent SARS-CoV- 2 antibodies in patients with IBD using single-cell immunophenotyping. Methods: We performed a study of 9 patients with IBD who were SARS-CoV-2 convalescent (recovered from COVID-19 and converted RNA positive to negative) and 9 matched SARS-CoV-2 naïve controls (no prior COVID-19, confirmed RNA negative). We measured plasma SARS-CoV- 2 antibody (N protein IgG, S1RBD IgG, S1RBD IgA) levels from patients with IBD two months after recovering from COVID-19 (RNA negative). We selected three patients with the highest SARS-CoV-2 antibodies and three matched (for age, sex, IBD subtype and disease activity, medications, COVID-19 severity) patients with the lowest antibodies and performed their peripheral blood mononuclear cell (PBMC) single-cell transcriptomics with paired TCR and BCR sequencing using 10X Genomics. Normalization, dimensionality reduction, and clustering were performed using Seurat. TCR and BCR immune repertoire analyses were performed using Immunarch. Results: SARS-CoV-2 convalescent patients with IBD had detectable but variable SARS-CoV-2 antibody levels (range 0-469 U/mL), whereas SARSCoV- 2 naïve IBD patients had no detectable antibodies. The mean SARS-CoV-2 antibody concentration among the three IBD patients with the highest and three patients with the lowest groups differed by more than 10-fold (206.0 vs 17.5 U/mL, P<0.001). PBMC singlecell immunophenotyping revealed decreased naïve CD4+ T cell and increased CD14+ monocyte and memory CD4+ T cell proportions in IBD patients in the low versus high SARSCoV- 2 antibody group. There were higher numbers of HLA-DQA1+ B cells and CD8 T cells and lower GPR183+ B cells and CD8 T cells in the high SARS-CoV-2 antibody group. There was a trend towards decreased TCR and BCR repertoire diversity in the low SARS-COV-2 antibody group. Finally, we identified immunoglobulin gene signatures (IGHV1-69D/IGLV3- 25, IGHV3-48, IGHV3-7/IGKV41/IGLV1-47, IGHV3-7/IGKV4-1, IGHV3-7/IGKV4-44) that were enriched only in the high SARS-CoV-2 antibody group. Conclusions: Single-cell immunophenotyping of PBMC from convalescent patients with IBD reveal differences in CD4+ T cell, CD14+ monocyte, and HLA-DQA1+ and GPR183+ B and CD8 T cell immunophenotypes, immune repertoire diversity, and immunoglobulin gene signatures in patients with high versus low SARS-CoV-2 antibody levels.(Figure Presented)Figure 1. SARS-COV-2 Antibodies in Convalescent Patients with IBD and Single-Cell Immunophenotypes. A) SARS-COV-2 antibody levels in COVID-19 convalescent versus SARS-CoV-2 naïve patients with IBD B) T-SNE plot of PBMC immunophenotypes in all convalescent patients with IBD C) Differences in proportion of single-cell PBMC immunophenotypes in high versus low SARS-COV-2 antibody patients D) Differences in HLA-DQA1 and GPR183 immunophenotypes in high versus low SARS-COV-2 antibody patients.

17.
Sleep Medicine ; 100:S104-S105, 2022.
Article in English | EMBASE | ID: covidwho-1967122

ABSTRACT

Introduction: The hypothalamus plays a crucial role in regulating vital functions and circadian rhythms. Both the tumor involving the hypothalamic area and its treatment can lead to hypothalamic dysfunction, resulting in disturbances in sleep-wake patterns, sleep fragmentation, and increased daytime sleepiness. We describe two patients with craniopharyngioma who came to our attention due to the occurrence of episodes characterized by psychomotor slowing and afinalistic limb movements, temporal and spatial disorientation, psychomotor agitation, and oneiric stupor like episodes diagnosed as severe sleep disturbances. Case reports: Patient 1 is a 19-year-old male diagnosed with surgically treated craniopharyngioma. Subsequently, episodes of psychomotor slowing, afinalistic movements of the upper limbs diagnosed as seizures in another neurological center appeared;antiepileptic treatment was started without improvement. At the first examination in our center, excessive daytime sleepiness (EDS), fragmented nighttime sleep, episodes characterized by bimanual automatic gestures occurring during drowsy state, hypnagogic hallucinations, and sudden loss of muscle tone while awake were recognized. Actigraphy demonstrated irregular bedtimes, frequent nocturnal activity, and inappropriate daytime rest episodes. The Epworth Sleepiness Scale (ESS) showed subjective EDS (ESS=19). At PSG, hypersomnolence, severe sleep-related breathing disorder (SRBD), and no interictal and ictal seizure abnormalities were found. A BiPAP NIV was started, and antiepileptic therapy was discontinued. In the following months, PSG revealed marked improvement in SRBD and 1 SOREMP, and the MSLT a mean SOL of 6 min and 10 sec and 3 SOREMPs. These data allowed the diagnosis of secondary narcolepsy, and treatment with pitolisant was initiated with clinical improvement and reduced daytime sleepiness (ESS=9). Patient 2 is a 12-year-old male, surgically treated for craniopharyngioma at the age of 4 years, who developed episodes of myoclonic jerks, temporal and spatial disorientation, and psychomotor agitation during the lockdown period for COVID-19 emergency. Surmising paroxysmal epileptic episodes, the patient was hospitalized. The anamnestic data collection revealed a sleep-wake rhythm dysregulation, fragmented nighttime sleep, EDS, oneiric stupor-like episodes during which the patient performed simple automatic gestures mimicking daily-life activity, and severe impairment of alertness. The Long-term video-EEG, including polygraphic measurements, showed destruction of the wake-NREM sleep-REM sleep boundaries, episodes of undetermined state of vigilance, and concurrence of elements typical of different sleep stages. Moreover, a severe SRBD (AHI 19/h) has been observed. The MRI showed a volumetric increase in the post-surgical interpeduncular fossa and right paramedian cysts. Therefore, a multifactorial therapeutic plan including sleep hygiene and slow-release melatonin was started with improvement in nighttime sleep, but EDS persisted. Surgical treatment of cyst fenestration improved sleep-wake rhythm and behavior;BiPAP NIV was initiated with very poor adherence. Discussion: We aim to focus on sleep disorders as a possible complication of tumors involving the hypothalamic region. Our cases highlight that the clinical manifestation of these dysfunctions can be challenging to diagnose and can lead to misdiagnosis and inappropriate treatment that can harm patients' health and the quality of life of patients and their families. Conclusion: These findings support the need to incorporate comprehensive sleep assessment in survivors from childhood brain tumors involving the suprasellar/hypothalamic region.

18.
Journal of the Academy of Consultation-Liaison Psychiatry ; 63:S85, 2022.
Article in English | EMBASE | ID: covidwho-1966675

ABSTRACT

Background: There is a relative paucity of data on the telehealth experience of health care providers. The present study helps to address this gap by examining the telehealth experiences of mental health providers. Methods: An IRB-approved anonymous survey (31 questions) was circulated in the state of Maryland at the Kennedy Krieger Institute, the Division of Child Psychiatry at Johns Hopkins University and at the University of Maryland, several community mental health practices, and professional organizations. Mental health professionals (physicians, psychologists, licensed social workers, nursing providers), and trainees (medical residents, post-doctoral fellows, and social work trainees) were eligible to participate in the survey. The survey focused on three key domains: patient care, work-life balance, and personal life. 175 providers participated in this survey Results: 75% of the respondents were female. 30% of respondents had been in practice for more than 20 years. 10% were trainees. The majority of respondents reported an overall positive impact of telehealth on their clinical practice. The comfort level with telehealth was high across the board. The impact on work-life balance and personal lives of practitioners was mixed with the highest negative impact (90%)reported by early-career practitioners. The majority of respondents reported a negative impact on education of trainees. Discussion: Several mental health disciplines were represented in the survey. Providers were comfortable with using technology and found benefits for patient care. Managing individual work schedules and maintaining the therapeutic relationship with patients seemed to be the areas of concern, especially for early-career providers. This may be due to relatively less control over their schedules and the presence of other competing responsibilities. Conclusion: The COVID-19 pandemic accelerated the establishment of telehealth services. The overall impact seems to be positive especially in the mental health field. In our attempt to understand the impact of this transition on the mental health providers, we found that there are specific trends for the degree of impact based on the duration of practice and field of practice of the providers. This information may help inform future clinical practices and policies, as telehealth will likely continue to be an integral part of medical care beyond the COVID-19 pandemic. References: 1. -19 and tele Health, education and research adaptations Wijesooriya NR, Mishra V, Brand PLP, Rubin BK. COVID-19 and telehealth, education, and research adaptations. Paediatr Respir Rev. 2020;35:38-42. doi:10.1016/j.prrv.2020.06.009 2. Donelan K, Barreto EA, Sossong S, Michael C, Estrada JJ, Cohen AB, Wozniak J, Schwamm LH. Patient and clinician experiences with telehealth for patient follow-up care. Am J Manag Care. 2019 Jan;25(1):40-44. PMID: 30667610.

19.
Journal of the Academy of Consultation-Liaison Psychiatry ; 63:S52, 2022.
Article in English | EMBASE | ID: covidwho-1966667

ABSTRACT

Introduction: Kratom (mitragynine speciosa) is a tree native to Southeast Asia that has both opioid, stimulant, and other unknown properties. It is currently legal in the United States and used for therapeutic and recreational purposes. There is a dearth of literature on kratom’s effects on the body. At least half of reported kratom exposures resulted in a serious medical outcome, including death (1). In contrast, there are no controlled clinical trials on safety and efficacy of kratom as a treatment (2). Case: A 32-year-old Caucasian, currently unemployed, unmarried, mother of two children presented intubated to the MICU from an outside hospital with acute fulminant hepatic failure in the setting of significant kratom use. The patient also presented febrile with intracranial hemorrhage, cerebral edema, GI bleeding, acute renal failure, and diffuse intravascular coagulation. Psychiatry was consulted for potential liver transplant candidacy. Her previous history included six years of opioid use and transition to kratom 1-2 years prior to admission, with recent ingestion up to twenty-five times the patient’s usual amount (up to 125mg). Pertinent positive labs included elevated troponin (0.4), transaminitis ( >11,000), elevated PT/PTT (99/52), D-dimer ( >20), hematuria, pyuria, serum ferritin, prolonged QTc (514), and hypoglycemia. Pertinent negatives included unrevealing serum ethanol, phosphatidylethanol, viral hepatitis, HIV, COVID-19, EBV, CMV, other viral panels, acetaminophen level, toxicology screen, and EEG. Imaging revealed interstitial pulmonary edema and diffuse cerebral edema. Given lack of published information on kratom, the team emergently listed the patient for liver transplant despite significant concern for kratom use disorder. Over the course of three days, the patient’s mental status and labs continued to worsen, ultimately resulting in death. Interventions pursued included dialysis, mechanical ventilation, intracranial pressure monitoring with pressure optimization, anticonvulsant therapy, antibiotic therapy, N-acetylcysteine, and other routine MICU care. Due to relatively unremarkable health before ingestion, lack of other significant events, and severe rapid decline, multidisciplinary team consensus cause of death was due to kratom ingestion causing “acute liver failure with hepatic coma”. Discussion: This case report will go into further detail on kratom by analyzing kratom’s mechanism of action, therapeutic use, known side effects including addictive potential, effects on the liver including acute fulminant injury, and current laws and regulations surrounding kratom in the United States with relevance to public health. This is relevant to psychiatrists in the general consult, transplant, and addictions services. References: 1. Post S, Spiller HA, Chounthirath T, Smith GA. Kratom exposures reported to United States poison control centers: 2011–2017. Clinical Toxicology. 2019 57:10,847-854. DOI:10.1080/15563650.2019.1569236 2. Prozialeck W. Update on the Pharmacology and Legal Status of Kratom. J of the AOA. 2016, 116, 802-809. DOI: https://doi.org/10.7556/jaoa.2016.156

20.
Journal of the Academy of Consultation-Liaison Psychiatry ; 63:S51, 2022.
Article in English | EMBASE | ID: covidwho-1966666

ABSTRACT

Background: The neurobiology of depression can be heterogeneous with multiple hypotheses proposed, including serotonin and neuroinflammatory pathways, each falling short of explaining the complete picture. Several reports describe the increased frequency of depression in the community following the COVID-19 pandemic and reports about neuropsychiatric sequela of the virus are emerging and the possible role of neuroinflammation. We present a patient who developed severe depression with psychotic features subsequent to his COVID-19 infection and was treated successfully with ECT following several failed medication trials. Case: A 49-year-old male with a past medical history of type II diabetes, hyperlipidemia, hypertension, chronic kidney disease, and gastroesophageal reflux disease was diagnosed with COVID-19 in January 2021. Upon initial diagnosis, neither admission nor treatment with steroids was required. He presented to the emergency department four days later with sepsis, pneumonia, and AKI secondary to COVID-19 along with the new onset of suicidal ideations with plans to cut himself and significant psychomotor features despite no previous history of mental illness or treatment. His EEG showed diffuse slow waves, consistent with encephalopathy, but no delirium was noted. He exhibited irritability, anger, anhedonia, negativism, and isolated himself in his room. He demonstrated delusional fear about his apartment exploding due to electricity disconnected for not paying his bills. He misinterpreted the blood draws as someone suspecting he has HIV. Treatment started on the medical floor and he was later transferred to the psychiatric floor. Several psychotropic medications were tried separately including citalopram 20mg, escitalopram 20mg, and bupropion (titrated to 300mg) with the addition of aripiprazole 5 mg without improvement. ECT was considered and his depression and psychosis improved following 6 treatments of bilateral ECT. He was discharged following completion of 10 ECT treatments on 300 mg of bupropion daily and 5mg olanzapine at night. Discussion: Viral infections such as HIV, Hepatitis C, and Influenza are associated with neuropsychiatric sequelae, including depression. COVID-19 infection is occasionally associated with ‘cytokine storm’ which may exacerbate neuroinflammation via increases in cytokines and possible activation of mast cells and microglia.[1] The role of elevated pro-inflammatory cytokines and glucocorticoid receptor resistance is widely studied. Interleukin-6 and CRP are the most strongly linked to depression with a high correlation for anhedonia and psychomotor retardation, prominent features of depression in our case, hinting at a possible role of neuroinflammation. [2] Psychotic features and psychomotor retardation are predictors of ECT response which matched the response to ECT in this case. References: 1. Kempuraj, Duraisamy, et al. COVID-19, mast cells, cytokine storm, psychological stress, and neuroinflammation. The Neuroscientist 2020: 402-414. 2. Tiemeier, Henning, et al. Inflammatory proteins and depression in the elderly. Epidemiology 2003: 103-107.

SELECTION OF CITATIONS
SEARCH DETAIL