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1.
British Journal of Dermatology ; 186(6):e254-e255, 2022.
Article in English | EMBASE | ID: covidwho-1956709

ABSTRACT

We present the case of a 68-year-old woman who presented with a blistering skin eruption 5 days after the administration of the first dose of Pfizer-BioNTech mRNA COVID-19 vaccine. Examination revealed tense bullae in a localized distribution confined to the dorsal aspect of her hands, forearms and ears only. This was preceded by severe pruritus. She had no mucosal involvement and was otherwise systemically well. She had a background of chronic obstructive pulmonary disease and hypercholesterolaemia with no previous history of COVID-19. Skin biopsy revealed a subepidermal bulla containing numerous eosinophils in keeping with bullous pemphigoid (BP). The diagnosis was confirmed with a positive direct immunofluorescence (IF) which showed linear IgG and C3 deposition at the basement membrane zone. Indirect IF was positive for anti-BP180 and anti-BP230. The patient was treated with oral prednisolone and doxycycline to good effect She proceeded to have the second dose of the Pfizer-BioNTech vaccine while on treatment and did not experience a flare of BP. However, a week later, she developed erythematous annular plaques with milia over the dorsi of her hands. Skin biopsy revealed multiple milia within the papillary dermis in keeping with milia en plaque. To to our knowledge, this is the first case of a patient developing BP with subsequent milia en plaque following the Pfizer-BioNTech mRNA COVID-19 vaccine (Damiani G, Pacifico A, Pelloni F, Iorizzo M. The first dose of COVID-19 vaccine may trigger pemphigus and bullous pemphigoid flares: is the second dose therefore contraindicated? J Eur Acad Dermatol Venereol 2021;35: e645-7). She has since been weaned off systemic treatment for BP;however, she continues to require ongoing input for the management of milia en plaque.

2.
Clinical Advances in Hematology and Oncology ; 19(4):17-18, 2021.
Article in English | EMBASE | ID: covidwho-1955684

ABSTRACT

Association of the Clinical Cell-Cycle Risk Score With Metastasis After Radiation Therapy and Identification of Men With Prostate Cancer Who Can Forgo Combined Androgen Deprivation Therapy Tward and colleagues examined the ability to identify individuals with localized prostate cancer with such a low risk for metastasis following dose-escalated radiation therapy that there is no benefit to adding ADT ( 195). A combined clinical cell-cycle risk score (CCR) combines the cell cycle progression score (CCP) with the UCSF Cancer of the Prostate Risk Assessment score (CAPRA). The CCR was found to be a significant predictor of metastasis (HR, 2.21;95% CI, 1.70-2.87;P=5.6×10–9). The CCR score continued to be highly predictive for metastasis in bivariate analyses when comparing ADT use vs none (HR, 2.19;95% CI, 1.68-2.84;P=1.0 × 10–8) or ADT duration as a continuous variable (HR, 2.11;95% CI, 1.59-2.79;P=3.0×10–7). Patients with CCR scores below the identified threshold of 2.112 had less than a 5% risk for 10-year metastasis regardless of ADT use (overall, sufficient ADT, radiation therapy with any duration of ADT, or radiation therapy alone with no ADT) or National Comprehensive Cancer Network risk group (favorable intermediate risk, unfavorable intermediate risk, or high/very high risk).

3.
Anti-Infective Agents ; 20(2), 2022.
Article in English | EMBASE | ID: covidwho-1938561

ABSTRACT

Coronavirus disease-2019 (COVID-19) has gained much popularity not only in the Wuhan city of China but internationally also;in January 2020, the corona rapidly spread to many countries like the USA, Italy, Russia, India, Singapore, Pakistan, Thailand, Canada, Australia, England, and so on through passengers traveling to other countries. Corona patients can be cured with synthetic drugs, traditional herbal medicines (THM), use of Vitamin D and the quarantine approach. Different allopathic medicines, herbal extracts, and vitamin D have been observed to be useful in the treatment of novel coronavirus, like Remdesivir, hydroxychloroquine, Teicoplanin, Lopinavir+ Ritonavir, Ribavirin + corticosteroids, Glycyrrhizin, Sanguisorbae radix, Acanthopanacis cortex, Sophorae radix, etc. Various antiviral drugs are used to treat COVID-19, alone or in combination with other medications like Interferon-α, Lopinavir + Ritonavir, Arbidol, corticosteroids, etc., and some herbal extracts;also quarantine approach and Vitamin D are used that not only cure the infection but also boost up our immunity. For this review article, different papers were searched on Google Scholar, Scopus, WHO’s website, PubMed, clinicaltrials.gov and other relevant scientific research websites. In this review article, we have discussed the current strategies that are being used to treat COVID-19. Along with allopathic drugs, some herbal extracts can also be used to treat this novel coronavirus, like Glycyrrhizin, Sanguisorbae radix, Acanthopanacis cortex, Sophorae radix, etc. and even vitamin D.

4.
Circulation: Cardiovascular Quality and Outcomes ; 15, 2022.
Article in English | EMBASE | ID: covidwho-1938112

ABSTRACT

Objectives: We aimed to evaluate the association of body mass index (BMI) with in-hospital mortality and cardiorespiratory outcomes in patients admitted with COVID-19 infection. Methods: This data was collected from an academic tertiary referral center in upstate New York. Retrospective cohort analysis was conducted on patients admitted with COVID-19 infection (n=194). BMI was calculated and patients were stratified into two categories: 'healthy' (BMI=18.5-24.5) and 'overweight' (BMI>25). Cardiorespiratory outcomes were classified as in-hospital mortality, need for vasopressors, mechanical ventilation, and hemodialysis. Transthoracic echocardiography was performed to evaluate for left ventricular (LV) ejection fraction, right ventricular (RV) systolic function and RV dilation. Cardiovascular (CV) risk factors such as history of COPD, Diabetes, HTN, CAD and cigarette smoking were analyzed. LDH, troponin, CRP and ferritin levels were also noted. Results: Out of 194 patients, 68% were overweight with a mean BMI of 29.8 +/-9.5 kg/m2 and a mean age of 66 +/-16, 75% of females and 63% of males were overweight. Mortality rate was 31% in overweight patients compared to 17% in healthy subset (p<0.04). The rate of need for mechanical ventilation was higher in overweight group as well (34% vs. 17%, p<0.02). There was no significant difference between the cohorts in terms of vasopressor and hemodialysis requirement (p=0.09 and 0.2 respectively). RV systolic function was depressed in 21% of overweight cohort vs. 8% of healthy patients (p<0.02) while RV dilatation was seen in 15% of overweight patients compared with 5% of healthy patients (p<0.03). There was no significant difference in LV ejection fraction between the groups. LDH was more frequently elevated in overweight cohort with a mean level of 346 +/-185 IU/L (p<0.01). No significant difference in rest of the laboratory analysis or CV risk factors were found. Conclusion: Elevated BMI (>25) is associated with a statistically significant increase in in-hospital mortality, need for mechanical ventilation, right ventricular abnormalities, and LDH levels in patients hospitalized with COVID-19 infection.

5.
Circulation: Cardiovascular Quality and Outcomes ; 15, 2022.
Article in English | EMBASE | ID: covidwho-1938111

ABSTRACT

Background: Impact of social isolation associated with the COVID-19 pandemic on the severity and frequency of cardiac symptoms has not been well investigated. Material and methods: This was a single tertiary center cohort study of inpatients admitted with a primary diagnosis of either CHF or acute myocardial infarction. Each patient rated the extent of isolation related to the pandemic and severity and frequency of symptoms during an in-person interview. Results: The study cohort included 54 patients, 48.1% females (26 of 54), 70.2+/-13.5 years old, who reported moderate or severe isolation in 57% (31 of 54). Symptom severity worsening was reported in 48% (26 of 54) of patients and was more common in socially isolated patients (74 vs. 29%, p=0.001;17 of 23 vs. 9 of 31). Symptom frequency increase was reported in 43% (24 of 54) and was also more common in socially isolated patients (61 vs. 33%, p=0.036;14 of 23 vs. 10 of 31). There was no difference in mortality between the two groups (p=0.6971). There was a trend of increased hospitalizations, on average, among patients who reported drastic isolation than patients who maintained social contacts (0.826+/-1.614 vs. 0.484+/-0.996 admissions, p=0.349). These findings were not affected by the diagnosis (CHF vs. MI), age, gender, race, and co-morbidities including HTN, DM, atril fibrillation, COPD or asthma, and/or chronic renal insufficiency. Likewise, there was no association between symptom worsening and GDT utilization including beta-blockers, RAAS inhibitors, MRA, anticoagulants, ICD or PPM placement. Conclusions: Our findings suggest that independent of age, gender, race, LVEF, recorded comorbidities, and recorded active therapeutics, the COVID-19 pandemic resulted in a significant cardiac symptom increase in patients who reported social isolation. Interventions aimed at reducing social isolation require investigation and implementation.

6.
Journal of Hypertension ; 40:e271-e272, 2022.
Article in English | EMBASE | ID: covidwho-1937756

ABSTRACT

Objective: The aim of the study was to compare the clinical particularities and the lab tests in hypertensive patients with metabolic syndrome, versus hypertensive patients without metabolic syndrome, admitted for SARS-COV2 infection. Design and method: We performed a retrospective study on 217 patients admitted to a Clinical Emergency Hospital between January 2021 and October 2021. Results: We had 217 patients admitted in internal medicine clinic for infection with SARS-COV2 virus. Patients with hypertension and metabolic syndrome (subgroup 1, 93 patients) were aged between 37 and 91 years (average age of 69 years). Patients with hypertension without metabolic syndrome (subgroup 2, 55 patients) were aged between 47 and 97 (average age of 72 years). Gender distribution in subgroup 1: 50% male, 50% female. In the subgroup 2, the gender distribution was: 51.52% male, 48.48% female. At admission, the stages of SARS-COV2 infection in subgroup 1, according to CT examination, were severe in 54.41%, moderate in 27.94%, and mild in 17.64%, and in subgroup 2 were severe in 47.16%, moderate in 24.52%, and mild in 28.30%. As comorbidities in subgroup 1: cancer in 5.88%, chronic heart failure in 26.47% of cases, atherosclerosis in 55.88%, COPD in 7.35%, depression in 7.35% and dementia in 5.88% of cases. In subgroup 2 the comorbidities were: cancer in 4.55% of patients, chronic heart failure in 36.36% of patients, atherosclerosis in 62.12%, COPD in 4.55%, depression in 3.03%, dementia in 10.61% of patients. High levels of the inflammatory markers in subgroup 1: CRP in 98.53% of cases, D-dimers in 85.29%, NT-proBNP in 76.34%, IL6 in 83.87%. In subgroup 2: high levels of CRP in 93.94% of cases, D-dimers in 84.85%, NT-proBNP in 69.09%, IL6 in 83.63%. Permanent atrial fibrillation was more prevalent in subgroup 2 (18.18% of cases) compared to subgroup 1 (9.67% of cases) while the prevalence of paroxysmal atrial fibrillation was higher in subgroup 1 (5.45% versus 8.60% of cases). Conclusions: Increased NT-proBNP and paroxysmal atrial fibrillation had a higher prevalence in patients with hypertension and metabolic syndrome for the same age group and degree of SARS-COV2 pulmonary infection.

7.
Journal of Hypertension ; 40:e181, 2022.
Article in English | EMBASE | ID: covidwho-1937746

ABSTRACT

Objective: The aim of the study was to assess the clinical particularities and the lab tests in hypertensive patients with metabolic syndrome, admitted for SARSCOV2 infection. Design and method: We performed a retrospective study on 217 patients admitted to a Clinical Emergency Hospital between January 2021 and October 2021. Results: We had 217 patients admitted in internal medicine clinic for infection with SARS-COV2 virus, most of them with moderate and severe form of disease. From them, 148 patients (68.20%) had hypertension on admission and 114 patients (52.53%) had metabolic syndrome. Patients were aged between 23 and 99 (average age of 65 years). In comparison, the patients in the hypertensive subgroup were aged between 37 and 97 (average age of 70). The gender distribution was similar in the large group and hypertensive subgroup: 52.07% male, 47.92% female in the large group, and 52.03% male, 47.97% female in the hypertensive subgroup. At admission, the stages of SARS-COV2 infection in patients with metabolic syndrome, according CT examination, were severe in 54.41% of cases, moderate in 27.94%, and mild in 17.64%. According the IDF definition of the metabolic syndrome, 8.33% of the patients had 5 criteria, 35.29% patients had 4 criteria, and 58.82% patients had 3 criteria of disease. Hypertension was encountered in 80.95% of patients with metabolic syndrome, obesity in 56.75% and diabetes mellitus in 52.70% of cases. As comorbidities: cancer in 5.88% of patients, chronic heart failure in 26.47% of cases (72.22% NYHA II class and 27.78% NYHA III class), atherosclerosis in 55.88%, COPD in 7.35%, depression in 7.35% and dementia in 5.88% of cases. High levels of the inflammatory markers or specific lab tests were encountered: CRP in 98.53% of cases, pro-calcitonin in 86.76%, ferritin 80.88%, IL-6 in 83.33%, D-dimers in 85.29%, NT-proBNP 71.92%, troponin 70.59%, LDH in 91.17%, uric acid in 11.76%. Conclusions: The most reliable comorbidity factor who predict evolution/prognosis of SARS-COV2 infection in patients with metabolic syndrome was diabetes mellitus (the levels of glycaemia and the need of high units of insulin), despite the fact that hypertension and obesity were more prevalent.

8.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927929

ABSTRACT

Rationale: Hypercapnia and respiratory acidosis lead to increased morbidity and mortality in critically ill patients. Extracorporeal CO2 removal (ECCO2R) can rapidly correct pH and PaCO2 as a treatment for refractory, hypercapnic respiratory failure. Current clinical evidence for the benefits of ECCO2R is primarily limited to case series and single-center studies. The Hemolung (ALung Technologies) is the only FDA cleared ECCO2R system and has been utilized to treat greater than 1,000 patients world-wide. The purpose of this study was to evaluate real-world evidence of the Hemolung ECCO2R system for the treatment of hypercapnic respiratory failure across a range of primary diagnoses. Methods: The Hemolung Registry was queried for patients with a baseline, pre- Hemolung pH < 7.35. Patients receiving either noninvasive or invasive ventilation were included in the analysis. Physiological benefits of Hemolung therapy were evaluated using a mixed model for repeated measures based on changes in pH and PaCO2 after 4-6 hrs and 16-35 hrs of Hemolung therapy compared to the baseline value. The model was used to calculate two-sided 95% confidence intervals and associated nominal p-values. Additional markers of clinical improvement included avoidance of intubation, survival to decannulation, and Hemolung CO2 removal rate and duration. Adverse events were also analyzed based on patient harm. Results:176 Hemolung patients were included in the analysis. Multiple primary diagnoses were represented: 31% ARDS, 22% COPD exacerbation, 32% COVID-19, and 15% Other. Median duration of Hemolung therapy was 6.0 days. Median CO2 removal by the Hemolung during the first day of therapy was 88 mL/min and resulted in a concomitant correction of pH from a median of 7.20 to 7.35 (p<0.001) and median PaCO2 correction of 81.7 to 57.0 mmHg (p<0.001). Correction of respiratory acidosis was independent of primary diagnosis, age, and BMI. 69% (112/162) of patients survived to decannulation. 86% (19/22) of patients failing NIV avoided intubation. There were no unanticipated complications, and the majority of adverse events did not require medical intervention or discontinuation of Hemolung therapy. 3 deaths associated with Hemolung therapy occurred. Conclusions: These data represent the largest reported analysis of ECCO2R therapy to treat a diverse population of hypercapnic respiratory failure patients. The results demonstrate significant correction of pH and PaCO2 within the first day of Hemolung therapy without significant adverse events. Data from forthcoming RCTs will shed further light on whether these physiologic benefits translate to improved outcomes compared to current standard of care.

9.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927927

ABSTRACT

RATIONALE The literature about respiratory outcomes in coronavirus disease 2019 (COVID-19) is continuously growing. The relation between severe COVID-19 and other risk factors shared in patients with obstructive sleep apnea (OSA) is well documented. However, data related to OSA as an independent risk factor for severe COVID-19 remains limited. The aim of this study is to assess whether OSA is associated with a higher risk of mechanical ventilation (MV) compared to non-OSA individuals in hospitalized COVID-19 patients. METHODS A retrospective cohort study was conducted at Hôpital Maisonneuve-Rosemont (Montreal, Canada). All COVID-19 adult patients admitted from March 1st to June 30th 2020 were included. Data on demographic characteristics, comorbidities, treatment, ICU admission and mortality were collected from electronic medical records. To evaluate the association between OSA and MV requirement, a multivariable logistic regression analysis was performed including known risk factors for severe COVID-19 disease. RESULTS Out of 697 patients included in this study, 43 (6.2%) were found to have OSA. The risk of MV requirement was statistically higher in the OSA group compared to the non-OSA group (18.6% [n=8] vs 9.0% [n=59], p=0.039). Multivariate logistic regression analysis showed that OSA was an independent risk factor for MV requirement when adjusted for age, sex, diabetes, chronic obstructive pulmonary disease, moderate to severe chronic renal disease, solid tumor malignancies, myocardial infarction and dementia (adjusted odds ratio 2.70 ;95% CI : 1.13-6.46, p=0.047). CONCLUSION OSA is independently associated with an increased risk of MV requirement among hospitalized patients affected by SARS-CoV2. This study emphasizes the need for OSA to be recognized as a high-risk medical condition in patients with SARS-CoV2 and warrants measures, such as OSA screening and increased in-hospital monitoring, to prevent lifethreatening complications. Further research must be done to understand the link between OSA and severe COVID-19.

10.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927913

ABSTRACT

RATIONALE. During the first wave of the SARS-CoV2 pandemic, many have highlighted a higher risk of mortality associated with hospital-acquired (HA) infections compared to non-hospital acquired (NHA) infections. However, there is currently limited data regarding the long-term outcome of those patients. The aim of this study was to compare the one-year mortality of patients with HA and NHA SARS-CoV2 infections. METHODS . A retrospective cohort study was conducted including all SARS-CoV2 patients hospitalized at Hôpital Maisonneuve-Rosemont, a tertiary-care hospital, during the first wave of the pandemic (March 1st 2020 to June 30th 2020). Data including demographic characteristics, comorbidities and mortality were collected using electronic medical records. Patients who died during the initial hospitalisation were excluded from the study. Hospital acquired cases were defined as a positive PCR test more than 7 days after hospital admission or an identified in-hospital epidemiological link. The follow-up period was one year after hospital discharge. To evaluate the association between HA SARS-CoV-2 infection and one-year mortality, we performed a multivariable logistic regression including the following prespecified risk factors for death in patients with SARS-CoV-2: age, sex, moderate to severe chronic renal disease (creatinine >3mg/dL or dialysis), solid tumour, diabetes, chronic obstructive pulmonary disease (COPD) and history of myocardial infarction (MI). Considering the possible interaction between age and HA status on mortality, we calculated age-group-specific odds ratios. RESULTS . Among 405 patients included in the final analysis, 127 (31.4%) were HA cases. One-year mortality was more than twofold among HA cases (22.0% vs. 9.4%). In patients less than 75 years old, HA infections were associated with a higher one-year mortality compared to NHA infections (OR 3.65;95% CI 1.04 - 12.78;p=0.042). This association was not present in patients of 75 years or more. Other factors associated with a higher one-year mortality included moderate to severe kidney disease (OR 6.99;95% CI 2.34 - 20.07;p<0.001), as well as localized solid tumors (OR 2.65;95% CI 1.15 - 6.11;p=0.023) and metastatic solid tumors (OR 41.68;95% CI 8.25 - 210.53;p<0.001). Sex, diabetes, COPD and MI did not have a statistically significant effect on one-year mortality. CONCLUSION. In patients less than 75 years old, hospital-acquired SARS-CoV2 infections were associated with higher one-year mortality. This finding highlights the fragility of those patients and the need to protect hospitalized patients from acquiring SARS-CoV2.

11.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927912

ABSTRACT

RATIONALE: SARS-CoV-2, a novel coronavirus, is the third coronavirus with an associated severe acute respiratory syndrome since SARS-CoV [1]. Patients with severe COVID-19 suffer from immune hyperactivity, also referred to as a cytokine storm, which causes increased vascular permeability and multiorgan dysfunction and is a significant source of morbidity and mortality.1 Because Bruton's Tyrosine Kinase (BTK) activity is thought to play a role in the cytokine storm, with elevated activity found in monocytes, it has been explored as a target for intervention for COVID- 19.2 METHODS : This observational, case-control study included 49 hospitalized patients with severe COVID-19. Of the 49 patients, 11 patients received off-label Acalabrutinib between May 2020 through June 2020. The purpose of the study is the assess the use of Acalabrutinib as a potential strategy for management of COVID-19 patients. Bivariate and Multivariate logistic regression models were used to analyze the data. The response variable was patient outcome (remission discharge or death). The main predictor of interest was the administration of Acalabrutinib on patients (Yes/No). For the multivariate analysis the covariates included were age, gender, change in CRP levels (Discharge CRP - Admission CRP), hypertension, COPD, and comorbidities status (Yes/No). Stata Version 17.0 (Stata Corp, College Station, Texas USA) was used in all analyses. RESULTS : The median age of patients was 58 with a majority being male (51%). The average length of hospitalization was 17 days with 23 (46.9%) patients receiving mechanical ventilation. Bivariate analysis revealed that acalabrutinib was protective against death from COVID-19. However, these results were nonsignificant (OR 0.36, 95 CI [0.04, 2.87], P=0.31). The multivariate analysis supported the results of the bivariate analysis. However, we did not observe a significant association between outcome and acalabrutinib when adjusted for the study covariates (OR 0.32, 95% CI [0.03, 3.79], P=0.37). CONCLUSION: Acalabrutinib did not significantly reduce morbidity or mortality on severe COVID-19 patients. Further studies are warranted to assess the efficacy of BTK inhibitors for COVID-19 in a larger clinical trial. (Table Presented).

12.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927893

ABSTRACT

Rationale: Over 350,000,000 people have had SARS-CoV-2 infection worldwide. COVID-19 poses many challenges in the management of patients causing a long-term and significant burden on the healthcare system. Understanding the long-term complications is a challenge that the healthcare community and patients will face. To our knowledge, this is one of the largest retrospective analyses with the aim to understand the functional lung sequelae of the disease. Methods: We retrospectively reviewed 782 survivors who had COVID-19 diagnosed by RT-PCR and followed up at an outpatient pulmonary clinic in Hartford, Connecticut, USA, from March 2020 to June 2021. Data included patient's age, sex, comorbidities, pulmonary function tests (PFT), the maximal requirement of low-flow oxygen (LF), high-flow nasal cannula (HFNC), non-invasive ventilation (NIV) and mechanical ventilation (MV). We performed an adjusted logistic regression model to evaluate if severity of disease according to maximal oxygen support is associated with DLCO<80% in follow-up. SPSS IBM was used for the statistical modeling. Results: Of the 782 patients evaluated, 314 patients had PFT results available post COVID-19 for analysis. The mean age was 58.9±14.5 years, and of the total number of patients, 200 were female (63.7%). Other demographics are as follows: 156 (49.7%) were obese, 129 (41.2%) had asthma, 48 (15.3%) had COPD, 5 (1.6%) had Interstitial Lung Disease, 35 (11.1%) had anemia, 70 (22.3%) had diabetes mellitus, 164 (52.2%) had hypertension, 26 (8.3%) had heart failure. Only 14 (4.4%) required MV, 14 (4.5%) NIV, 29 (9.2%) HFNC, 94 (29.9%) LF and 153 (51.9%) remained on room air. Altered DLCO was seen in 107 patients (34.1%), 189 (60.1%) had normal DLCO, and 18 (5.7%) did not have DLCO, of which the latter were excluded from the analysis. Maximal oxygen support was associated with DLCO<80% on unadjusted analysis (p=0.003). However, it was not associated with DLCO<80% (p=0.2) when adjusted. Other variables associated with a higher risk of DLCO<80% were age (p<0.001) and COPD (p<0.028). Asthma was associated with lower risk of developing DLCO<80% (p<0.001). Conclusion: Patients with post-acute sequelae of SARS-CoV-2 infection can develop DLCO<80%, which may contribute to long-term symptoms. Altered DLCO was not associated with maximal oxygen support in the adjusted logistic regression analysis. However, this may be due to the low number of cases requiring MV or NIV, resulting in selection bias, given there was a higher mortality rate in patients requiring positive pressure ventilation. Additionally, age and COPD were correlated with DLCO<80%.

13.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927891

ABSTRACT

Introduction/Rationale: People with multiple chronic diseases, such as heart failure (HF) or chronic obstructive pulmonary disease (COPD), are at elevated risk of unplanned repeated hospitalization. Transitional care has been recognized as reducing unexpected rehospitalization after discharge from hospital to home. As the COVID-19 pandemic is prolonged, individual home healthcare services are getting increased attention for post-acute care. However, less is known about the effectiveness of nurse-led transitional care programs, including home-visit intervention. Objectives: This study aimed to identify the effectiveness of nurse-led home-visit transitional care programs in improving health service utilization, functional status, and quality of life (QoL) among people discharged from hospital to home. Methods: We conducted a scoping review of the EBSCOMedline, Cochrane Library and Embase databases searching for articles containing a combination of “home care,” “transitional care,” and “care coordination” between 1973 and 2021. Inclusion criteria were: randomized controlled trials (RCTs) or quasi-experimental studies, adults who need continuing healthcare after discharged to home, and affecting at least one of the following outcomes: hospital readmission, functional status, and QoL. Results: Initial searching identified 1552 potential records, 1328 s were screened, and 105 full texts were retrieved. A total of 16 studies met the selection criteria. Seven studies were conducted in North America and most were RCTs (n=14). Most participants (mean=73 years) had multiple chronic diseases, such as stroke, COPD, or HF. Regarding discharge plans, two-thirds of the studies included a pre-and a post-discharge plan (n=11). All studies included a home-visit intervention regularly or as needed over a period from one week to two years. Intervention team providers were the research team only (n=2), a collaboration with a hospital team (n=4), a community team (n=4), or a hospital team plus a community team (n=6). Hospital readmissions were assessed in 12 studies and found to be significantly lower in the intervention group (n=4). Physical function status was assessed in seven studies and was significantly better in the intervention group (n=2). QoL was assessed in eight studies and was significantly greater in the intervention group (n=3). Conclusions: About 30% of the studies reported that home-visit transitional care interventions had positive effects on hospital readmissions, physical function status, and QoL. More studies are required to include patient engagement and the use of technology, such as telehealth, in transitional care plans to improve selfcare at home.

14.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927855

ABSTRACT

Rationale: Recent advancements in sequencing technologies have led to a substantial increase in the scale and resolution of transcriptomic data. Despite this progress, accessibility to this data, particularly among those who are coming from non-computational backgrounds is limited. To facilitate improved access and exploration of our single-cell RNA sequencing data, we generated several data sharing, mining and dissemination portals to accompany our idiopathic pulmonary fibrosis (IPF), chronic obstructive pulmonary disease (COPD), and lung endothelial cells (Lung EC) cell atlases. Descriptions and links of each website can be found here: https://medicine.yale.edu/lab/kaminski/research/atlas/. Methods: Each interactive data mining website is coded in the R language using the Shiny package and is hosted by Shinyapps.io. Percell expression data for each website is stored on a MySQL database hosted by Amazon Web Services (AWS). Time-associated website engagement statistics and gene query information is collected for each website using a combination of Google Analytics and a gene search table stored on our MySQL database. User exploration of available data is facilitated through several easy-touse visualization tools available on each website. Results: Website usage statistics since the publication of each website shows that 9,772 unique users from 56 countries and five continents have accessed at least one of the three websites. At the time of writing, 300,748 total queries have been made for 15,627 unique genes across the websites. The top five searched genes for the IPF Cell Atlas are CD14, ACE2, ACTA2, IL11 and MUC5B while for the COPD Cell Atlas they are FAM13A, MIRLET7BHG, HHIP, ISM1 and DDT. Finally, the top searched genes for the Lung Endothelial Cell Atlas are BMPR2, PECAM1, EDNRB, APLNR and PROX1. Of note, interaction with the IPF Cell Atlas increased dramatically at the start of the COVID-19 pandemic, with queries for the ACE2 gene, the putative binding receptor for the SARS-CoV-2 virus, increasing substantially at the pandemic's onset in the United States. Conclusions: Usage statistics, gene query information and feedback from users, both within academia and industry, have shown broad engagement with our websites by individuals across computational and non-computational backgrounds. We envision widespread adoption of web-based portals similar to ours will facilitate novel discoveries within these complex datasets and new scientific collaborations.

15.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927848

ABSTRACT

Introduction: Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) is a major cause of hospitalization and re-admissions. Lack of standardized management and non-adherence to guideline-directed treatment may lead to poor outcomes and increase cost. Interventions implemented by health systems to reduce readmissions have had varied success. Heterogeneity in the target patient population is a significant challenge. The Cleveland Clinic COPD Care Path consists of an admission order set that incorporates multi-disciplinary management, evidence-based medications, and postdischarge integrated care. In this study, we examined impact of this Care Path on quality metrics and 30-day readmissions of patients with proven COPD on spirometry. Methods: We studied patients with spirometry proven persistent airflow obstruction (postbronchodilator FEV1/FVC<70) admitted to the general nursing floor with AECOPD during the 3 years prior to the COVID pandemic (February 2, 2017 to January 31, 2020), excluding those who left against medical advice, hospice and transplant patients. Patient's Care Path status (On vs Off), age, gender, BMI, baseline lung function and comorbidities were recorded. We measured process metrics such as appropriate use of antibiotics and corticosteroids, and post-discharge integrated disease management (rates of prescribing long-acting bronchodilator, follow-up appointments). 30-day readmission rate, length of stay (LOS) observed to expected (O: E) ratio and cost per case were recorded. For continuous variables, we used means and standard deviations and the ANOVA test for statistical analysis. For categorical variables, percentages, and the t- test were used. The level of statistical significance was set at p < 0.05. Results: Of the total of 857 patients with airflow obstruction, the Care Path was utilized in 52.8% and 21.94% were readmitted within 30 days. Lower re-admissions were associated with lower comorbidity index and completed follow-up appointments. Lung function, long acting bronchodilator prescription and cost or length of index hospitalization did not affect readmission. The care path was utilized more among patients with lower FEV1/FVC ratio but less in patients with concomitant heart failure. Use of the care path was associated with more follow-up appointments (scheduled and completed), long-acting bronchodilator prescription on discharge, lower cost but not length of stay. On-Care-Path patients did not have a reduced risk of readmission on univariate analysis. Conclusions: The findings from this retrospective study of patients with spirometry proven COPD suggest that using standardized care path for AECOPD hospitalizations is associated with lower cost and facilitates transitions of care. However, length of stay and 30-day readmission rates are unaffected. (Figure Presented).

16.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927823

ABSTRACT

Rhinoviridae are the most common cause of upper respiratory tract infections, especially in children, and often referred to as “the common cold”. Symptoms are usually mild, nasopharyngeal in nature;they have, however, been implicated in cases of infantile viral pericarditis. Its role in the presentation of adult viral pericarditis remains unclear. We present the case of a 45-year-old male with a past medical history of pre-diabetes, hyperlipidemia and hypertension with complaints of severe left-sided chest pain that worsened with movement and coughing but improved when lying supine. Two weeks prior to presentation, he had developed an intermittent cough, treated with antibiotics and steroids. On presentation to the ED, the patient was afebrile but hypotensive to 80/52 mmHg, tachycardic to 116 BPM, hypoxic to 88% on room air, improving to 91% with 3L nasal cannula. Physical examination was notable for wheezing and egophony. Laboratory findings were concerning for WBC 19.97x10-3/uL, Hgb 13.4 g/dL, CRP 176 mg/L, Ferritin 772 ug/L, D-dimer 3.70 ug/mL FEU;procalcitonin 0.2 ng/mL and troponin <0.015 ng/mL. Respiratory viral panel revealed negative COVID-19 test but positive for rhinovirus/enterovirus. Electrocardiogram showed sinus tachycardia. Chest computed tomography demonstrated moderate pericardial effusion, ground glass attenuation of the lungs bilaterally with moderate left pleural effusion and reflux of contrast into the hepatic veins, suggestive of right heart failure. Echocardiogram demonstrated small to moderate pericardial effusion. The patient was admitted with the diagnosis of acute rhino/enteroviral-associated pleuropericarditis. Broad-spectrum antibiotics, prednisone, colchicine and indomethacin were commenced. Upon clinical stabilization of his condition, steroids were discontinued and he was discharged home with close follow-up. While rhinovirus has been associated with infantile viral pericarditis, it is implicated in pneumonia and COPD exacerbations in adults but rarely reported as a cause of adult pericarditis. A case-control study of adults diagnosed with acute idiopathic pericarditis had an independent association with an upper respiratory tract infection or gastroenteritis in the month preceding pericarditis diagnosis but did not delineate causative viruses. Therefore in cases of unknown causes of viral pericarditis, thorough history is vital. Steroids as part of the treatment algorithm for pleuropericarditis management has long been debated. Older literature has not favored the use of steroids due to high recurrence rate. However, Perrone et al refuted this point, noting that low-dose steroids with gradual tapers have equal efficacy and recurrence rates as compared with NSAIDs/colchicine. Therefore, steroids may be a reasonable option for patients with contraindications to NSAIDs/colchicine.

17.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927797

ABSTRACT

Rationale: Individuals with COPD who develop COVID-19 are at increased risk of hospitalization, ICU admission and death. COPD is associated with increased airway epithelial expression of ACE2, the receptor mediating SARS-CoV-2 entry into cells. Hypercapnia commonly develops in advanced COPD and is associated with frequent and potentially fatal pulmonary infections. We previously reported that hypercapnia increases viral replication, lung injury and mortality in mice infected with influenza A virus. Also, global gene expression profiling of primary human bronchial epithelial (HBE) cells showed that elevated CO2 upregulates expression of cholesterol biosynthesis genes, including HMGCS1, and downregulates ATP-binding cassette (ABC) transporters that promote cholesterol efflux. Given that cellular cholesterol is important for entry of viruses into cells, in the current study we assessed the impact of hypercapnia on regulation of cellular cholesterol levels, and resultant effects on expression of ACE2 and entry of Pseudo-SARS-CoV-2 in cultured HBE, BEAS-2B and VERO cells, and airway epithelium of mice. Methods: Differentiated HBE, BEAS-2B or VERO cells were pre-incubated in normocapnia (5% CO2, PCO2 36 mmHg) or hypercapnia (15% CO2, PCO2 108 mmHg), both with normoxia, for 4 days. Expression of ACE2 and sterol regulatory element binding protein 2 (SREPB2), the master regulator of cholesterol synthesis, was assessed by immunoblot or immunofluorescence. Cholesterol was measured in cell lysates by Amplex red assay. Cells cultured in normocapnia or hypercapnia were also infected with Pseudo SARS-CoV-2, a Neon Green reporter baculovirus. For in vivo studies, C57BL/6 mice were exposed to normoxic hypercapnia (10% CO2/21% O2) for 7 days, or air as control, and airway epithelial expression of ACE2, SREBP2, ABCA1, ABCG1 and HMGCS1 was assessed by immunofluorescence. SREBP2 was blocked using the small molecules betulin or AM580, and cellular cholesterol was disrupted using MβCD. Results: Hypercapnia increased expression and activation of SREBP2 and decreased expression of ABC transporters, thereby augmenting epithelial cholesterol levels. Elevated CO2 also augmented ACE2 expression and Pseudo-SARSCoV- 2 entry into epithelial cells in vitro and in vivo. These effects were all reversed by blocking SREBP2 or disrupting cellular cholesterol. Conclusion: Hypercapnia augments cellular cholesterol levels by altering expression of cholesterol biosynthetic enzymes and efflux transporters, leading to increased epithelial expression of ACE2 and entry of Pseudo-SARS-CoV-2 into cells. These findings suggest that ventilatory support to limit hypercapnia or pharmacologic interventions to decrease cellular cholesterol might reduce viral burden and improve clinical outcomes of SARSCoV- 2 infection in advanced COPD and other severe lung diseases.

18.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927791

ABSTRACT

Rationale: Patients with chronic obstructive pulmonary disease (COPD) suffer heightened morbidity, mortality, and readmission rates. COPD is co-prevalent with obstructive sleep apnea (OSA) in 20-60% of patients, and patients with COPD/OSA overlap are at higher risk for hospital readmission and mortality compared to COPD alone. Current COPD readmission reduction programs are focused on decreasing COPD readmissions;however, few explore impactful comorbid conditions. No study has identified peri-discharge barriers in the acute care setting from the perspective of patients with COPD/OSA or healthcare workers to identify areas of improvement. Methods: Semi-structured interviews, conducted via telephone (recorded) of hospitalized patients with COPD/OSA and acute care healthcare workers were conducted at an urban academic medical center (11/2020-1/2021) among a convenience sample of recruited participants. All recordings were transcribed and uploaded to NVivo, which facilitated thematic analysis, using an a priori codebook. Coding was conducted in rounds, and meetings were used to resolve differences and update the codebook as needed. This iterative process continued until all transcripts were analyzed. Results: Thirty-five participants were interviewed, 27 healthcare workers (HCW), 4 nurses, 6 respiratory therapists, 5 physicians, 3 case managers, 4 social workers, and 5 pharmacists, and 8 patients. The HCWs interviewed served an average of 7.5 years, were <50 years old (81.5%), and most were female (74.1%), white (81.5%), and non-Hispanic (100%). HCW respondents identified barriers that mapped to four main levels: patient, team, hospital, and the healthcare system. Select barriers HCWs identified included health literacy, patient cognitive impairments, peri-discharge time management, lack of resources for patients post-discharge, cost, and insurance. All patient interviewees were <50 years old, most were male (62.5%), white (62.5%), and non-Hispanic (87.5%). Select barriers patients identified included current SES status, care team discussions, disease burden (visits to ED/hospital), follow-up care (including transportation), and perceptions of healthcare due to COVID-19. Conclusion: Healthcare workers and COPD/OSA patients report multilevel hospital discharge barriers. To improve barriers to care for these complex patients, multilevel interventions addressing noted barriers are needed.

19.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927775

ABSTRACT

IntroductionCrack lung is a clinically diagnosed form of diffuse alveolar hemorrhage that occurs acutely within 48 hours of smoking crack cocaine. The diagnosis of crack lung is based on history, clinical presentation, laboratory, and radiographic findings. Unlike most other forms of alveolar hemorrhage, crack lung does not require extensive or invasive work up and is managed symptomatically. We hereby present a case of acute diffuse alveolar hemorrhage secondary to crack cocaine which was clinically diagnosed and managed symptomatically. Case reportPatient was a 46-year-old female with a past medical history of type II diabetes mellitus, chronic obstructive pulmonary disease and polysubstance abuse that was brought to the emergency room after she was found unresponsive. 4mg of Narcan was administered and she became alert. Following Narcan administration, patient remained altered and confused. At the emergency room patient endorsed shortness of breath at rest which she associated it with a prior COVID-19 pneumonia one month ago. Vital signs were significant for a Temperature:99.2 blood pressure: 130/66, heart rate: 125, respiratory rate:27, Oxygen saturation: 95% on non-rebreather at 15L/min. Laboratory investigations were significant elevated creatinine (1.38, baseline unknown);white blood cell count (30.25), arterial blood gas was reported as 7.26/45/69 on 100%. Serum troponin was elevated at 3.12. Electrocardiogram showed sinus tachycardia, chest x-ray showed diffuse bilateral patchy airspace disease, computed tomography of the chest showed bilateral diffuse lung consolidation with small ground glass opacities (figure 1). Computed tomography of the head showed no acute intracranial process and urine drug screen was positive for cocaine. Patient was started on 4 mg of Narcan, 125 mg of methylprednisolone and transferred to the medical intensive care unit (MICU). In the MICU, blood, sputum and urine culture were obtained. Pt was empirically managed on vancomycin and piperacillin-tozabactam. Because of diffuse alveolar hemorrhage was in the differential, patient was continued on 80 mg of IV methylprednisolone every 8 hours. Patient was observed in the unit for 2 days. During stay in the MICU, repeat chest x-ray showed improvement in lung opacities bilaterally. Vitals were within normal range. Patient was weaned down from non-rebreather to 2 Liters of oxygen and then transferred to the general floor. ConclusionPatients with crack lung often present with shortness of breath, fever, cough with or without hemoptysis and sometimes hypoxemia within 48 hours of insult. Early diagnosis based on history, physical examination, laboratory and radiographic findings can ensure prudent management.

20.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927759

ABSTRACT

Introduction: Before the covid pandemic we provided community respiratory nursing support for patients with chronic lung diseases especially COPD, pulmonary rehabilitation (PR) and a home oxygen service supporting/assessing patients needing oxygen in the community. The pandemic has led to refocussing our services and staff, helping to keep patients out of hospital. Group pulmonary rehabilitation classes were no longer possible. Methods: We have refocussed our service to provide covid-safe services with PPE and early staff immunisation. Some staff were seconded to a rapid response unit for those acutely ill. Others carried out a care homes initiative to review all patients with respiratory disease in care homes. The oxygen team picked up patients discharged post covid from hospital requiring oxygen at home. We identified high risk patients for regular telephone contact. Results: Referrals after admission for non-covid respiratory infections fell as patients stayed at home and reduced contacts. 1.1-1.4 2020v 2021: 236 v 79;GP referrals also fell 1.1-1.4 2020-2021;87 v 35. Both have increased post lockdown. Referrals for PR fell. Total 1.1-1.4. 2020 v 2021, 373 v 107, GP referrals 226 v 54. Post lockdown 1.7.21-1.10.21 there has been an increase, total 139:GP 81. Group PR is starting up again. Oxygen referrals after covid admissions up to 1.10.20 were only 8 from the first wave of disease, but 119 from 15.10.20-10.5.21, and 18 from 9.8.21-1.11.21 (11 ambulatory alone): all patients discharged after covid requiring oxygen at home are contacted by telephone and visited at home. We identified 380 patients who were rated as high risk, either having <3 admissions in 12 months, recent oxygen required at home or PCO2 <7.5Kpa. These were contacted weekly as they sheltered at home. Our staff reviewed 163 patients in nursing homes, 116 with respiratory disease, 31/116 already known to the service. 75% of patients needed a new reliever inhaler or spacer. 58% did not have a rescue pack of antibiotics and steroids, 85% required a salbutamol inhaler. Conclusion: Identification of “high risk patients allowed us to provide telephone support to keep them safe at home. Reviewing all residents in care homes identified unmet needs for therapy and support. Prompt review of patients requiring oxygen after admission for covid helps them once discharged. Admissions for non covid exacerbations fell as patients remained at home with limited contacts, but on re-entering the outside world, admissions for COPD have risen again.

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