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1.
Med Sci (Basel) ; 10(4)2022 Oct 10.
Article in English | MEDLINE | ID: covidwho-2071634

ABSTRACT

SARS-CoV-2-infected symptomatic patients often suffer from high fever and loss of appetite which are responsible for the deficit of fluids and of protein intake. Many patients admitted to the emergency room are, therefore, hypovolemic and hypoproteinemic and often suffer from respiratory distress accompanied by ground glass opacities in the CT scan of the lungs. Ischemic damage in the lung capillaries is responsible for the microscopic hallmark, diffuse alveolar damage (DAD) characterized by hyaline membrane formation, fluid invasion of the alveoli, and progressive arrest of blood flow in the pulmonary vessels. The consequences are progressive congestion, increase in lung weight, and progressive hypoxia (progressive severity of ARDS). Sequestration of blood in the lungs worsens hypovolemia and ischemia in different organs. This is most probably responsible for the recruitment of inflammatory cells into the ischemic peripheral tissues, the release of acute-phase mediators, and for the persistence of elevated serum levels of positive acute-phase markers and of hypoalbuminemia. Autopsy studies have been performed mostly in patients who died in the ICU after SARS-CoV-2 infection because of progressive acute respiratory distress syndrome (ARDS). In the death certification charts, after respiratory insufficiency, hypovolemic heart failure should be mentioned as the main cause of death.


Subject(s)
COVID-19 , Respiratory Distress Syndrome , Humans , SARS-CoV-2 , Hypovolemia , Lung/diagnostic imaging
2.
American Journal of Transplantation ; 22(Supplement 3):664, 2022.
Article in English | EMBASE | ID: covidwho-2063499

ABSTRACT

Purpose: Transplantation of kidneys from donors with active SARS-CoV-2 infection is uncommon due to concerns about the risk of viral transmission and kidney quality. To date, there is no conclusive data that viral transmission from extra-pulmonary solid organ transplant is a possibility. Given the prevalence of SARS-CoV-2 infections in potential donors, the shortage of kidneys available for transplantation and the low risk of viral transmission, we developed a clinical protocol for accepting kidneys from donors with active SARS-CoV-2 infection and preserved kidney function. Method(s): Retrospective chart review of 5 kidney transplant recipients from 4 deceased donors with severe SARS-CoV-2 infection. Donor and recipient characteristics are reported using descriptive characteristics. Result(s): Donor creatinine ranged from 0.51 to 0.60 mg/dL and KDPI ranged from 14% to 52%. Three of the 5 kidneys came from donation after circulatory death donors. All recipients were fully vaccinated, and 4/5 received post-exposure prophylactic monoclonal antibody treatment. 3 recipients had delayed graft function but were off of dialysis by postoperative day 6 or 8. 3 recipients were readmitted, one for fluid overload and mild rejection on two different occasions, one for hypotension from dehydration and one for sepsis secondary to an aspiration pneumonia. The latter recipient subsequently died with a functioning graft secondary to a severe bacterial infection. This recipient was also found to have a femoral DVT during readmission on the contralateral side to the kidney graft. At 30 days post-transplant, no recipients displayed signs or symptoms of SARS-CoV-2 infection and the three who were readmitted tested negative for SARS-CoV-2 via nasopharyngeal swab. All had a creatinine less than 2 at the most recent follow up. Conclusion(s): Our findings suggest that kidney grafts from donors with severe SARSCoV- 2 infection but preserved kidney function can be safely used and have good early outcomes. However, more research is needed to determine the safety and long term outcomes of kidney transplantation from donors with severe COVID-19 pneumonia.

3.
Journal of Comprehensive Pediatrics ; 13(Supplement 1):32-33, 2022.
Article in English | EMBASE | ID: covidwho-2058676

ABSTRACT

Upper respiratory tract infection (URI) is one of the most frequent diseases observed at centers for pediatric care and results in significant morbidity worldwide. URI is the most common cause in children treated against acute respiratory infection. The difficulty found by clinicians in establishing the differential and etiologic diagnosis of URIs and the occasionally indiscriminate use of antimicrobial drugs. URIs range from the common, cold-typically a mild, self-limited, catarrhal syndrome of the nasopharynx to life-threatening illnesses such as epiglottitis. Viruses account for most URIs. Appropriate management in these cases may consist of reassurance, education, and instructions for symptomatic home treatment. Diagnostic tests for specific agents are helpful when targeted URI therapy depends on the results. Bacterial primary infection or superinfection may require targeted therapy. The upper respiratory tract includes the sinuses, nasal passages, pharynx, and larynx, gateways to the trachea, bronchi, and pulmonary alveolar spaces. Rhinitis, pharyngitis, sinusitis, epiglottitis, laryngitis, and tracheitis are specific manifestations of URIs. Most URIs are viral in origin. Typical viral agents that cause URIs include the Rhinoviruses, Coronaviruses, Adenoviruses, and Coxsackieviruses. In the emergency department, attention should be paid to the patient's vital signs, including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation (if obtained). Neonates are obligate nose breathers and may be at greater risk for respiratory distress;hence practitioners should auscultate the lungs for adequate aeration and assess breathing quality. The cardiovascular examination should assess adequate distal perfusion and an appropriate-for-age heart rate. Finally, dehydration can be a complication of any viral illness, and therefore, an assessment of hydration should be a part of the initial evaluation. Tests of nasopharyngeal specimens for specific pathogens are helpful when targeted therapy depends on the results (e.g., group A streptococcal infection, gonococcus, pertussis). Specific bacterial or viral testing is also warranted in other selected situations, such as when patients are immunocompromised, during inevitable outbreaks, or provide specific therapy to contacts. Symptombased therapy represents the mainstay of URI treatment in immunocompetent adults. Antimicrobial or antiviral therapy is appropriate in selected patients.

4.
Journal of Neuromuscular Diseases ; 9:S36, 2022.
Article in English | EMBASE | ID: covidwho-2043377

ABSTRACT

The clinical syndrome of rhabdomyolysis is based on the 'classical' triad of myalgia, weakness and pigmenturia. For this lecture it will be defined as an acute such clinical syndrome with markedly elevated serum CK. The common general triggers of rhabdomyolysis are: Exertion, heat & fever, fasting and dehydration, drugs and anesthesia and muscle trauma. The causes of rhabdomyolysis are divided to two general groups: Genetic (metabolic myopathies and dystrophies) and acquired. The main complications of rhabdomyolysis are acute kidney failure and electrolyte imbalance. There is no consensus on treatment guidelines but the main therapeutic modes are high fluid load (if renal status allows) and alkalization of urine. Initial observations on rhabdomyolysis and COVID-19 will be discussed. The lecture will present the issues with clinical cases and their dilemmas to enhance the relevance between the theory and clinical practice.

5.
Journal of the Intensive Care Society ; 23(1):156-157, 2022.
Article in English | EMBASE | ID: covidwho-2042971

ABSTRACT

Introduction: Clinical pharmacists specialising in critical care have become integrated into the critical care workforce providing valuable contributions to patient care.1 These findings are supported through the inclusion of clinical pharmacy services within national professional and commissioned standards for critical care.2,3 On admission to critical care, clinical focus changes from management of any chronic conditions to that of immediate preservation of life. This is inherently associated with acute changes in prescribed medicines.Medicines reconciliation on admission to and discharge from critical care is included specifically within the commissioning standards3 and aims to address any discrepancies generated by this change in focus. Unprecedented pressures experienced during the COVID-19 pandemic have resulted in stretched staff to patient ratios and mobilisation of less experienced staff. This has negatively impacted the end-to-end reconciliation process causing patients to be discharged home with unresolved medicines discrepancies. In line with recent NICE4 and Intensive Care Society guidance,5 rehabilitation of patients, post-critical care is important in completing unresolved actions and optimising care. Consequently, in September 2020 a carousel rehab clinic was introduced. All professional groups were invited to contribute. Objectives: To embed a pharmacist within the rehabilitation clinic to focus on any unresolved medicines reconciliation issues. Methods: Five senior critical care pharmacists (band 8a or above) participated in service provision to the clinic, which ran on two days a week. For consistency and structure, a local SOP and electronic note template was produced. All interventions recommended were discussed with the patient at the time and for GPs to review and action as appropriate in the context of their responsibility for ongoing care. Data collection for this service evaluation was retrospective and performed by one of the critical care pharmacists who had participated in the clinic. Historic clinic dates for September - November 2020 (inclusive) were reviewed on the electronic scheduling system to identify patients who attended clinic;these were then filtered for pharmacist entries to ascertain: • Number of patients reviewed • Number of medication-related interventions made • Intervention type and medication(s) involved Results: Over the 3-month period 51 patients were reviewed with a total of 59 medicine interventions made. The average number of interventions per patient was 1.2, with a range of 0 - 7. Eight intervention categories were identified (see Figure 1);the top three of which recommended stopping a medication (27%), reviewing a medication's need (19%) or restarting a medication (17%). The drugs most frequently intervened on were lansoprazole (12%) and bisoprolol (7%). Examples of significant clinical interventions made include: • Stopping acutely initiated bisoprolol (resolution of acute AF secondary to acute sepsis/dehydration on ICU) • Stopping of acutely started olanzapine for ICU-related agitation/delirium • Dose optimisation of bisporolol (post recent NSTEMI) • Re-initiation of atorvastatin (for secondary prevention of IHD) Conclusion: Medication interventions made by pharmacists in the post ICU rehabilitation clinic setting are clinically significant and add value to patient care both in terms of morbidity and mortality. Our results demonstrate a reduction in polypharmacy burden in line with wider healthcare initiatives.

6.
Archives of Disease in Childhood ; 107(Suppl 2):A165-A166, 2022.
Article in English | ProQuest Central | ID: covidwho-2019859

ABSTRACT

AimsThe average maximal early weight loss in exclusively breastfed babies is 5.5-8.6%1 which is predominantly due to excretion of excess fluid as urine. Babies who experience difficulty establishing effective breastfeeding risk having higher levels of weight loss and hypernatraemic dehydration which can have significant morbidity and mortality.2 Routine weighing is used to screen for babies at risk of dehydration at a premorbid stage and allow for enhanced support.Objectives1. To assess the impact of the Covid-19 Pandemic on rates of markers of significant dehydration in breastfed babies2. To benchmark the rate of markers of significant dehydration in early life, to allow individual trusts to assess their own performanceMethodsAudit criteria were developed by the Hospital Infant Feeding Network (www.hifn.org) and NHS Trusts across the UK were invited to participate. Each trust registered and performed the audit in line with local governance policies and reported aggregate anonymised outcomes.Inclusion criteriaBabies born ≥34 weeks’ postmenstrual age who were assessed or treated in hospital with weight loss ≥12.5% and/or plasma sodium ≥155mmol/L in the first 21 days of life.Exclusion criteriaExclusive formula feeding by day 3 of life and/or congenital abnormality affecting feeding, identified before day 3 of life.Data were collected for two six months epochs: 01/09/19-29/02/20 (pre-pandemic) and 01/04/20-30/09/20 (early pandemic).Analysis used Chi square testResults13 NHS trusts from across the UK submitted data, representing approximately 29,000 births in each epoch. All responding trusts were Unicef Baby Friendly Initiative accredited at Stage two or above. Routine weighing of babies varied between day 3-5, with the majority (73%) using ≥12.5% weight loss as the threshold for medical review. There was no statistically significant differences between rates of weight loss or serum sodium ≥155mmol/l between the two epochs. Data were therefore pooled for benchmarking: 0.8% of babies had ≥12.5% weight loss (approximating the 99th centile), 0.2% had ≥15% weight loss (approximating the 99.8th centile) and 0.1% had hypernatraemia ≥155mmol/l (approximating the 99.9th centile).ConclusionThis national collaborative audit is the first of its kind to provide benchmarking data for trusts to focus on their own service improvement. The rate of ≥12.5% weight loss found is consistent with that published by NICE, supporting the validity of the approach despite a skew towards Unicef accredited units in Southern England. There was no significant increase in excess weight loss or severe hypernatraemia during the early pandemic despite the disruption to breastfeeding support services - it is also known that national breastfeeding rates remained stable.3 It is possible that an increase in dehydration in some babies due to poor breastfeeding support is masked by increased formula use in others, or by improved breastfeeding efficacy due to reduced competing demands. This is supported by other evidence showing a mixed picture of feeding outcomes for different families during the pandemic.4ReferencesNICE Guideline 75. 2017.Laing IA. Archives F&N 2002;87:F158-F162.Harrison S. You and your baby: a national survey NPEU. 2021.Brown A. Mater Child Nutr. 2021;17:e13088.

7.
Kafkas Universitesi Veteriner Fakultesi Dergisi ; 28(4):507-514, 2022.
Article in English | EMBASE | ID: covidwho-2006516

ABSTRACT

In this study, it was aimed to evaluate the relationship between the clinical course of the disease and hematological data, serum 25-hydroxyvitamin D (25 (OH) D), iron (Fe), free iron-binding capacity (UIBC), and D-dimer levels in calves with diarrhea in the neonatal period. Within the scope of the study, 10 healthy calves (group-I) and 30 diarrheal calves in the neonatal period of different races, ages and genders were used. Calves with diarrhea were divided into mild (group-II, n=10), moderate (group-III, n=10) and severe (group-IV, n=10) groups. Blood samples were taken from calves in all groups at once. Hematological analyzes were performed using a veterinary-specific hematology analyzer device. In serum samples, 25 (OH) D3, Fe and UIBC levels were determined with an autoanalyzer, and D-dimer levels were determined with an automatic immunoassay analyzer. In the hematological analysis, an increase was observed in the number of LYMs (lymphocytes) in group-II (5.04±1.3) and III (5.2±3.3) compared to group-I (4.47±1.2), and a decrease was observed in group IV (2.76±0.9) (P<0.05). Fe levels in group-II (59±56), group III (56±52) and group IV (72±63) were found to be decreased compared to group-I (131±66) (P<0.05). It was determined that the 25 (OH) D3 level of group IV (13.4±8.5) was higher than that of group-I (6.12±2.73) (P<0.05). D-dimer levels of group-III (1.15±1.13) and group-IV (0.96±0.88) were found to be higher than group-I (0.10±1.46) (P<0.05).

8.
Surgery for Obesity and Related Diseases ; 18(8):S49, 2022.
Article in English | EMBASE | ID: covidwho-2004514

ABSTRACT

Peter Ng Raleigh NC1, Afton Carducci Raleigh NC1, Lindsey Sharp Raleigh NC1, Dustin Bermudez Raleigh NC1, Linda Youngwirth Durham NC1, Tricia Burns Raleigh NC1, Erica McKearney Raleigh NC1, Lauren Massey Raleigh NC2 UNC Rex Bariatric Specialist1 UNC REX Hospital2 Introduction: The COVID-19 pandemic stressed inpatient hospital capacity and restricted elective surgery, limiting bariatric access. A novel outpatient home health program was introduced to support early discharge after bariatric surgery and preserve inpatient healthcare resources for COVID. This retrospective study evaluates the clinical/financial impact of enhanced home health in early post-operative bariatric recovery. Methods: Our program offered enhanced home health (EHH) to all bariatric patients with insurance inclusion. Patients were separated into 3 care tiers based on BMI and comorbidity with each tier adding complementary services. Tier 1 provided home intravenous hydration, anti-emetics x 3 days, and home nursing care. Tier 2 (BMI>50 kg/m2) added physical therapy. Tier 3 (plus comorbidity) added virtual primary care medical consultation. Patients were planned for scheduled discharge on post-operative day one by 10 am, if deemed medically appropriate. Results: From December to June 2021, 355 bariatric cases were performed, 158 non-EHH patients and 197 EHH patients with the following combined case mix: duodenal switch (54.6%), revision (17.2%), sleeve gastrectomy (16.6%), SADI-S (7.7%), and Roux-en-Y gastric bypass (3.9%). The prior year average hospital length of stay (LOS) was 2.0 days, non-EHH LOS of 2.0 days, versus EHH LOS of 1.5 days. A 6% reduction in direct variable costs per case was demonstrated, $9607 non-EHH versus $9036 EHH. Comparative readmission rates for nausea/vomiting/dehydration (NVD) equaled 3.8% for non-EHH and 1.5% for EHH patients. Conclusion: Enhanced home health preserved access to bariatric care while decreasing length of stay, variable costs, and reduced readmission for NVD.

9.
EJVES Vascular Forum ; 54:e50, 2022.
Article in English | EMBASE | ID: covidwho-2004044

ABSTRACT

Introduction: Inflammatory mechanisms triggered and supported by SARS-CoV-2 infection can increase venous thromb-oembolism (VTE) risk. Aim: The aim of the present comparative study was to report on the incidence of VTE in a prospective consecutive series of COVID-19 negative outpatients referred to our vascular ultrasound laboratory for suspected VTE with (COVID+) or without (COVID–) recent SARS-CoV-2 infection during the COVID-19 pandemic. Methods: All patients included in the present study were assessed by duplex ultrasound for the detection of VTE. The following data were collected for each patient: time from first negative swab after COVID-19 infection and VTE diagnosis in COVID+ patients;administration of heparin prophylaxis during COVID-19 infection;presence of venous risk factors (previous VTE episode, chronic venous insufficiency, thrombophilia, recent surgery with prolonged immobilisation, history of malignancy, need for high dose steroid therapy, and dehydration during infection). Rate of VTE was detected and compared between the two groups of COVID+ or COVID– patients by chi square test for categorical data. The presence of risk factors for VTE were analysed as related to VTE occurrence in both groups. Results: From 1 February 2021 to 31 March 2021, 34 patients were included in the study. Among them eight had previous SARS-CoV-2 infection and were negative at the time of investigation. In COVID+ patients, time from first negative swab after COVID-19 infection and VTE diagnosis ranged between 3 and 50 days (mean 17 ± 14.39 days), and 12.5% (n = 1/8) had heparin prophylaxis during infection. Risk factors for VTE were detected in all COVID+ patients and 80.7% (n = 21/26) of COVID– patients. Rate of VTE was 87.5% (n = 7/8) in COVID+ patients and 11.5% (n = 3/26) in COVID– patients (odds ratio 53.66, 95% confidence interval 4.79 – 601.23;p <.001). In the COVID+ population only one patient receiving heparin prophylaxis during infection did not present with VTE. One COVID+ patient presented with both arterial and venous popliteal thrombosis. By comparing directly COVID+ patients with no heparin prophylaxis and venous risk factors (n = 7) to COVID– patients with venous risk factors (n = 21), VTE risk was strongly associated with the presence of previous SARS-CoV-2 infection without proper heparin prophylactic administration (p <.001). Conclusion: In this preliminary series presence of risk factors for VTE and recent SARS-CoV-2 infection with no heparin prophylaxis is strongly associated with VTE occurrence. COVID-19 outpatients should be treated by prophylactic heparin whenever VTE risk factors are detected and duplex ultrasound cannot be performed to exclude a VTE episode, so that physicians treating outpatients should be aware of the VTE risk in those patients. Both arterial and venous conditions prone to thrombosis should be fully assessed in patients when diagnosing a new SARS-CoV-2 infection.

10.
Pediatrics ; 149, 2022.
Article in English | EMBASE | ID: covidwho-2003337

ABSTRACT

Introduction: Multisystem Inflammatory Syndrome in Children (MIS-C) is a constellation of symptoms involving fever, laboratory evidence of inflammation, and >/= 2 organ systems involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurologic) in a patient who is positive for current or recent COVID-19 infection by RT-PCR, serology or by antigen testing. The total number of cases reported in the United States with MIS-C is more than 3000 as of May 2021. We present a case of MIS-C presenting as a retropharyngeal abscess in a 17- year-old with dendritic cell neoplasm. Case Description: 17-yearold male with a past medical history of metastatic, recurrent, atypical dendritic tumor currently in remission presented with fever for 4 days, associated with headache, sore throat and dysphagia, with a normal examination except 3+ tonsils without midline shift. He had an asymptomatic COVID 19 infection 2 months prior to this presentation. On admit, labs revealed hyponatremic (129) dehydration and a CRP of 29. CT neck showed a well-defined retropharyngeal fluid collection. He was started on Vancomycin and Cefepime and was also given a dose of Dexamethasone. Due to clinical improvement on Day 3, the antibiotics were changed to Unasyn and Clindamycin for the presumed retropharyngeal abscess. He however became hemodynamically unstable and was taken for an emergent incision •drainage by ENT but there was no fluid to be drained. He remained intubated and admitted to the ICU. He required vasopressors because of his hemodynamic instability and broadspectrum antibiotics for concerns of sepsis. Further workup showed signs of end organ damage and inflammation including severe myocardial dysfunction (EF ∼ 20%) and a positive COVID 19 antibody. He was diagnosed with MIS-C and started on IVIG, steroids and Enoxaparin. He showed significant improvement in his clinical status, inflammatory markers and myocardial function over the next 24-48 hours following initiation of treatment. Discussion: MIS-C is believed to develop due to an abnormal immune response to the COVID 19 virus. There has only been a single case reported in a healthy individual presenting as a retropharyngeal abscess. Most of the cases of MIS-C are reported in primarily healthy children or with comorbidities like obesity and asthma but there have been very few cases reported in oncology patients possibly because of an inadequate immune response in these patients. Our case to the author's knowledge is the first case of MIS-C presenting as a retropharyngeal abscess in an oncology patient. Conclusion: It is important to identify the history of COVID 19 infection and have a high index of suspicion in unusual presentations so that early investigation and management is possible to prevent morbidity and mortality due to MIS-C.

11.
Lung Cancer ; 165:S52-S53, 2022.
Article in English | EMBASE | ID: covidwho-1996676

ABSTRACT

Introduction: Due to COVID-19, NCCC established a Stage III cCRT review clinic. From April 2020 a prospective audit of patients treated was established. Methods: All lung radiotherapy referrals were scrutinised from January-December 2020. Electronic data was obtained from radiotherapy software. Patients treated with cCRT were analysed for: 1) Toxicity data. 2) Hospital admissions. 3) PDL1 status. 4) Adjuvant durvalumab treatment. Patients who received either unimodality radiotherapy or sequential chemoradiotherapy were reviewed for justification for not treating with cCRT . Results: Of 670 patients treated. 295 received palliative and 375 radical radiotherapy. 141 patients received radical radiotherapy (55Gy in 20#). 55 were Stage III NSCLC, 18 received sequential chemoradiotherapy. 49 patients received cCRT, 41 were stage III NSCLC. 55 stage III patients did not receive cCRT. 8 reason codes were identified: 1) Comorbidity (N=16). 2) Size (N=18). 3) No histopathology (N=3). 4) Consented for cCRT, but disease progression/too big at time of radiotherapy planning (N=6). 5) Relapse (N=3). 6) Reason not annotated (N=5). 7) Patient declined (N=2). 8) Adjuvant RT after surgery (N=2). Of the 41 cCRT NSCLC patients. All patients experienced some toxicity. There were no grade 4 toxicity. 2 patients reported Grade 3 toxicity (nausea and fatigue);dyspnoea, cough, fatigue, oesophagitis and nausea being the most common. 4 out of 41 patients were admitted. Reasons were dehydration, chest infection, oesophagitis, hyponatraemia, neutropenia. 1 patient did not proceed to durvalumab, due to deterioration of performance status. 30 out of 41 patients were PDL1 +, of which 26 were consented for durvalumab. Reasons for no durvalumab were: rheumatoid arthritis, inflammatory bowel disease, interstitial lung disease and deterioration after cCRT. Conclusion: cCRT is an effective delivery as an outpatient. However, ongoing audit is imperative to ensure optimal patient treatment. The data as highlights multidisciplinary input is essential, as most cCRT patients experience toxicity. Disclosure: No significant relationships.

12.
Journal of General Internal Medicine ; 37:S526, 2022.
Article in English | EMBASE | ID: covidwho-1995635

ABSTRACT

CASE: An 84-year-old woman with atrial fibrillation on Digoxin presented with acute onset of confusion associated with a week history of abdominal pain, vomiting, and poor fluid intake. A few days prior, Amiodarone was added to her drug regimen which included Lasix. Additionally, she received the COVID-19 booster vaccine which led to a viral-like syndrome resulting in dehydration. The patient was afebrile, normotensive, but bradycardic. EKG showed a prolonged PR interval and scooped ST segments. Labs showed hyperkalemia, pre-renal acute kidney injury (AKI), and a Digoxin level of 4.3 ng/mL (therapeutic range: 0.8-2.0 ng/mL). Digoxin and Lasix were held and Digoxin antidote, Digibind, was administered with normalizing heart rate, potassium, and clinical improvement. IMPACT/DISCUSSION: Digoxin is used to slow conduction in atrial fibrillation and increase cardiac contractility in heart failure. It inhibits the membrane sodium-potassium-adenosine triphosphatase pump (Na/K ATPase), resulting in increased cytosolic calcium and subsequent cardiac contractility and automaticity. In turn, this can also cause premature ventricular contractions and tachycardia. In the carotid sinus, increased baroreceptor firing and subsequent increased vagal tone occurs which can cause bradycardia, atrioventricular blocks, hypotension, and GI symptoms. In skeletal muscle, hyperkalemia can result due to the abundance of Na/K ATPase pumps. Digoxin has a narrow therapeutic index with serum levels easily affected by many commonly prescribed drugs by way of decreasing renal clearance, inhibiting P-glycoprotein, and inducing secondary electrolyte disturbances. That said, drug dosing should be individualized with close monitoring to avoid potentially life-threatening effects that may result with even mildly increased digoxin levels. Acute toxicity manifests as non-specific GI, and neurologic symptoms (confusion, lethargy, visual changes), hyperkalemia, and brady or tachy-arrhythmias. Treatment is with digoxin specific fragment antigen binding (Fab) antibody, Digibind, which binds digoxin, inactivating it within 6-8 hours. Postadministration, digoxin serum testing cannot distinguish free verse bound drug;therefore, drug levels remain elevated for days to weeks until the FabDigoxin complex is excreted. In the case above, the viral-like-syndrome after the booster vaccine with subsequent AKI secondary to dehydration likely precipitated Digoxin toxicity. Accompanying drug interactions of diuretics causing dehydration and hypokalemia, P-glycoprotein inhibitors (Amiodarone, Verapamil, Diltiazem, Quinidine), and ACE inhibitors can further worsen renal clearance and culminate in Digoxin toxicity. CONCLUSION: Given Digoxin's narrow therapeutic index, small clinical changes such as post COVID-19 vaccine flu-like symptoms, dehydration, and medication changes can manifest drug toxicity. Therefore, attentive monitoring of accompanying comorbidities and drug interactions is imperative at preventing catastrophic toxic effects.

13.
Journal of the Academy of Consultation-Liaison Psychiatry ; 63:S20-S21, 2022.
Article in English | EMBASE | ID: covidwho-1966660

ABSTRACT

Introduction: Anorexia Nervosa (AN) is an eating disorder defined by an abnormally low body weight due to purging behaviors/food intake restrictions and distorted self-image. Coronavirus disease 2019 (COVID-19) has changed our environment due to social distancing, lockdown, and reduced access to regular mental health services. Reports indicate a negative impact of COVID-19 on mental health1, including patients with AN2. Our Consultation-Liaison service noticed an increase in new-onset AN cases and a worsening of established AN cases attributed to the environment created by COVID-19. Methods: PubMed literature review with keywords “COVID-19” and “AN.” Review of seven AN cases seen during the pandemic. Case series: Seven cases (COVID-19 negative) of worsening AN were seen by our Consultation-Liaison service between August 2020 and January 2021. Six cases were newly diagnosed, five cases presented severe dehydration, electrolyte imbalance, or bradycardia requiring inpatient stabilization, and five cases needed transfer to inpatient eating disorder units. The lack of structured activities and increased social media use leading to distorted self-image were found to be a trigger. Discussion: The impact of the Pandemic in AN can vary. The lack of structure, increased social media use, and reduced access to mental health services may increase AN incidence and worsening of symptoms3. However, a study reported a positive response to AN treatment during confinement4, possibly due to family dynamics5. It is important to note that patients with AN are a vulnerable population that requires greater support and monitoring to prevent worsening symptoms and long-term consequences. These observations suggest the need for further research to understand the impact of the pandemic on AN symptoms onset and severity. References: 1. Phillipou, A., et al. (2020). Eating and exercise behaviors in eating disorders and the general population during the COVID-19 pandemic in Australia: Initial results from the COLLATE project. The International journal of eating disorders, 53(7), 1158–1165. https://doi.org/10.1002/eat.23317 2. Termorshuizen, J. D., et al. (2020). Early impact of COVID-19 on individuals with self-reported eating disorders: A survey of ∼1,000 individuals in the United States and the Netherlands. The International journal of eating disorders, 53(11), 1780–1790. https://doi.org/10.1002/eat.23353 3. Branley-Bell, D., et al. (2020). Exploring the impact of the COVID-19 pandemic and UK lockdown on individuals with experience of eating disorders. Journal of eating disorders, 8, 44. https://doi.org/10.1186/s40337-020-00319-y 4. Fernández-Aranda, F., et al. (2020). COVID Isolation Eating Scale (CIES): Analysis of the impact of confinement in eating disorders and obesity-A collaborative international study. European eating disorders review: the journal of the Eating Disorders Association, 28(6), 871–883. https://doi.org/10.1002/erv.2784 5. Yaffa, S., et al. (2021). Treatment of eating disorders in adolescents during the COVID-19 pandemic: a case series. Journal of eating disorders, 9(1), 17. https://doi.org/10.1186/s40337-021-00374-z

14.
Neurology ; 98(18 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1925572

ABSTRACT

Objective: We aim to report clinical characteristics of an extremely rare case of myelitis with Guillain-Barré syndrome (GBS) and cerebellar ataxia (CA) after COVID-19 infection. Background: There have been many reports about neurological complications following the world pandemic of COVID-19. We found about 100 GBS, 50 myelitis, and 10 CA cases after COVID-19 infection. To best our knowledge, this is the first report of myelitis with GBS and CA accompanied by multiple autoantibodies. Design/Methods: NA Results: A 60-year-old man with fever and cough was diagnosed with mild COVID-19 infection. Fourteen days later from the onset, he developed gait disturbance and fell frequently. On hospitalization, he exhibited fever, hypoxemia, mild consciousness disturbance, flaccid paraplegia, mild numbness and severe deep sensory disturbance in the lower limbs, bladder and bowel disturbance, mild muscle weakness in the fingers, myoclonus in the extremities, and CA. The PCR of COVID-19 was negative. Blood investigations showed elevated inflammatory markers with dehydration, rhabdomyolysis, and hypercoagulation. Cerebrospinal fluid (CSF) analysis presented mild pleocytosis and elevated protein without anti-COVID-19 antibodies. Contrast-enhanced CT showed massive pulmonary embolisms and deep venous thromboses. Brain SPECT showed cerebellar hypoperfusion despite no abnormalities in brain MRI. Spine MRI revealed longitudinal hyperintense lesions mainly in the dorsal white matter, compatible with myelitis. Additional investigations of autoantibodies realized anti-GM3, TPI, GluR, and NMDAR IgG antibodies in serum, and anti-GluR and NMDAR IgG antibodies with increased granzyme B in CSF. Treatments of corticosteroid and intravenous immunoglobulin resulted in complete recovery to consciousness disturbance, muscle weakness of fingers, myoclonus, and CA, while paraparesis with deep sensory and bladder and bowel disturbance remained. Conclusions: We highlight the possibility of the coexistence of several post-infectious autoimmune neurological complications in patients of COVID-19. It is important to search autoantibodies carefully corresponding to clinical manifestations for appropriate treatments and understanding of pathophysiology.

15.
Angew Chem Int Ed Engl ; 61(28): e202202637, 2022 Jul 11.
Article in English | MEDLINE | ID: covidwho-1919226

ABSTRACT

Herein we report secondary pyrrolidin-2-ols as a source of cyclic (alkyl)(amino)carbenes (CAAC) for the synthesis of CAAC-CuI -complexes and cyclic thiones when reacted with CuI -salts and elemental sulfur, respectively, under reductive elimination of water from the carbon(IV)-center. This result demonstrates a convenient and facile access to CAAC-based CuI -salts, which are well known catalysts for different organic transformations. It further establishes secondary alcohols to be a viable source of carbenes-realizing after 185 years Dumas' dream who tried to prepare the parent carbene (CH2 ) by 1,1-dehydration of methanol. Addressed is also the reactivity of water towards CAACs, which proceeds through an oxidative addition of the O-H bond to the carbon(II)-center. This emphasizes the ability of carbon-compounds to mimic the reactivity of transition-metal complexes: reversible oxidative addition and reductive elimination of the O-H bond to/from the C(II)/C(IV)-centre.

16.
Nephrology Dialysis Transplantation ; 37(SUPPL 3):i263, 2022.
Article in English | EMBASE | ID: covidwho-1915823

ABSTRACT

BACKGROUND AND AIMS: Acute renal failure in hospitalized patients for COVID- 19 occurs in 3%-28% and is a poor prognostic factor. The mechanisms of renal involvement are not completely clarified. However, it has been evaluated that the presentation of renal failure increases adverse outcomes. METHOD: Prospective observational study of all the cases that were admitted for COVID-19 between January and December 2021. Clinical and analytical data of kidney complications in patients with COVID-19 were collected. RESULTS: A total of 306 patients with a mean age of 70.2 years, 75.1% men and with previous chronic kidney disease in 29.7% were analyzed. A total of 50.8% had severe pneumonia or acute respiratory distress syndrome and 22.9% required admission to the ICU. Proteinuria was registered in 77.6% and hematuria in 67.6%. A total of 20.9% of the patients required renal replacement therapy. Renal failure was of prerenal etiology in 59.2%, acute tubular necrosis in the context of sepsis in 23.5%, glomerular in 8.1% and due to tubular toxicity in 9.2%. The median stay was 15 days, and 31.7% died. Patients who developed kidney failure during admission had higher C-reactive protein, LDH, and D-dimer values, more severe lung involvement, more need for ICU admission, and greater need for renal replacement therapy. CONCLUSION: Hypovolemia and dehydration are common causes of acute kidney injury in COVID-19 patients. Those who develop renal complications have a worse pulmonary, renal and systemic prognosis profile. We point out that monitoring an individualized management of blood volume can be decisive in preventing worse outcomes.

17.
Nephrology Dialysis Transplantation ; 37(SUPPL 3):i770-i771, 2022.
Article in English | EMBASE | ID: covidwho-1915812

ABSTRACT

BACKGROUND AND AIMS: The number of patients requiring home dialysis in Japan is increasing due to COVID-19 and the aging of the population. Home haemodialysis has been performed in Japan since the 1960s. However, as of March 2019, there were 720 home haemodialysis patients in Japan, which is only 0.2% of the total number of dialysis patients. The possible causes are as follows. The number of home haemodialysis patients has not increased markedly due to safety concerns as home haemodialysis patients perform dialysis at home, and the out-ofpocket costs are high. In addition, patients and caregivers must be able to manage themselves, and the burden on both patients and caregivers is heavy. Therefore, the Ministry of Health, Labour and Welfare (Japan) has advocated the need for home patients to share information with medical institutions to improve their quality of life, including COVID-19 measures. We have built a system to support home dialysis patients. Here, we have added an exercise therapy function to this system to encourage patients to continue exercising. METHOD: The items recorded/displayed in the patient's home peritoneal dialysis support system included records such as time, blood pressure, blood glucose level, urine volume, meal content, replacement start time, dialysate/plasma ratio, drainage volume, injection volume, water content and water removal and drainage. These inputs were entered via drop-down menus and displayed visually in graphs or by uploading images. The medical staff could see photographs of the affected areas and of meals entered by the patient. Patients could also share their opinions and treatment schedules with the medical staff at the medical institution. In addition, when exercising, the patients used an ergometer that allowed them to sit or lie down. The developed system incorporates records of the patient's exercises. Data were captured directly from the ergometer into the developed system in CSV format and could also be entered manually via drop-down menus. RESULTS: Using the developed system, we were able to enter and view patients' vital data and display photographs showing the color and volume of the drainage pack. By viewing these photographs, the medical staff could confirm the photographs of the affected areas, the color of the packs and the contents of the patients' meals. In addition, displaying the patient's vital records in a graph allowed for visual evaluation over time, which was useful when giving advice to patients. Using the two-way communication function, patients were also able to share their opinions and treatment schedules with the medical staff of the medical institution. Patients can now consult with medical staff, making their homes more like part of the hospital and giving them greater peace of mind. Figure 1 shows an example of the display of the developed system. Figure 2 shows an example of the patient's pedaling exercise results input from the ergometer. The amount of pedal movement performed by the patient was conserved through the dynamo and used to charge mobile devices. This allows the patient to charge their mobile devices while exercising, thus encouraging them to continue exercising. CONCLUSION: We have developed a support system for home haemodialysis patients that allows the input and display of patients' vital records and consultation with medical staff online. We have added a function to the system to encourage home haemodialysis patients to continue exercising. By using the developed system, patients can now perform home dialysis, including continuous exercise safely and with peace of mind, and healthcare professionals can access all medical information of patients, including changes over time. (Figure Presented).

18.
Nephrology Dialysis Transplantation ; 37(SUPPL 3):i214, 2022.
Article in English | EMBASE | ID: covidwho-1915694

ABSTRACT

BACKGROUND AND AIMS: Despite the lungs are the major targets of COVID-19, other organs such as the kidneys are also affected. Renal complications of COVID-19 are not yet well studied. We aimed to study the prevalence of acute kidney injury (AKI) among positive COVID-19 cases that were managed in the intensive care unit (ICU) in a single isolation hospital during the pandemic, and to explore its impact on patient outcome. METHOD: This retrospective study included 616 patients with COVID-19 who were managed in the ICU in a single isolation hospital in Kuwait during the pandemic, from February to December 2020. AKI was defined according to the serum creatinine criteria in the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Of the 616 patients, 40.2% developed AKI (group 1, n = 248) and were compared with the patients without AKI (group 2, n = 368). RESULTS: Most of cases in the two groups were males (73% versus 70.7%), aged (60.8 ± 14 versus 51.7 ± 16 years), respectively. The two groups were comparable regarding chronic kidney disease (2% versus 0.8%) and chronic pulmonary disease. Other factors were significantly predominating among group 1 as diabetes mellitus (63.7 versus 40.5%), hypertension (74.2% versus 40.5%) and ischemic heart disease (26.2% versus 12.5%) (P < .05). Fever, cough, shortness of breath and dehydration were significantly more frequent presentations among patients of group 1, and had radiological findings that were synchronized with COVID-19 (89.5% versus 50.8%) (P < .05). Moreover, sepsis, volume depletion, shock, arrhythmias and ARDS predominated among the AKI group (P < .05). The number of cases who were managed by therapeutic anticoagulation was significantly higher in AKI patients (89.9% versus 51.9%);also, cases who received supportive vasopressors and convalescent plasma transfusion as well as steroid were significantly higher in the same group (P < .05). Other therapeutic modalities such as antivirals, tocilizumab and hydroxychloroquine were comparable in both groups. We found that acute respiratory failure requiring mechanical ventilation was significant among the AKI group (66.8% versus 29.4%), and the overall mortality rate was significantly higher in the same group (62.5% versus 32.8%). CONCLUSION: The prevalence of AKI in patients with COVID-19 was 40.2%, and it was associated with poor prognosis among ICU COVID-19 positive cases.

19.
Diseases of the Colon and Rectum ; 65(5):73-74, 2022.
Article in English | EMBASE | ID: covidwho-1893980

ABSTRACT

Purpose/Background: Historically, diversion was performed prior to resection of complex diverticular disease. This fell out of favor, but with the advent of laparoscopy, we investigated whether fecal diversion as a first step is a safe alternative in select patients who would otherwise undergo a Hartmann's procedure. Hypothesis/Aim: For select patients with acute medically-refractory diverticulitis, diversion without resection controls sepsis and is a safe option. Methods/Interventions: Single institution retrospective chart review of all patients presenting with acute complicated diverticulitis from July 2016- June 2021 was performed. The subset of patients who underwent diverting loop ileostomy or colostomy without initial resection were analyzed for demographics, reason for diversion alone and clinical course. Results/Outcome(s): Nineteen patients who underwent loop diverting ostomy (17 ileostomies, 2 colostomies) were identified. Seventeen of 19 were performed laparoscopically. The average patient age was 52.8 years old (SD 18.1) and 47% were men. Six patients had preoperative abscesses, one of which was amenable to percutaneous drainage. Several patients were initially admitted for another diagnosis and subsequently developed diverticulitis. Comorbidities included cases of severe COVID, recent bone marrow transplantation, and current chemotherapy for lymphoma. The average time from admission to operation was 3.3 days (SD 2.9), and the average postoperative length of stay was 10.1 days (SD 10.7). None of the 19 patients required resection for failure to improve during that hospitalization. Two patients (10.5%) required placement of a percutaneous drain post-operatively. Seventeen patients were discharged home (89.5%) and 2 were discharged to a rehabilitation facility. Six patients required emergency department visits or readmission, most often for dehydration. Since their diversion, 16 patients have subsequently undergone sigmoid resection (84.2%), 15 with primary anastomosis and subsequent diverting ostomy takedown, and one with conversion from loop colostomy to descending colostomy and Hartmann's pouch. Five of the 16 sigmoid resections were performed laparoscopically (31.3%). Limitations: This study is a single institution retrospective review with a small sample size. Conclusions/Discussion: Fecal diversion appears to be a safe initial surgical strategy, providing adequate control of local sepsis in patients who are felt to be poor candidates for sigmoid resection with primary anastomosis and diversion, and allows patients to avoid an initial Hartmann's procedure. All 19 patients were discharged without requiring additional surgery. For patients with severe acute confounding medical comorbidities, initial diversion may allow the patient to recover from their acute process, permit optimization of their health status, and allow an elective sigmoid resection at a more opportune time. (Table Presented).

20.
International Journal of Toxicological and Pharmacological Research ; 12(4):87-97, 2022.
Article in English | EMBASE | ID: covidwho-1857331

ABSTRACT

Objective: To classify the haematological pattern, severity of anemia in children 5-12 years age admitted and to find its correlation with the clinical conditions. Methods Crossectional study of 160 patients in two years was done. Patients satisfying the inclusion criteria were selected for study. Relevant clinical data were recorded in a structured proforma including detailed history was recorded with particular symptoms suggestive of anemia such as weakness and easily fatigability, breathlessness on exertion and pica. A thorough clinical examination of every child was done followed by routine investigations for anemia Results Patients between 7-8 year were found to be the most affected. Anemia was found to be more common in female children as compared to male children (F:M=1.13). Anemia is more common in undernourished child. Most common presenting symptoms were gastrointestinal including vomiting, diarrhea and pain abdomen. Most common sign was Pallor followed by other common signs included signs of dehydration associated with diarrhea, hepatosplenomegaly. microcytic hypochromic anemia was the most common morphological type of anemia and macrocytic anemia was the least common.Thalassemia cases were most common among hemolytic anemias. Iron Deficiency Anemia (Nutritional Anemia) was the most common etiology of anemia. Conclusion Dietary deficits affect children aged 5 to 12, creating financial, emotional, and psychological burden for patients and their families, as well as depleting critical national resources. As a result, screening for these illnesses, as well as early detection of anemia and related problems, is essential.

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