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1.
Acta Medica Mediterranea ; 38(5):3367-3374, 2022.
Article in English | EMBASE | ID: covidwho-2081232

ABSTRACT

Objectives: D-dimer is increasingly becoming an important auxiliary marker in guiding diagnosis and treatment in various fields of medicine. Moreover lastly, D-dimer has become one of the most common tests during the COVID-19 pandemic. In this study, we aimed to investigate the value of D-dimer in predicting the prognosis and surgery in burn patients. Method(s): A total of 136 burn patients hospitalized in our center were retrospectively analyzed. All patients were treated in the inpatient setting and had complete clinical and laboratory test results.Data including demographic, clinical, and laboratory data, length of stay(LOS) in the hospital, and surgeries were recorded. Plasma D-dimer levels were analyzed using an automatic analyzer. The D-dimer levels were analyzed according to two ranges: 0-0.5microg/mL FEU and >0.5microg/mL FEU. Result(s): Of a total of 136 patients (median age:37,interquartile range:45.75), 32.4% (n=44) were females and 67.6% (n=92) were males.The median burn percentage and length of hospital stay were higher in patients with D-dimer level>0.5ug/mL FEU (p=0.007,p<0.001). The number of patients with a D-dimer level of >0.5microg/mL FEU (high range) was significantly higher in the grafted group(p=0.043). Conclusion(s): The D-dimer test can be a valuable criterion in deciding on graft surgery and predicting the prognosis of burn patients. Copyright © 2022 A. CARBONE Editore. All rights reserved.

2.
Int J Osteopath Med ; 2022 Oct 14.
Article in English | MEDLINE | ID: covidwho-2076199

ABSTRACT

Background: SARS-CoV-2 infection responsible for the COVID-19 pandemic has demonstrated a significant burden on the mental health of health care providers. The purpose of the study is to evaluate the mental health symptoms among osteopathic physicians from a single academic institution during the COVID-19 pandemic. Methods: This was a cross-sectional, survey-based study conducted during the COVID-19 pandemic from January 2021 to March 2021. The survey was emailed to 4239 alumni physicians from the single medical school in California, USA. Burnout, anxiety, and depression were assessed by the single-item Mini-Z Burnout Assessment, 7-item Generalized Anxiety Disorder Scale, and 2-item Patient Health Questionnaire, respectively. Results: A total of 104 survey responses were analyzed. Of them, 53 (51.0%) were attending physicians and 51 (49.0%) were residents or fellow physicians. Anxiety, burnout, and depression were reported in 29 (29.9%), 31 (32%), and 11 (11.3%), respectively. Females had increased anxiety (OR 1.66, CI 1.21-2.27; P = 0.002). Resident had higher burnout symptoms (OR 1.28, CI 1.06-1.53; p = 0.009) and depression symptoms (OR 1.15, CI 1.01-1.30; p = 0.032) compared to attending physicians. Physicians who encountered >50 COVID-19 patients had higher depression symptoms (OR 1.17, CI 1.02-1.35; p = 0.027). Conclusion: Our survey study demonstrated that osteopathic physicians graduated from a single academic institution experienced symptoms of anxiety, burnout, and depression during the COVID-19 pandemic based on the validated questionnaires. A higher prevalence was shown in the lesser experienced group of residents and fellow physicians compared to more experienced attending physicians. In addition, adjustments to the pandemic have caused a financial burden among osteopathic physicians. Future studies are warranted to assess the long-term effects of the pandemic on mental health among osteopathic physicians.

3.
NeuroQuantology ; 20(10):6704-6711, 2022.
Article in English | EMBASE | ID: covidwho-2067306

ABSTRACT

PURPOSE: Lockdown guidelines during COVID-19 pandemic increased the e-learning methods and gadgets use, basically to undergo classes, recreation procedures and media news updates, which subsequently upsurgedasthenopic symptoms as digital eye strain (DES) epidemic amid COVID-19 lockdown. This is a descriptive cross-sectional questionnaire based study which is aimed to assess the prevalence, risk factors.Pattern of gadgets used, screen time and symptomatology of Digital eye strain among medical students, teaching doctor faculties and paramedical staff during COVID-19 lockdown at BBMCH, Balangir. METHODS: This e-filled self survey analysed 570 responses from medical students of online classes(200), teachers of online classes (38), paramedical staff (122) and general population(210) .Aprevalidated CVS-Q and OSDI questionnaire regarding screen time spent, was used to calculate the DES score. Median DES Score was compared by medians or non-parametric tests. Categorical variables were compared by Chi Square test and predictors of DES were found by binary logistic regression. SPSS Version 21.0 was used to interpret and analyse the collected data. RESULTS: Majority of survey participants(78%) had at least one symptom of digital eye stain;The reported symptoms during electronic device usage in decreasing frequency were Eye fatigue(65%), Eye strain(52%), Ocular discomfort(50%), headaches(48%), Burning eyes(42%), and Dry eyes(35%), watering(34%), shoulder pain(30%) DES symptoms were found to be more than that of dry eye symptoms. The prevalence of DES in students taking e-learning surpassed to those found with other health staff and general population. DES score was also observed to be on higher side for more screen time users, use of gadgets in dark, screen distance<25cm. Lens or spectacle users suffered worsening of vision and needed change of glasses. No association between DES and exacerbation of pre-existing dry eyes and eye diseases were appreciated due to exclusion of such participants from our survey. CONCLUSION:Eye care tips are needed at periodic intervals to create awareness and to reduce eye strain symptoms, closing of eyes on regular basic, maintaining reading distance between 25-30cm and reducing screen time by breaks can lessen the prevalence of DES. As because, use of gadgets were the major media for learning or communication, so ocular health, hygiene and practical precautions should be kept in mind.

4.
Archives of Pediatric Infectious Diseases ; 10(4) (no pagination), 2022.
Article in English | EMBASE | ID: covidwho-2067103

ABSTRACT

Background: Given that immunocompromised patients are more at risk for the infection of SARS-CoV-2, epidemiological data are critical for assessing the corresponding prevalence among health care workers (HCWs) and patients at health centers. Objective(s): This study aims to investigate the prevalence of SARS-CoV-2 infection among the staff of two hospitals that take care of immunocompromised patients, including pediatrics and adults with special medical conditions. Method(s): This cross-sectional study includes all HCWs of the two hospitals;Abu Ali Sina Transplant Hospital (AASTH) and Amir al-Momenin Burn Injury Hospital (AABIH) in Shiraz, southern Iran, conducted from April 11, 2020, to June 16, 2021. The TaqMan real-time PCR assay was used to assess the SARS-CoV-2 infection rate in the suspected HCWs. Result(s): Out of 1232 sampled HCWs, 694 (56%) were female. Two hundred sixty-five samples (21.5%) and 967 samples (78.5%) were prepared from AABIH, and AASTH, respectively. The results showed that 30% (373) of the clinically suspected employees had positive test results. There was a significant correlation between the risk of exposure to COVID-19 patients and the PCR positivity rate, which could be explained by the fact that 58% of the infected HCWs were in a high-risk group, 20% medium-risk, and the remaining 22% were low-risk (P < 0.0001). The rates of positive cases in females were higher than that among male counterparts (P < 0.05). Conclusion(s): In order to protect health care workers and reduce the prevalence and transmission of diseases, deficiencies must be identified and eliminated. Copyright © 2022, Author(s).

5.
CMAJ. Canadian Medical Association Journal ; 64(5 Supplement 1):S43-S44, 2021.
Article in English | EMBASE | ID: covidwho-2065168

ABSTRACT

Background: Alcohol is a major factor in traumatic injuries. Accreditation bodies recommend alcohol screening and intervention programs as trauma quality indicators. Previous research in Alberta reported increasing alcohol use prevalence in major trauma. The COVID-19 pandemic has also been linked to increased alcohol consumption. Our objective was to characterize injury characteristics and their relationship to alcohol use during the summer trauma season after the COVID-19 lockdown, and compliance with alcohol misuse screening, at a level 1 trauma centre in Edmonton, Alberta. Method(s): We conducted a retrospective chart audit for trauma patients aged 18-64 years who were admitted to the University of Alberta Hospital Trauma Service from June 1 to Aug. 31, 2020. Variables included demographics, injury characteristics, ethanol level on presentation, history of substance use and screening or intervention. Tertiary surveys as well as psychiatry and addictions consultations were reviewed to assess compliance with screening and intervention. Frequencies and basic descriptives were calculated. Logistic regression was performed to identify relationships between alcohol use and injury patterns. Result(s): A total of 176 patients met the inclusion criteria. The mean age was 40 (standard deviation [SD] 13.8) years, and 128 (72.7%) were male. Blunt injuries were most common (144 patients [81.8%] had a blunt injury, 27 [15.3%] had a penetrating injury and 3 [1.7%] had a burn), with average Injury Severity Score 13 (1-45) and average length of stay 10.6 (SD 14.6) days. Motor vehicle crashes (MVCs) predominated (66 patients, 37.5%) followed by falls (33 patients, 18.8%), sport-related injuries (30 patients, 17.1%) and stabbings (17 patients, 9.7%). A total of 156 patients (88.6%) had an ethanol level drawn on presentation;50 (32%) were positive, and 33 of these (66%) were legally intoxicated. Forty-five patients (25.6%) had a documented addiction history with alcohol use disorder, 29 of whom presented with a positive ethanol level. Of the 50 patients with elevated ethanol level on presentation, the average age was 36 (SD 12.1) years and the mean ethanol level was 36.9 (SD 23.3) mmol/L. MVCs were the most common mechanism (18 patients, 36%). Screening for alcohol use disorder was performed in 39 (78%) of these 50 patients who presented with a positive ethanol level (unclear documentation in the remainder). Addiction services were offered to 10 of 50 patients (20%). Positive ethanol level was associated with younger age (36 v. 41 yr, p = 0.02). Logistic regression revealed that positive ethanol level was significantly associated with stab mechanism of injury (odds ratio [OR] 3.75, 96% confidence interval [CI] 1.1-11.6, p < 0.05);intoxication further increased association with stab injury (OR 4.4, 95% CI 1.4-15, p < 0.01). Conclusion(s): The prevalence of positive ethanol level in trauma patients is rising: 32% currently, compared with 24% from Alberta 2010 data. Over one-quarter of MVC patients had a positive ethanol level, and intoxication increased the odds of stab injury. Compliance with alcohol misuse screening was 78% with only 20% of patients offered intervention, despite 58% having alcohol use disorder. Interventions to reduce preventable injuries and alcohol misuse at the population and hospital levels are needed..

6.
Chest ; 162(4):A2065, 2022.
Article in English | EMBASE | ID: covidwho-2060893

ABSTRACT

SESSION TITLE: Etiologies of Cardiovascular Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Troponin level (Tnl) is usually used as confirmation of acute myocardial infarction (AMI) and is a sensitive marker. It is usually increased within 2-3 hours after AMI. In most cases, increased in Tnl is associated with symptomatic chest pain, cardiac ischemia, chronic coronary syndromes, etc. It can also be elevated in other conditions without cardiac injuries, like critical illness: COVID infection, septic shock, acute stroke and burns. CASE PRESENTATION: A 72 y/o man with history of b/l internal carotid artery (ICA) stenosis (70% in R-ICA and 80-90% in L-ICA) underwent elective left trans-carotid artery revascularization (TCAR). He was transferred to ICU after an uneventful procedure, for monitoring. His history was significant for HTN, HLD, Meniere's disease, gout, prior CVA of L-frontal lacunar and R-PICA (posterior inferior cerebellar artery). Postop vitals: BP 114/60 mmHg, HR 65, RR 16, O2 sat 98%. Tnl increased to 1.95 and then declined (normal 0 - 0.4 ng/ml). He was AAOx4, and asymptomatic. Post-op serial EKGs: normal sinus rhythm with no ST/T wave changes. Echo: EF 60%, normal biventricular size and function. LDL <70, A1C 5.9, normal TSH, no CPK elevation. Other labs: normal, No new neurological deficits. He was continued on ASA, clopidogrel, metoprolol, amlodipine and lisinopril. His hospital stay was uneventful, and he was discharged on post-op day 3. DISCUSSION: Cardiac troponin complex has its distinct subunits according to their functions: highly conserved Ca2+ binding subunit (cTnC);actomyosin ATPase inhibitory subunit and tropomyosin binding subunit. They play the pivotal role in regulating myocardial muscle contraction and relaxation and demonstrate as sensitive biomarkers for the myocardial injuries. Interestingly, there are many other causes that lead to increased cardiac troponin level without remarkable myocardial injuries or ischemia. Elevated Tnl after TCAR procedure can also be due to its surgical complication of a chance of hypoperfusion during the procedure. Our patient's surgery was uneventful. In one randomized controlled trial, it is stated that the risk of having CVA and AMI is higher in carotid endarterectomy compared to revascularization in patients with carotid artery stenosis. Our patient did not have any post-op complication, and only had an idiopathic elevation of troponin. CONCLUSIONS: The role of Tnl plays an important role in confirmation of myocardial infarction or ischemia but it can be idiopathic. Unpublished data from our institution revealed no increase in troponin s/p TCAR after uneventful procedures. This is the first reported case presenting with elevated troponin level without any pertinent positive findings (EKG changes/symptoms). Maybe in uneventful TCAR procedure troponin should not be ordered? Reference #1: Defilippi, C.R., Tocchi, M., Parmar, R.J., Rosanio, S., Abreo, G., Potter, M.A., Runge, M.S., & Uretsky, B.F. (2000). Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes. Journal of the American College of Cardiology, 35 7, 1827-34. Reference #2: Gordon AM, Homsher E, Regnier M. Regulation of contraction in striated muscle. Physiol Rev. 2000 Apr;80(2):853-924. doi: 10.1152/physrev.2000.80.2.853. PMID: 10747208. Reference #3: Brott, T.G., Hobson, R.W., Howard, G., Roubin, G.S., Clark, W.M., Brooks, W., Mackey, A., Hill, M.D., Leimgruber, P.P., Sheffet, A.J., Howard, V.J., Moore, W.S., Voeks, J., Hopkins, L.N., Cutlip, D.E., Cohen, D.J., Popma, J.J., Ferguson, R.D., Cohen, S.N., Blackshear, J.L., Silver, F.L., Mohr, J.P., Lal, B.K., & Meschia, J.F. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. The New England journal of medicine, 363 1, 11-23. DISCLOSURES: No relevant relationships by Moses Bachan No relevant relationships by Zin Min Htet No relevant relationships by Z nobia Khan No relevant relationships by Zin Oo

7.
Chest ; 162(4):A2036, 2022.
Article in English | EMBASE | ID: covidwho-2060889

ABSTRACT

SESSION TITLE: ECMO and ARDS in COVID-19 Infections SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Inhaled nitric oxide (iNO) is a potent vasodilator of pulmonary vasculature improving perfusion to ventilated alveoli in ARDS and other lung pathologies. During the pandemic, intensivists turned to iNO as “salvage” therapy in COVID-19 patients. Rationale was driven by vasodilatory effect and antiviral properties despite lack of evidence of clear benefit even in patients without COVID. We hypothesized that iNO would provide reduced increases in pulmonary perfusion and subsequent gas exchange improvement in COVID-19 patients due to extensive endothelial damage and coagulopathy throughout the pulmonary vasculature. METHODS: Our IRB exempt analysis examined patients hospitalized with and without COVID-19 from January 2020 to September 2021 who received at least 24h of invasive mechanical ventilation with iNO (15-20ppm). Effectiveness outcomes were PaO2/FIO2 ratio(PFR), PEEP/CPAP level, and PaCO2 serially measured and observed up to 24 hours prior to initiation of iNO and for up to 120h post iNO administration. Data were statistically controlled for age, sex, race, time to initiation of therapy and COVID-19 directed treatment. RESULTS: From January 2020 and September 2021, 42 patients were admitted to the ICU and received invasive mechanical ventilation and iNO. Results are sequenced as ARDS COVID-negative, ARDS COVID-positive, viral pneumonia COVID-negative, viral-pneumonia COVID-positive. Patient n = 8/14/6/14. Median age was 56/55/63/62 years. Demographics split 64-62% male vs 36-38% female in ARDS without/with COVID, 50%/83% male vs 50%/17% female in viral pneumonia without/with COVID. Racial distribution resulted 75%/93%/86%/83% White vs 25%/0%/17%/14% Black. Other races constituted less than 7% of patient total in any category. PFR delta from -24h to +120h post-iNO = +35/+35/+41/+22. PEEP/CPAP delta from -24h to +120h = -4/-1/-3/-2. PaCO2 delta mmHg from -24h to +120h = -21/-23/-9/-13. Median Hospital LOS = 26/26.5/17/19 days. Median ICU LOS = 15.8/19.0/13.8/17.6 days. Hospital mortality = 100% across all 4 subgroups. CONCLUSIONS: ARDS patients with or without COVID showed similar rates of PFR response to iNO, however viral pneumonia patients with COVID exhibited a blunted PFR response vs those without COVID. No statistically significant difference was observed with respect to PEEP/CPAP levels, PaCO2 mmHg, hospital or ICU LOS, or mortality. CLINICAL IMPLICATIONS: Our findings suggest that the presence of COVID-19 did not significantly inhibit response to iNO in ARDS or other viral pneumonia patients. Further evaluation of other indirect markers of gas exchange could provide further evidence of responsiveness. DISCLOSURES: No relevant relationships by Katherine Burns No relevant relationships by Karen Hamad No relevant relationships by Bobby Malik No relevant relationships by Richard Walo Jr No relevant relationships by Wilhelmine Wiese-Rometsch No relevant relationships by Stephanie Williams

8.
Chest ; 162(4):A1801, 2022.
Article in English | EMBASE | ID: covidwho-2060864

ABSTRACT

SESSION TITLE: Imaging, ECMO, and other Procedures in the ICU Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Inhalation of various organic and non-organic compounds like toxic fumes, batteries, and dust can result in lung irritation called chemical pneumonitis (1). Chemical Pneumonitis can cause acute complications like secondary pneumonia or long-term complications like bronchiectasis or lung destruction (2). Classical radiograph findings of chemical pneumonitis show pulmonary edema or radiographic opacities (3). This type of injury can initially present as no damage in radiograph scans, and the extent of damage can be difficult to determine initially. Chemical pneumonitis can also be difficult to distinguish from pneumonia caused by bacteria or a virus. CASE PRESENTATION: A 40-year-old male presented to the emergency department with an 18% total body surface area burn to his upper extremities from an oil pump battery explosion that released chemicals he likely aspirated. The patient was intubated and transferred to the Burn ICU where a bedside bronchoscopy was performed. It revealed no soot or signs of inhalation injury. On the day of admission, he had a 100% oxygen dependence. A CT scan was done and showed no lung damage. The patient was extubated and moved to a high-flow nasal cannula of 40 liters per minute. A repeat CT scan was performed of his chest on hospital day 4. The results appeared to be multifocal pneumonia eliciting a possible diagnosis of Covid 19 pneumonia. This delayed his excision and grafting by 5 days. Through aggressive respiratory therapy intervention, oxygen dependence was reduced until the patient was on room air. The patient was discharged to inpatient rehab on hospital day 21. DISCUSSION: There are several factors presented in this case that should be kept in mind when treating a patient exposed to compounds that can cause chemical pneumonitis. Chemical pneumonitis likely has no findings on bronchoscopy. Furthermore, previous literature has suggested that CT chest scans of chemical pneumonitis may initially present with no apparent injury. Regardless of these initial findings, it is important that patients receive intense pulmonary hygiene to avoid delays in other interventions. Chemical pneumonitis injuries can be associated with chemical burns, and it is imperative to avoid delays in interventions including excision and skin grafting. Findings from a chemical pneumonitis injury may present on a CT scan later in a patient's course of injury. The findings of the CT scan could resemble multifocal pneumonia. This may complicate treatment plans as SARS-CoV-2 is also known to cause multifocal pneumonia. CONCLUSIONS: This case highlights the complexity that chemical pneumonitis traumatic injury may present, and the various factors providers should keep in mind. In the aftermath of the COVID-19 pandemic, another factor has emerged: the resemblance of chemical pneumonitis to SARS-CoV-2 multifocal pneumonia. Reference #1: Andujar, P., & Nemery, B. (2009). Pathologies respiratoires aiguës et subaiguës d'origine toxique [Acute and subacute chemical pneumonitis]. Revue des maladies respiratoires, 26(8), 867–885. https://doi.org/10.1016/s0761-8425(09)73682-4 Reference #2: Neill, S., & Dean, N. (2019). Aspiration pneumonia and pneumonitis: a spectrum of infectious/noninfectious diseases affecting the lung. Current opinion in infectious diseases, 32(2), 152–157. https://doi.org/10.1097/QCO.0000000000000524 Reference #3:.White, C. S., & Templeton, P. A. (1992). Chemical pneumonitis. Radiologic clinics of North America, 30(6), 1231–1243. DISCLOSURES: No relevant relationships by Genesy Aickareth No relevant relationships by Deepak Bharadia No relevant relationships by John Griswold No relevant relationships by Alan Pang No relevant relationships by Jad Zeitouni

9.
Chest ; 162(4):A1597, 2022.
Article in English | EMBASE | ID: covidwho-2060847

ABSTRACT

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The vaccines against SARS-CoV-2 or COVID-19 have been shown to be safe and effective at preventing severe disease and death. In a phase 3 trial the BNT162b2 mRNA COVID-19 vaccine showed a 52% and 95% efficacy after the first and second doses, respectively (1). Side effects following vaccination are common but are typically mild and self limited (2). The most common side effects are headache, fever, fatigue, arthralgias and pain at the injection site (2). More severe and devastating side effects have been reported including cerebral venous thrombosis and myocarditis (3) (4). Here we report a case of unilateral diaphragmatic paralysis following the second dose of the BNT162b2 mRNA COVID-19 vaccine. CASE PRESENTATION: The patient was a 56 year old female with a past medical history of reactive airways disease and hypertension who was seen in the pulmonology clinic shortly after receiving her second dose of the BNT162b2 mRNA COVID-19 vaccine. After her second dose she developed burning shoulder pain, erythema and swelling that extended to the neck and axilla. She went to an urgent care and was advised to treat with ice and NSAIDs, she had a chest radiograph performed which was reported to be negative. Her symptoms persisted and she was sent to the emergency room, chest x-ray showed interval development of an elevated left hemidiaphragm. A CT Chest with inspiratory and expiratory films was performed and the left diaphragm was noted to be in the same location during inspiration and expiration consistent with diaphragmatic paralysis. PFT showed a reduction in her FVC, TLC and DLCO compared to 13 years prior. DISCUSSION: Diaphragmatic paralysis is a well described clinical entity that is most often associated with cardiothoracic surgery where hypothermia and local ice slush application are thought to induce phrenic nerve injury (5). It has also been described as a complication of viral infections, including a recent report of unilateral diaphragm paralysis in a patient with acute COVID-19 infection (6). In a case series of 246 patients with amyotrophic neuralgia which can include diaphragm paralysis, 5 patients received a vaccine in the week before developing symptoms (8) Additionally, Crespo Burrilio et al recently described a case of amyotrophic neuralgia and unilateral diaphragm paralysis following administration of the Vaxzevri (AstraZeneca) COVID-19 vaccine (7). This case highlights a potential side effect of the BNT162b2 mRNA COVID-19 vaccine that has not been previously reported CONCLUSIONS: Reference #1: Polack FP, Thomas SJ, Kitchin N. Safety and efficacy of the BNT162b2 mRNA COVID-19 vaccine. N Engl J Med. 2020;383:2603–2615. Reference #2: Menni, C., Klaser, K., May, A., Polidori, L., Capdevila, J., Louca, P., Sudre, C. H., Nguyen, L. H., Drew, D. A., Merino, J., Hu, C., Selvachandran, S., Antonelli, M., Murray, B., Canas, L. S., Molteni, E., Graham, M. S., Modat, M., Joshi, A. D., Mangino, M., … Spector, T. D. (2021). Vaccine side-effects and SARS-CoV-2 infection after vaccination in users of the COVID Symptom Study app in the UK: a prospective observational study. The Lancet. Infectious diseases, 21(7), 939–949. https://doi.org/10.1016/S1473-3099(21)00224-3 Reference #3: Jaiswal V, Nepal G, Dijamco P, et al. Cerebral Venous Sinus Thrombosis Following COVID-19 Vaccination: A Systematic Review. J Prim Care Community Health. 2022;13:21501319221074450. doi:10.1177/21501319221074450 DISCLOSURES: No relevant relationships by Jack Mann No relevant relationships by John Prudenti

10.
Chest ; 162(4):A833, 2022.
Article in English | EMBASE | ID: covidwho-2060699

ABSTRACT

SESSION TITLE: COVID-Related Critical Care Cases SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: Multisystem Inflammatory Syndrome in Adult (MIS-A) is a rare hyperinflammatory response occurring 2 to 6 weeks after COVID-19 resembling Kawasaki disease. CASE PRESENTATION: A 23-year-old male presented to the emergency room with fevers, cough, shortness of breath, fatigue and painful rashes all over his body. 3 weeks prior, he was diagnosed with COVID-19 which was managed conservatively at home. He recovered within 3 days. He had received 2 doses of Moderna COVID-19 vaccine 6 months prior. He denied recent drug intake. Vitals were BP 116/78 mmHg, heart rate 164/min, temperature 97.3℉, SpO2 96% on room air. Physical exam revealed macular erythematous rash in his trunk and extremities. Leukocyte count was 4 k/uL, hemoglobin 15.5 g/dL, platelets 99 k/uL, sodium 126 mmol/L, bicarbonate 20 mmol/L, BUN 30 mg/dL, creatinine 2.2 mg/dL, lactate 5.1 mmol/L, ferritin >7500 ng/mL, total bilirubin 7.6 mg/dL, AST 298 U/L, ALT 291 U/L, ALP 106 U/L, procalcitonin 14.71 ng/mL, D-dimer 11.98 FEUug/mL. Troponin-I peaked at 1359 pg/mL. CT angiography of the chest showed clear lung fields without pulmonary embolism. Venous doppler was negative. Echocardiogram showed normal biventricular function and valves. An extensive infectious disease workup was negative. He was suspected to have MIS-A from recent COVID-19. He was started on methylprednisolone 1g/day, intravenous immunoglobulin (IVIG), anakinra and empiric antibiotics. Over the next 2 days, there was progression of rash with sloughing of skin in his trunk, back and extremities with bullae on his legs, and thigh sparing the face (figures). Skin biopsy revealed epidermal necrobiosis with apoptosis consistent with Toxic Epidermal Necrolysis (TEN). On day 3, he had a cardiac arrest from ventricular fibrillation but was successfully resuscitated. Subsequently, he was intubated, and required escalating vasopressor support for shock. On day 5, he also developed non-purulent conjunctivitis. On day 6, he was transferred to a higher center with a burns unit. However, despite aggressive supportive measures he succumbed to refractory shock the following day. DISCUSSION: Our patient fit the criteria for MIS-A outlined by CDC (1) with age ≥21 years, fevers, rash with non-purulent conjunctivitis for primary clinical criteria, hypotension and thrombocytopenia for secondary clinical criteria, several laboratory criteria, negative infectious work-up with a history of recent COVID-19. It is unclear if the COVID-19 vaccine increased his risk of MIS-A. There have been case reports of MIS-A presenting as TEN following COVID-19 and COVID-19 vaccines in the absence of typical triggering drugs. (2,3) MIS-A is treated with high dose steroids, IVIG, tocilizumab and supportive measures. Anakinra was used for our patient because of liver dysfunction. CONCLUSIONS: MIS-A following COVID-19 can also present as life-threatening skin reactions like TEN in the absence of triggering drugs. Reference #1: Retrieved from https://www.cdc.gov/mis/index.html Reference #2: Narang I, Panthagani AP, Lewis M, Chohan B, Ferguson A, Nambi R. COVID-19-induced toxic epidermal necrolysis. Clin Exp Dermatol. 2021;46(5):927-929. Reference #3: Kherlopian A, Zhao C, Ge L, Forward E, Fischer G. A case of toxic epidermal necrolysis after ChAdOx1 nCov-19 (AZD1222) vaccination. Australas J Dermatol. 2022;63(1):e93-e95. DISCLOSURES: No relevant relationships by Fady Jamous No relevant relationships by Swaminathan Perinkulam Sathyanarayanan

11.
Chest ; 162(4):A362-A363, 2022.
Article in English | EMBASE | ID: covidwho-2060574

ABSTRACT

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Covid 19 pandemic has infected 125 million people so far (1). The development of safe and effective vaccines is crucial to lessen the impact of SARS-COV 2 on global health. Some adverse events of the covid 19 vaccination have been reported including few dermatological reactions. We report a case of severe allergic erythematous drug reaction that occurred 3 days after the second dose of messenger RNA (mRNA) Pfizer vaccine. CASE PRESENTATION: A 42 year old female with past medical history of Grover's disease and Multiple Sclerosis presented to the Emergency department from the nursing home with complaints of erythematous, scaly, painful rash that occurred 3 days after the second dose of mRNA covid 19 vaccine. Patient states she had a generalized rash after the first dose of vaccine but it resolved spontaneously and did not require treatment. This time the rash started on the scalp and gradually progressed to the rest of the body. It was associated with severe itching, burning and serosanguinous discharge. Patient did not report any change in medication, use of new detergent or contact with an offending agent. The patient denied fever, chills, nausea, vomiting, diarrhea, constipation, abdominal pain, chest pain or palpitations. She had no history of similar complaints in the past. On physical examination, she was afebrile and hemodynamically stable but in severe distress due to pain. The rash covered 95% of the body surface area and was more severe around the mouth, in the axilla, neck and the inframammary area. Erosions could be seen in the skin folds with serosanguinous discharge. The laboratory results were positive for eosinophilia with absolute eosinophil count of 0.7. Remaining laboratory results were within normal limits. The pathology report for the erythematous rash was consistent with drug reaction. A slight vacuolar degeneration along the dermal epidermal junction with few apoptotic keratinocytes were noted. A compact horn and band-like lymphoid infiltrate were also noted. The patient was started on high dose steroids, analgesics and antihistamines. Petroleum gel impregnated gauze was used for dressing. She was placed in the intensive care unit for careful monitoring. Her rash resolved gradually and her symptoms improved. DISCUSSION: mRNA vaccines are associated with type 1 interferon responses that result in inflammation and autoimmune conditions. This could explain the skin manifestations associated with these vaccines. Allergenic components in the vaccines could also be a possible cause of these reactions. A patch test can be performed to prevent these reactions in susceptible individuals. CONCLUSIONS: This report highlights the need for vigilance to detect severe allergic reactions after covid 19 vaccination to improve the safety of the vaccine. Reference #1: WHO coronavirus (COVID-19) dashboard. [ Jul;2021 ];https://covid19.who.int/ 2021 DISCLOSURES: No relevant relationships by Ruhma Ali No relevant relationships by Sneha Bijoy No relevant relationships by Chrystina Kiwan no disclosure on file for Richard Miller;No relevant relationships by Aditya Patel No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim

12.
Journal of Pediatric Gastroenterology and Nutrition ; 75(Supplement 1):S184-S185, 2022.
Article in English | EMBASE | ID: covidwho-2058674

ABSTRACT

Introduction: Esophageal strictures in children are in most cases associated with a benign etiology. There are multiple conditions that are associated with esophageal strictures including congenital stenosis, secondary to surgical repair of esophageal atresia, caustic burns following ingestion of acids or alcalis, radiation therapy and secondary to some pathologies as gastroesophageal reflux disease, eosinophilic esophagitis, scleroderma, epidermolysis bulllosa and idiopathic. Esophageal dilation can be performed with different techniques that include endoscope dilators, dilations performed over the wire and using the endoscope itself. Some cases require other adjunctive techniques that improve the results after failed progressive dilation. This therapies includes medical treatment and surgical derivations, with some cases known as recalcitrant. Also, esophageal strictures and its management could produce motility disorders. There is no consensus in the literature regarding the management process, especially in frequency of interventions, use of adjunctive therapies and alternatives for conservative management. This problem is more evident in developing countries. Objective(s): The objective of this study was to describe the cases of esophageal strictures and its management in children between 2016 and 2022 in the Instituto Nacional de Pediatria in Mexico City. Method(s): This was a six year retrospective study involving pediatric patients with esophageal stricture. We retrospectively reviewed the medical records of 23 pediatric patients who underwent endoscopic treatments for esophageal strictures, between January 2016 and May 2022 in the Comprehensive Pediatric Gastroenterology Diagnostic Unit in the Instituto Nacional de Pediatria in Mexico City. Result(s): The mean age at diagnosis was 24 months (Q1 15, Q3 35), 12 patients were male (52%) and 11 patients were female (48%). The most prevalent etiology was caustic strictures in 10 patients (43%). Six patients (26%) had esophageal atresia (4 type III, 1 type I and 1 type V), all whose received surgical management in the first days of life. All required repeated pneumatic dilation (between 1 and 11) for the management of postsurgical stenosis. Other etiologies that were found include Schatzki Ring, congenital stenosis, esophageal fibrosis associated with congenital dyskeratosis, epidermolysis bullosa, graft-versus-host disease and gastroesophageal reflux disease (one patient for each cause). In one patient the etiology remains unknown. Seventeen patients had one stricture, 5 patients had two strictures and 1 had 3 strictures. Ten patients had esophageal pseudodiverticula and two had mucosal fold. Six patients underwent dilation with Savary-Guilliard dilators combined with pneumatic balloon dilation. Four patients received mitomycin- C as an adjuvant therapy during dilations. The average diameter of stenosis was increased from 7 mm (range 4-15 mm) to 13,5 mm (range 8-18mm). Two patients had severe complications, one had a esophageal perforation associated with dilation. The other one had a pneumothorax related with anesthetic management. In the outcome 6 patients are asymptomatic, 1 patient persist with dysphagia after completed treatment, 9 patients are under treatment, 1 patient died secondary to its underlying disease and 6 patients lost follow up. Conclusion(s): Post-corrosive esophagitis and post-esophageal atresia anastomotic strictures were the most frequent types of cicatricial esophageal strictures. The conservative treatment was the first management strategy in the majority of patients, being the endoscopic balloon dilation the first choice. The SARS-COV-2 sanitary emergency limited the progressive intervention rate and appropriate clinical follow up of patients, reason why there is an important loss of follow up in the described group. A number of patients are currently on management, reason why their outcomes will be assessed in the future.

13.
Investigative Ophthalmology and Visual Science ; 63(7):3371-A0158, 2022.
Article in English | EMBASE | ID: covidwho-2057451

ABSTRACT

Purpose : Lockdowns from the COVID-19 caused a significant increase in the use of digital devices. This increase could result in ocular sequelae such as eyestrain. We used a crosssectional survey to assess the magnitude severity and determinants of eye strain among Saudi population during the COVID-19 pandemic, lockdown and abuse of digital devices. Methods : Saudi population of both genders, aged > 15 years old were invited. The questionnaire included demography, eye strain related symptoms, severity, and use of optical aid during covid-19 lockdown. The frequency and severity of eye strain were calculated. Based on the sum of 15 eye strain related sign and symptom, Computer Vision Syndrome (CVS) score was graded as none/ mild moderate and severe CVS. CVS was associated/correlated to determinants. The total score was calculated using a formula score of A X B for each sign and symptom,. The sum of 15 eye strain related sign and symptom score was further graded as <30 = no or mild CVS, 30 to 59 = moderate CVS and more than 60 = severe CVS. Results : There were 2,009 surveyed participants. Their median age was 20 years. The purpose of using digital devices was work and social purposes for 68.4%, and 61% used the digital devices for more than 6 hours daily. The prevalence of knowledge about CVS and '20-20 rule for using digital devices' was 9.4% and 6.9 respectively. Two hundred and eighty-two (14%) of the study participants were diagnosed with COVID-19, and 223 (11.1%) were quarantined. Three fourth of participants did not use contact lens (CL) or spectacles, 393 (19.6%) were using spectacles, 59 (2.9%) were using CL and 55 (2.7%) were using both Spectacles and CL. The most experienced symptoms of eye strain due to digital devices use were headache, burning, itching, tearing, and redness of eyes. The median of eye strain symptom score was 20 (IQR 10: 32). Based on the symptom score, 'no/ mild' grade of eye strain was perceived by 1,486 (74%), moderate eye strain by 468 (23.3%) and severe eye strain by 55 (2.7%) participants. The daily six hours usage of digital devices was found to have a significant and positive association to the eye strain severity grade during COVID-19 lockdown. Conclusions : Saudi-population suffered from eye strain during COVID-19 lockdown due to excessive digital devices use. Health care provider should educate general population about healthy measures during daily use of digital devices.

14.
JPRAS Open ; 34: 82-90, 2022 Dec.
Article in English | MEDLINE | ID: covidwho-2049572

ABSTRACT

Introduction: The ongoing COVID-19 pandemic caused by SARS-CoV-2 has changed everyday life worldwide. To reduce disease transmission, governments introduced various policies such as social distancing, stay-at-home orders, and travel restrictions. The goal of this study was to investigate the characteristics of burn patients admitted to the burn intensive care unit before and during the COVID-19 pandemic. Patients and methods: A retrospective descriptive analysis of the hospital's burn registry was performed from 1 March 2019 until 1 January 2022. Results: A total of 326 patients were included in this study. Eighty-eight patients presented before and 238 patients during the COVID-19 pandemic. The majority of burns occurred during private incidents (80% [2022], 92% [2020]), and burns were most frequently caused by flames (24% [2022], 32.99% [2021]). Work-related injuries occurred less frequently (7.76% [2020], 20% [2022]). Constant results were obtained regarding severity and total body surface area affected (1-80%). Conclusion: This study highlights high numbers of burn patients admitted to the burn intensive care unit before and during the COVID-19 pandemic. Consequently, burn intensive care units must retain their special position within the national health system and should not be included in resource relocation during the prioritisation of intensive care resources. Multicentre studies should focus on the national impact of COVID-19 on the treatment of burn patients.

15.
British Journal of Surgery ; 109:vi40, 2022.
Article in English | EMBASE | ID: covidwho-2042535

ABSTRACT

Aim: The aim of this study was to look at the teaching and knowledge of plastic surgery emergencies and referral criteria in medical students from 3rd to 5th year. Method: 400 students were sent a survey via email and invited to participate 278 replied (69.7%). Students were asked 20 questions including demographics, if they were interested in surgery/ED, if they had teaching in B+P and what type, if there was clinical exposure, how to classify TBSA and factors deciding considered in classifying the burn, if they were confident to treat a burn, when to make a referral and burn mechanisms, common complications of burns, what is a flap and types and how to assess, what a plastic surgeon does. Results: 58% (161) declared an interest in surgery or ED, 32% (88) had teaching in B+P with 63% (252) attending a lecture and 5% (13) a formal Placement, others were adhoc and 21% (59) had clinical exposure. 74% (205) identified depth as important, 42% (117) TBSA. 58% (161) could not classify TBSA, 97% (271) did not feel confident treating a burn + only 8% (32) knowing when to refer although most could identify mechanisms. 92% (368) knew infection was a complication but only 1 knew why smoking was contraindicated. 1 student knew what a flap was with non able to classify or assess. few could identify what B+P do. Conclusions: There is a lack of consistent undergraduate education on plastic emergencies and knowledge, perhaps resulting from less experience from cancelled placement.

16.
Annals of Clinical Psychiatry ; 34(3):10-11, 2022.
Article in English | EMBASE | ID: covidwho-2030804

ABSTRACT

BACKGROUND: Self-mutilating behavior in the pediatric population is associated with psychiatric and psychosocial factors. Autosarcophagy, or self-cannibalism, is an extremely rare form of self-mutilation and is predominantly seen with psychosis or substance use.1 We report a case of oral autosarcophagy in a pediatric patient in the absence of substance use or psychosis. OBJECTIVE: To learn about autosarcophagy and its treatment in the pediatric population and to explore other neuropsychiatric disorders in which it is a predominant manifestation. METHODS: Review of a case using electronic medical records and relevant literature. Key terms: 'autosarcophagy,' 'body focused repetitive behavior,' 'oral self injury,' 'pediatric self-mutilation' using Medscape and Google Scholar. RESULTS: We present a 14-year-old female with history of seizure disorder in full remission, depression, self-cutting behavior, and suicidal ideation with 2 psychiatric hospitalizations, who presented to the pediatric emergency department with oral bleeding after eating one-third of her tongue over the course of a month. Evaluation was notable for poverty of speech and constricted affect. Patient stated she was 'trying to remove an infection' and alleviate discomfort. She denied that this behavior was an attempt to end her life but endorsed past suicidal ideations and cutting behavior. History revealed emergency room evaluation for aggressive behavior and episodes of volitional enuresis. We diagnosed major depressive disorder, recurrent episode in remission without psychosis. Drug screen, complete blood count, complete metabolic panel, COVID-19, urinalysis, thyroid-stimulating hormone, head computed tomography, and beta-human chorionic gonadotropin were negative. Patient continued home oral medications aripiprazole 10 mg daily, fluoxetine 30 mg daily, and levetiracetam 500 mg twice daily and was discharged the next day. CONCLUSIONS: Self-harm is observed in 17.2% of adolescents, 13.4% of young adults, and 5.5% of older adults.2 Cases of self-mutilation in pediatric patients typically present as cutting, burning, or head banging.3 Our differential diagnoses include borderline personality disorder due to repeated impulsivity and self-harm, and body focused repetitive behavior disorder (obsessive-compulsive disorder-related disorder), which presents with repetitive strain injuries and dental malocclusions. Treatment of self-mutilation involves treating the underlying psychiatric condition with psychotropic medications.4,5 In pediatric patients, dialectical behavioral therapy has been shown to reduce parasuicidal behaviors after 1 year of therapy.6 Our patient, under constant 24-hour observation, was cleared by medical, psychiatric, and dental teams. The patient followed up with outpatient psychotherapy and psychiatry. We are presenting this rare case for clinicians to identify and manage pediatric patients presenting with unique forms of self-harm tendencies.

17.
Indian Journal of Critical Care Medicine ; 26:S61, 2022.
Article in English | EMBASE | ID: covidwho-2006352

ABSTRACT

Introduction: Sepsis is a common cause of morbidity and mortality with no gold standard diagnostic test for detecting sepsis. Blood cultures are a frequent diagnostic step but the results take at least 48 hours and timely recognition of infection and initiation of appropriate antibiotics remain crucial in the treatment of sepsis. Biomarkers thus come in handy for rapid diagnosis and risk stratification. Objectives: Primary objective: To assess the diagnostic and prognostic value of procalcitonin (PCT), interleukin-6 (IL-6), ferritin, and C-reactive protein (CRP) levels in differentiating between Gram-negative and Gram-positive sepsis patients. Secondary objective: To determine the relationship between serum PCT, IL-6, ferritin, and CRP levels and isolated sepsis pathogens. Materials and methods: We are conducting a cross-sectional study for a period of 2 years on 360 adult patients admitted in an intensive care unit (ICU) of a tertiary care hospital with sepsis or septic shock. Our exclusion criteria are patients with burns, suspected or documented non-bacterial infections, viral hepatitis, iron overload states, and active COVID-19 infection. We are using convenience sampling. Demographic details of patients are collected. Blood is drawn for estimation of the four aforementioned biomarkers as well as body fluids of the patient based on clinical suspicion are sent for microbiological evaluation on admission to ICU before administration of antibiotics. Based on the culture reports, patients are classified as culture-positive or culture-negative sepsis and the biomarkers in each group are analyzed for diagnostic and prognostic accuracy. The primary outcome of the study is the survival or death of the patient while the secondary outcome is the number of days of ICU stay. During the time of submission, only 25 patients had been recruited and an interim analysis is being conducted. Results: During the time of submission, only 25 patients had been recruited and an interim analysis is being conducted. The mean age of our patients was 57.16 years. The study population was predominantly males (20 subjects) with ten subjects of urosepsis, three with pancreatitis, two with pneumonia, and the remaining ten had a miscellaneous diagnosis. The mean values of the inflammatory markers were as follows: PCT = 16.672 (±24.3495), CRP = 85.8428 (±62.1224), IL-6 = 610.268 (±723.3846), and ferritin = 625.0832 (±628.5289). The p value of the biomarkers is <0.00001 and is significant at p < 0.05. The following combinations of biomarkers were found to be statistically significant - PCT with IL-6 (p = 0.00018), PCT with ferritin (p = 0.00012), CRP with IL-6 (p = 0.00116), and CRP with ferritin (p = 0.00079). The sensitivity of CRP and IL-6 was 100% while specificity was highest for PCT at 50%. Eight of the subjects had Gram-negative sepsis. The mean days of hospitalization were 19.92 days. Eight of the subjects died contributing to a mortality rate of 3.2 per 10 subjects. Conclusion: The combination of biomarkers reflects different aspects of sepsis pathophysiology and would be feasible to incorporate as a point of care testing. The biomarker panel that would provide diagnostic information for the investigation of a patient with suspected sepsis earlier than cultures is PCT with IL-6 and ferritin.

18.
Frontiers in Cardiovascular Medicine ; 9, 2022.
Article in English | EMBASE | ID: covidwho-2005852

ABSTRACT

Prolonged critical care stays commonly follow trauma, severe burn injury, sepsis, ARDS, and complications of major surgery. Although patients leave critical care following homeostatic recovery, significant additional diseases affect these patients during and beyond the convalescent phase. New cardiovascular and renal disease is commonly seen and roughly one third of all deaths in the year following discharge from critical care may come from this cluster of diseases. During prolonged critical care stays, the immunometabolic, inflammatory and neurohumoral response to severe illness in conjunction with resuscitative treatments primes the immune system and parenchymal tissues to develop a long-lived pro-inflammatory and immunosenescent state. This state is perpetuated by persistent Toll-like receptor signaling, free radical mediated isolevuglandin protein adduct formation and presentation by antigen presenting cells, abnormal circulating HDL and LDL isoforms, redox and metabolite mediated epigenetic reprogramming of the innate immune arm (trained immunity), and the development of immunosenescence through T-cell exhaustion/anergy through epigenetic modification of the T-cell genome. Under this state, tissue remodeling in the vascular, cardiac, and renal parenchymal beds occurs through the activation of pro-fibrotic cellular signaling pathways, causing vascular dysfunction and atherosclerosis, adverse cardiac remodeling and dysfunction, and proteinuria and accelerated chronic kidney disease.

19.
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.

20.
Pediatrics ; 149, 2022.
Article in English | EMBASE | ID: covidwho-2003195

ABSTRACT

Introduction: This case describes a curious cutaneous finding with a unique etiology from a cultural remedy. Case Description: A 19-month-old female was brought in by ambulance for an acutely progressive abdominal rash. Three days prior to presentation, she had a febrile seizure. The next day, she continued to have low grade temperatures and developed a faint red rash on the abdomen. On the day of presentation, the mother found a dark violaceous rash on the abdomen and called 911. The patient's presenting vital signs were unremarkable except for tachycardia to 133 and lower blood pressure for age of 86/67. She was tired and irritable. She had a large welldemarcated dusky and dark plaque with central denudation over the whole abdomen and right lateral back [Figures]. She was exquisitely tender to light palpation and guarding her abdomen. The remainder of her exam was unremarkable. Given the extent of her skin injuries, differential included intra-abdominal injury, intra-abdominal hemorrhage, burn or bruise from accidental and non-accidental cause, allergic dermatitis and disseminated intravascular coagulation in the setting of sepsis. Laboratory evaluation revealed mildly low hemoglobin for age at 10.5 g/dl with low MCV 74.2fL and a leukocytosis with WBC of 18.41 x10-3 πl with neutrophil predominance. Coagulation factors were normal. CMP revealed mild acidosis with CO2 of 17 mmol/L. Imaging studies included normal: CT head and CT abdomen with mild subcutaneous edema in the anterior abdomen near the umbilicus. Additional infectious studies were negative including nasal SARS-CoV-2 PCR, blood culture and urine culture. After the work-up, findings were consistent with a second-degree burn confirmed by Dermatology and Plastic Surgery. Suspected Child Abuse and Neglect team conducted additional social history with maternal grandmother because she is the caretaker when parents are at work, given parental denial of witnessing or causing the burn. Grandmother had limited English proficiency, so history was taken using a Medical Spanish interpreter. Grandmother explained that one day prior to presentation, she used an Oaxacan folk remedy to alleviate abdominal pain in which green tomato pulp was applied like a salve. Final diagnosis was second degree burn from phytophotodermatitis. Patient's skin improved with daily dressing changes and application of silver sulfadiazine, and she was discharged home to parents. Discussion: The use of tomato salve is a unique etiology of phytophotodermatitis that has not been well-characterized. Typical vegetation that causes burn injuries include figs, lemons and common wildflowers. Tomatillos or green tomatoes contain plant psoralens that can induce a strong phototoxic reaction to ultraviolet A radiation exposure after cutaneous contact. Conclusion: We present this case to highlight the importance of conducting thorough social history in the family's preferred language and to share a unique folk practice that can present as a severe burn and mimic child abuse.

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