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1.
EJIFCC ; 33(2): 131-144, 2022 Aug.
Article in English | MEDLINE | ID: covidwho-2093012

ABSTRACT

Background: Coronavirus Disease 2019 (COVID-19) patients can present with a wide array of symptoms. For laboratory investigation of these patients several biochemical tests are routinely requested. Here we wanted to evaluate the utility of procalcitonin (PCT), ferritin, D-dimer, interleukin 6 (IL-6) and total lactate dehydrogenase (LDH) activity in predicting severe COVID-19 infection. Patients and methods: This study was undertaken at a tertiary care medical hospital in Tamil Nadu, India representing 183 COVID-19 RT-PCR positive patients, who were grouped based on their disease severity as mild (n=21), moderate (n=115) and severe (n=47) cohorts. All routine clinical chemistry analysis was performed as part of routine baseline assessment. Biomarkers of inflammation and infection were tested via the measurement of IL-6, PCT, ferritin, and D-dimer. Serum IL-6 concentration was estimated by ELISA, while total LDH activity was analyzed by kinetic colorimetric assay. Serum ferritin, PCT and D-dimer were measured by fluorescent immunoassay by sandwich immuno-detection method. Results: Biomarkers were significantly different among subgroups, and the highest concentrations were found in those with intensive care unit (ICU) admission. Serum PCT showed the best power to predict the need for ICU treatment followed by D-dimer, IL-6 and total LDH. Based on the AUC-ROC analysis, mortality was most effectively indicated by D-dimer followed by PCT, LDH, IL-6 and ferritin. Conclusion: Our study highlights the utility of some routinely available biochemical tests in the management of severe COVID-19. The higher baseline values of these biomarkers hint towards the probability of severe infection and a larger risk of death.

2.
Int J Mol Sci ; 23(21)2022 Oct 22.
Article in English | MEDLINE | ID: covidwho-2081827

ABSTRACT

Systemic juvenile idiopathic arthritis (sJIA) and its complication, macrophage activation syndrome (sJIA-MAS), are rare but sometimes very serious or even critical diseases of childhood that can occasionally be characterized by nonspecific clinical signs and symptoms at onset-such as non-remitting high fever, headache, rash, or arthralgia-and are biologically accompanied by an increase in acute-phase reactants. For a correct positive diagnosis, it is necessary to rule out bacterial or viral infections, neoplasia, and other immune-mediated inflammatory diseases. Delays in diagnosis will result in late initiation of targeted therapy. A set of biomarkers is useful to distinguish sJIA or sJIA-MAS from similar clinical entities, especially when arthritis is absent. Biomarkers should be accessible to many patients, with convenient production and acquisition prices for pediatric medical laboratories, as well as being easy to determine, having high sensitivity and specificity, and correlating with pathophysiological disease pathways. The aim of this review was to identify the newest and most powerful biomarkers and their synergistic interaction for easy and accurate recognition of sJIA and sJIA-MAS, so as to immediately guide clinicians in correct diagnosis and in predicting disease outcomes, the response to treatment, and the risk of relapses. Biomarkers constitute an exciting field of research, especially due to the heterogeneous nature of cytokine storm syndromes (CSSs) in the COVID era. They must be selected with utmost care-a fact supported by the increasingly improved genetic and pathophysiological comprehension of sJIA, but also of CSS-so that new classification systems may soon be developed to define homogeneous groups of patients, although each with a distinct disease.


Subject(s)
Arthritis, Juvenile , COVID-19 , Macrophage Activation Syndrome , Humans , Child , Macrophage Activation Syndrome/diagnosis , Macrophage Activation Syndrome/drug therapy , Macrophage Activation Syndrome/etiology , Arthritis, Juvenile/diagnosis , Arthritis, Juvenile/drug therapy , COVID-19/diagnosis , Biomarkers
3.
Pathophysiology ; 29(4): 583-594, 2022 Oct 11.
Article in English | MEDLINE | ID: covidwho-2071678

ABSTRACT

Cytokines are expressed by various cells after several stimuli such as surgical tissue damage, producing a systemic inflammatory response (SIR). C-reactive protein (CRP) is used extensively in clinical practice after operative injury, but proinflammatory cytokines, iron status, albumin, neutrophil-to-lymphocyte (N/L) ratio and hemoglobin, as acute phase reactants, have been poorly documented. This study aims to show how they behave after surgery, comparing laparoscopic (LC) versus open cholecystectomy (OC). In total, 55 patients were included in a prospective non-randomized form to undergo a cholecystectomy: 8 patients OC (50% females) and 47 patients LC (68% females). Before (A1) and 24 h after surgery (A2), blood samples were taken for an ordinary analysis and IL6, IL8 and TNFα determination. There were no differences between LC and OC groups concerning age, CRP, IL6 and TNFα at day A1. In the LC group at day A2, CRP, IL6, IL8, TNF, ferritin, leukocytes and N/L ratio increased; hemoglobin, lymphocytes, prothrombin and albumin decreased (p < 0.05). In the OC group at day A2, only IL6 (p < 0,07), ferritin, leukocytes, N/L ratio and CRP (p < 0.05) increased; serum iron, hemoglobin, lymphocytes and albumin (p < 0.05) decreased. At day A2, OC vs. LC group, higher values were observed in IL6, ferritin and CRP (p ≤ 0.05), and lesser values were observed in serum iron and prothrombin (p < 0.05). In conclusion, classic markers of inflammation are altered after surgery, in a milder way in laparoscopic surgery. Ferritin can be used as an inflammatory marker, as has been described in COVID-19 infection.

4.
Pakistan Journal of Medical and Health Sciences ; 16(8):24-26, 2022.
Article in English | EMBASE | ID: covidwho-2067738

ABSTRACT

Aim: To evaluate the potential use of ivermectin with standard therapy among mild to moderate covid-19 illness. Methods: This is a single-centered, prospective observational, randomized, parallel group (1:1 ratio), standard versus controlled ivermectin study recruited 210 confirmed COVID-19 positive patients who were admitted in COVID treatment center of Dr Ruth Kum Pafu Civil hospital Karachi, Pakistan from 1st November 2020 to 30th May 2021. Data were analyzed using SPSS version Results: Total of 210 patients were enrolled in the study and aged matched patients were divided in two groups 105 patients received ivermectin 6 mg twice a day for five days along with standard therapy while remaining 105 patients received standard therapy as per local and international guidelines. Male were 140(66.7%) and female 70(33.3%);age ranges between 26 to 77 years and majority 140( 66.7%) were more than 50 years of age. Fever, dry cough and dyspnea were the major symptoms seen;112(53.3%) patients had DM as a comorbid illness . Total of 21(20%) of 105 patients of ivermectin group had negative PCR for COVID 19 on day seven while the other group had positive covid test in all of 105 patients . On day 10 total of 49 more patients from ivermectin group found COVID negative along with 21 previously negative had second PCR was found negative in this way total of 70( 66.7%) of ivermectin group had negative PCR for COVID 19 while 21(20%) patients from non ivermectin got negative PCR for COVID 19 on day 10 . Conclusion: Use of ivermectin with standard therapy clear the virus earlier than standard therapy in mild to moderate COVID-19 infected patients admitted in COVID treatment center of Dr Ruth Kum Pafu Civil Hospital Karachi.

5.
Archives of Clinical Infectious Diseases ; 17(4), 2022.
Article in English | EMBASE | ID: covidwho-2067098

ABSTRACT

Background: The application of methylprednisolone in ARDS patients has led to a sustained reduction in inflammatory plasma cytokines and chemokines and has recently been used in the treatment of patients with SARS-CoV-2 infection. Objectives: In this study, the effect of methylprednisolone on clinical symptoms and antioxidant changes of patients with COVID-19 has been investigated. Methods: In the present study, patients with moderate to severe COVID-19 who required hospitalization were entered into the study phase. Then, in addition to standard treatment, patients received methylprednisolone at a dose of 250 mg intravenously over three days. Necessary evaluations include analysis of arterial blood gases, pulse oximetry, monitoring of patient clinical signs, examination of inflammatory biomarkers, and also receiving 10 cc of peripheral blood samples to check for antioxidant changes, at the beginning of the study, after 24 hours, and 72 hours after receiving methylprednisolone was on the agenda. Results: Changes in fever, superoxide dismutase (SOD, Glutathione-S-Transferase (GST, the ferric reducing ability of plasma (FRAP, malondialdehyde (MDA, Nitric oxide, Ferritin, and TNF-α before treatment and 72 hours after treatment were significantly different between the two stages (P < 0.05). Conclusions: The use of methylprednisolone improves the balance of antioxidants and immunological factors in patients with COVID-19 and thus improves some clinical indicators in these patients.

6.
Indian Journal of Critical Care Medicine ; 26(10):1091-1098, 2022.
Article in English | EMBASE | ID: covidwho-2066996

ABSTRACT

Background: It is known that coronavirus disease-2019 (COVID-19) pneumonia causes cytokine storm, and treatment modalities are being developed on inhibition of proinflammatory cytokines. We aimed to investigate the effects of anticytokine therapy on clinical improvement and the differences between anticytokine treatments. Method(s): A total of 90 patients with positive COVID-19 polymerase chain reaction (PCR) test were divided into three groups, group I (n = 30) was given anakinra, group II (n = 30) was given tocilizumab, and group III (n = 30) was given standard treatment. Group I was treated with anakinra for 10 days;tocilizumab, intravenously, was given in group II. Group III patients were selected from those who did not receive any anticytokine treatment other than the standard treatment. Laboratory values, Glasgow coma scale (GCS), and PaO2/FiO2 values were analyzed on days 1, 7, and 14. Result(s): The seventh-day mortality rates were 6.7% in group II, 23.3% in group I, and 16.7% in group III. In group II, the ferritin levels on the 7th and 14th days were significantly lower (p = 0.004), and the lymphocyte levels on the seventh day were significantly higher (p = 0.018). Examining the changes between the first intubation days, in the early period (seventh day), group I was found to be 21.7%, group II was 26.9%, and group III was 47.6%. Conclusion(s): We observed the positive effects of the use of tocilizumab on clinical improvement in the early period;mechanical ventilation requirement was delayed and at a lower rate. Anakinra treatment did not change mortality and PaO2/FiO2 rates. Mechanical ventilation requirements occurred earlier in the patients who were not receiving any anticytokine therapy. Studies with larger patient populations are needed to demonstrate the potential efficacy of anticytokine therapy. Copyright © The Author(s).

7.
Journal of Acute Disease ; 11(4):120-126, 2022.
Article in English | EMBASE | ID: covidwho-2066823

ABSTRACT

Unbalanced magnesium levels in the body, like other minerals, are a factor that is important in the severity and mortality of COVID-19. This study was designed to investigate the relationship between serum magnesium levels and clinical outcomes in COVID-19 patients. In this systematic review, a comprehensive search was performed in PubMed, Scopus, and Web of Science databases until September 2021 by using the keywords COVID-19, severe acute respiratory syndrome coronavirus 2, coronavirus disease, SARS- COV-infection 2, SARS-COV-2, COVID 19, and magnesium. End-Note X7 software was used to manage the studies. Articles that evaluated effect of magnesium on COVID-19 were included in the analysis. After reviewing several articles,12 studies were finally included in the ultimate analysis. The studies show that hypomagnesemia and hypermagnesemia are both factors that increase mortality in patients with COVID-19, even in one study, hypomagnesemia is the cause of doubling thedeaths in COVID-19 patients. Some studies have also found a negative correlation between magnesium deficiency and infectionseverity, while some others have reported no correlation between magnesium level and disease severity. According to the important role of magnesium in the body and its involvement in many physiological reactions, as well as differences in physical and physiological conditions of COVID-19 patients, in addition to the need for studies with larger sample sizes, monitoring and maintaining normal serum magnesium levels during the disease seems necessary as a therapeutic target, especially in patients admitted to the intensive care unit.

8.
Sri Lankan Journal of Anaesthesiology ; 30(2):118-123, 2022.
Article in English | EMBASE | ID: covidwho-2066752

ABSTRACT

Background and aims:The ongoing Covid pandemic has burdened the medical system, more so due to the limited availability of ventilators. Our study aims at identifying the role of hematological markers in the risk stratification and the need for ventilator support among ICU admitted COVID-19 patients. Method(s): A single centre prospective study was conducted on 100 Covid positive patients admitted in the ICU to determine association between the haematological markers such as Hb, Platelet count, Total and Differential leukocyte count, CRP, AST, ALT, LDH, Ferritin and D-Dimer with the need for oxygen therapy with or without invasive ventilatory support. Comparative analysis was performed between the 2 groups. Result(s): Neutrophilia, a mean of 76.7% among those ventilated and 71.6% among those non ventilated (p value 0.002;highly significant) and Lymphocytopenia (p value 0.004) with a mean of 14% and 18.6% respectively was noted. Hemoglobin levels were lower in ventilated (mean 11.6g/dl) as against those non ventilated (mean 12.58%) p value 0.046 which was significant. D-dimer was increased in COVID-19 patients;mean 5380 ng/ml in ventilated patients and mean 949ng/ml in those non ventilated (P < 0.001 highly significant). Elevated D-dimer and presence of diabetes correlated with increased chances of mechanical ventilation, while higher hemoglobin levels and associated COPD have a negative association with the need of mechanical ventilation. Conclusion(s): Hypercoagulability along with neutrophilia and lymphocytopenia can be used as positive associations for the need for invasive mechanical ventilation. Copyright © 2022, College of Anaesthesiologists of Sri Lanka. All rights reserved.

9.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P15-P16, 2022.
Article in English | EMBASE | ID: covidwho-2064492

ABSTRACT

Introduction: Anosmia has been described as one of the characteristic symptoms of COVID-19 disease. It is even considered as a key marker for COVID-19 diagnosis. The aim of the study is to evaluate anosmia as prognostic factor in moderate and severe cases of COVID-19 patients. Method(s): Our study is a multicenter prospective study;300 patients were recruited and confirmed COVID-19 infection and admitted into 3 tertiary referral quarantine hospitals to receive medical treatment in Minia, Egypt. The study was conducted between April and October 2021. The selected random sample met the following inclusion criteria: adults older than 18 years, rhinopharyngeal swab positive for SARS-CoV-2 infection, and moderate and severe cases of COVID-19. The patients were subjected to the following protocol: full clinical history, general medical examination, otorhinolaryngological evaluation, mandatory swab for COVID-19, and recording of laboratory data. Patients underwent olfactory assessment and follow-up for 3 months. Olfactory assessment was done subjectively by odor recognition thresholds using L-butanol;after evaluation, the patients were divided into anosmic and nonanosmic groups. Collected data were compared and statistically analyzed. Result(s): Olfactory impairment was seen in 35% of moderate cases and 13% in severe cases. Our study revealed that patients with anosmia were younger and mostly female. Hospitalized patients with anosmia had a better prognosis. Our results showed no significant differences between the 2 groups regarding temperature, heart rate, and respiratory rate. Of patients with anosmia, 70% were associated with dysgeusia, and 50% recovered within 13 days while 85% recovered within 28 days. There was significant relationship (parallel relationship) between progress of anosmia and level of D-dimer, C-reactive protein, and serum ferritin. This indicateds that the prognosis of anosmia is highly related to the inflammatory process of COVID-19 pathophysiology. Conclusion(s): Anosmic patients with COVID-19 have more favorable prognosis and recovery than nonanosmic patients do, and anosmia improves with treatment of the disease.

10.
Gut ; 71(Suppl 3):A24, 2022.
Article in English | ProQuest Central | ID: covidwho-2064221

ABSTRACT

IntroductionDuring the COVID-19 pandemic, many elective services were discontinued, including day-case venesection for patients with haemochromatosis. As services resumed, prioritisation of patients for venesection was required according to clinical need. Venesection procedure codes are recorded within inpatient episodes in the hospital electronic health record (EHR). This study aimed to use analysis of these episodes to stratify patients requiring the most urgent venesection.MethodsUtilising a database of 540 patients with haemochromatosis, details of all inpatient episodes between January 2015 and March 2020 were obtained from the hospital’s Informatics Department. For each patient, the total number of venesections for each calendar year was obtained, along with the start date of venesection and the hospital site. Patients with cirrhosis were identified from analysis of diagnosis codes contained within the EHR. Those patients with the highest intensity venesection prior to the discontinuation of services, and those who had commenced venesection most recently, were considered the highest priority for venesection.ResultsBetween January and March 2020, 31 patients had started venesection for haemochromatosis. Among the 540 patients receiving treatment, those undergoing the most intense venesection included 29 patients who had more than 16 procedures in 2019 and 2020. A further 20 patients had received 12–15 venesection and 54 had undergone 8–11 procedures during this period. Patients were stratified according to their local treatment site and venesection was restarted according to clinical need identified by this analysis.ConclusionsAnalysis of EHRs has been used extensively in epidemiological research and various methodologies have been developed. This study demonstrates its utility in service development with a direct impact on patient care. This analysis enabled a rapid framework for identifying clinical need, prior to restarting routine monitoring with serum ferritin.Since venesection for haemochromatosis requires a day case admission, these episodes are captured nationally in the Hospital Episode Statistics (HES) database. This study also demonstrates the use of EHRs for future studies in patients with haemochromatosis, including the prevalence of cirrhosis and its complications, analysis of regional variation in service provision, and clinical outcomes.

11.
Archives of Disease in Childhood ; 107(Supplement 2):A261, 2022.
Article in English | EMBASE | ID: covidwho-2064031

ABSTRACT

Aims Anakinra is an Interleukin-1 receptor (IL-1) antagonist;a biologic drug that has historically been used as part of longerterm management in methotrexate-resistant rheumatoid arthritis, cryopyrin-associated periodic syndromes and systemic juvenile idiopathic arthritis. We describe its successful use in acute multisystem inflammation in a cohort of recently treated children in a Tertiary Children's Hospital. Methods We reviewed the details of 6 acutely unwell inpatients admitted over the last 6 months, with acute multisystem inflammation, who had been treated with Anakinra as a rescue medication, following resistance to first-line anti-inflammatory medications. Five of these patients had been diagnosed with Paediatric Multisystem Inflammatory Syndrome temporarily associated with COVID-19 (PIMS). One of these patients had been diagnosed with Hemophagocytic Lymphohistiocytosis (HLH). Results The average length of initial treatment was 3.5 days before commencing Anakinra. All patients on Anakinra also received contemporaneous intravenous methylprednisolone treatment (IVMP), and 5/6 patients had received intravenous immunoglobulin therapy (IVIG). Common indications for commencing Anakinra were: persisting fevers despite at least 3 days of IVMP, and increasing inflammatory markers despite first line treatment. The average C-reactive Protein (CRP) at initiation of Anakinra was 82 (range 32 to 132) and the average Ferritin at initiation was 1500 (range 129 to 4640), with the average treatment duration of 6.7 days until CRP normalised, and all with normal CRP two weeks after treatment. All patients were started on an initial 2mg/kg dose of Anakinra, rounded up to nearest 100mg dose in most. Five patients were prescribed a subcutaneous route whilst one patient was started on an IV route. Half of patients were commenced on a once daily regime, two patients were started on a twice daily regime, and one patient was started on a QDS regime. One patient required a dose increase due to ongoing fevers after initiation. Average treatment length for the patients diagnosed with PIMS was 8.6 days, whereas treatment length was 25 days in the patient with HLH. We also describe the need for inotropic support (1/5), significant echocardiography findings at presentation (3/5) and at 2 weeks post-discharge (1/5) in this cohort of patients with PIMS. Conclusion Anakinra was successfully used as an acute treatment for our 6 described patients with multisystem inflammation. With more recent waves of PIMS, Anakinra has increasingly been used as a second-line treatment. Its introduction ceased ongoing fevers in all patients;5 of 6 with immediate effect. There are some clear advantages of Anakinra as a rescue drug over other potential biological alternatives, namely;choice of preparation, tolerability and few described side effects with short-term use. We highlight the experiential effectiveness of the acute use of Anakinra in our cohort of children with hyperinflammation, and recommend its accessibility as an emergency drug.

12.
Archives of Disease in Childhood ; 107(Supplement 2):A203-A204, 2022.
Article in English | EMBASE | ID: covidwho-2064028

ABSTRACT

Aims Multisystem inflammatory syndrome in children (MIS-C) secondary to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has affected not only the older children, adolescents and adults but also infants, more so during the second wave of the global pandemic. Thus, this study was done to describe the profile of infants presenting with multisystem inflammatory syndrome (MIS) with the aim to alert clinicians regarding the need for its early diagnosis and timely management in this vulnerable age group to prevent the morbidity, mortality and long term complications associated with MIS-C. Methods All sequentially admitted infants hospitalized during a period of 6months from,who fulfilled the WHO/CDC/RPCH criteria for MIS-C were included in the study. The data was recorded in a semi-structured pre-tested self-designed proforma regarding the demographic profile, presenting symptoms, clinical signs, laboratory parameters and treatment received. The data was analysed using appropriate statistical tools. Results A total of 19 infants were studied. Of these, 68.3% (13) had an evidence of recent COVID-19 infection. The median age of presentation was 2 months. The male:female ratio was 1.1:1. The most common presenting symptoms were fever (68.4%), gastrointestinal complaints (63.1%) and edema (36.8%) (figure 1). Other predominant signs were shock (78.9%), myocarditis (52.6%) and neurological complaints (26.3%). Incomplete Kawasaki disease was present in 21% patients. Elevated CRP, ferritin, D-Dimer, NT pro BNP and reduced fibrinogen were markers of severe illness. All subjects received IVIG (100%), 31.5% received a second dose of IVIG and 63.1% received pulse intravenous methylprednisolone. (table 1) A total of 5(26.3%) died as a result of the disease process. Conclusion MIS-C in infants is usually under-diagnosed and under-reported due to the considerable overlap between sepsis and MIS-C especially due to the higher incidence of sepsis in developing countries. The spectrum of this illness can be varied and is different from the overt clinical signs seen in older children and adolescents. Thus, these investigations should be done early in the course for optimal therapy with immunomodulators and favourable outcome.. (Figure Presented).

13.
Cardiology in the Young ; 32(Supplement 2):S176, 2022.
Article in English | EMBASE | ID: covidwho-2062097

ABSTRACT

Background and Aim: Mixed shock in multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 is con-sequence of acute heart failure, inflammation-induced vasodilation and potential volume loss. Method(s): Retrospective analysis included 25 patients (7 girls) with MIS-C-related combined shock, treated in period from April 2020 to December 2021. Result(s): Mean age of patients was 12.6 +/- 4.0 years. Admission was 6.1 +/- 1.6 days after symptoms onset. Systemic inflammatory response was manifested with neutrophilia (10.7 +/- 4.2 x109/), lymphopenia (1.1 +/- 0.7 x109/L), elevated CRP (220.9 +/- 86.1 mg/L), ferritin (684.5 +/- 549.5 mug/L) and D-dimer (1528 +/- 1254 ng/mL). One third of patients had acute kidney injury with glomerular filtration rate of 64 +/- 22 mL/min/1.73 m2 and urea level of 16.0 +/- 8.4 mmol/L. All patients had acute heart failure with ejection fraction 47.2% +/- 7.7% and fractional shortening 23.6% +/- 4.9%, 92% of patients had NTproBNP gt;1500 pg/mL and 58% had elevated troponin I (1.34 +/- 1.47 ng/mL). Z-scores for end-diastolic left ventricle, interventricular septum and pos-terior wall diameters were 0.7 +/- 1.1, 1.7 +/- 1.3 and 0.6 +/- 0.7 respectively. All patients had mild/moderate mitral regurgitation, and 60% had mild pericardial effusion. Inotropes, administered during first 3.7 +/- 1.6 days, were divided in three groups: 1) dop-amine (n = 14), 2) dobutamine + dopamine (n = 5), 3) milrinone +/- dopamine (n = 6). Additional treatment included diuretics and captopril. Total fluid balance (including insensible loss of 300 mL/m2/day) through days 1-7 was +860 mL/m2, +128 mL/m2,-108 mL/m2,-36 mL/m2,-306 mL/m2,-335 ml/m2,-298 ml/m2 (total-95 ml/m2). Methylprednisolone/intravenous immuno-globulin and low-molecular-weight heparin/acetylsalicylic acid were administered and fever persisted 1.2 days averagely. Oxygen supplementation was needed in 71% of patients. Transitory bradycardia was noticed and there was no difference in heart rate between treatment groups. Profound hypotension was revealed on admission and correction differed regarding treat-ment (p lt;0.05) (Figure 1). All patient survived with clinical improvement (one had mechanical ventilation, and one had stroke). Conclusion(s): Mixed shock is the most severe manifestation of MIS-C, and treatment of heart failure should be combined with cau-tious fluid resuscitation.

14.
Chest ; 162(4):A2693-A2694, 2022.
Article in English | EMBASE | ID: covidwho-2060983

ABSTRACT

SESSION TITLE: Late Breaking Posters in Critical Care SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: This systematic review aims to better understand the clinical characteristics, comorbidities, diagnostic findings, and clinical outcomes associated with COVID-19 myocarditis. METHODS: A search for “COVID-19 OR SARS COV-2 OR Coronavirus AND Myocarditis” was performed on 1/4/2022. 2011 studies from Embase and 1165 studies from PubMed were identified. Selection criteria included studies on SARS COV-2 infection-related myocarditis. 142 PubMed and 104 Embase studies were identified. Studies were appraised per protocols and s, vaccine-related myocarditis, uncertain vaccine/infection-related myocarditis, and, systematic reviews. Duplicate studies were removed. A total of 53 articles from which 57 cases were selected to be part of this systematic review. Data on age, sex, days since diagnosis, comorbid conditions such as morbid obesity, hypertension, hyperlipidemia, CAD, preexisting CHF, ischemic heart disease, D- Dimer, ferritin, high sensitivity troponin, BNP, EKG, echocardiogram, cMRI findings, medications, ventilation requirements, and mortality were extracted from 57 studies and were analyzed using IBM SPSS v26. RESULTS: Mean EF was 32.65 ± 16.57 %. EKG findings of diffuse ST elevation were present in 22% of all cases. Echocardiogram findings of diffuse hypokinesis present in 42.1% and depressed EF in 31.6% of all cases. 21.1% required non-invasive ventilation while 26.3% of all cases ended up requiring mechanical ventilation. Ischemic cardiomyopathy was present in 1.7%, Hypertension in 24.5%, Hyperlipidemia in 7%, Morbid obesity, and a previous diagnosis of CHF was present in 0% of all cases. Overall mortality was seen in 5.3% of all cases. 50% of the cases reported using cardiac MRI (cMRI) and 58% with reported cMRI findings met the Lake Louis criteria for diagnosis of myocarditis. CONCLUSIONS: This systematic review presents findings of demographics, comorbidities, diagnostic findings, and clinical outcomes of adult COVID-19 patients with myocarditis. The mean days since COVID-19 diagnosis has a wide range due to varied presentations noted in case reports. The previously presumed high-risk factors for COVID-19-related myocarditis are not present in a significant percentage of the cases. SARS-CoV2 myocarditis-related mortality is lower in cases than expected. In the setting of the appropriate clinical context, acute/subacute chest pain, with elevated cardiac biomarkers, abnormal EKGs, and echocardiogram findings in patients with recent or /remote SARS-CoV2 infection/ vaccination, a clinical diagnosis of myocarditis can be made in absence of cMRI. CLINICAL IMPLICATIONS: Diagnosis of SARS-CoV2-related myocarditis can be made based on clinical presentation, abnormal EKG, and echocardiogram with or without the added benefit of cardiac MRI. This systematic review aims to update current knowledge on the characteristics of COVID-19 infection-related myocarditis. DISCLOSURES: No relevant relationships by Mubashir Ayaz Ahmed No relevant relationships by Hari Bhattarai No relevant relationships by shyam chalise No relevant relationships by Saral Desai No relevant relationships by Shayet Hossain Eshan No relevant relationships by Sudha Misra No relevant relationships by Zahin Islam Rafa No relevant relationships by Shrungavi Ramanathan No relevant relationships by Monica Sharma

15.
Chest ; 162(4):A2662-A2663, 2022.
Article in English | EMBASE | ID: covidwho-2060980

ABSTRACT

SESSION TITLE: Late Breaking Chest Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Initial reports of COVID-19 autopsies revealed significant evidence of micro and macrovascular thrombosis. Due to concern for increased thrombotic events, many institutions implemented anticoagulation (AC) protocols for hospitalized patients. The study’s objective is to evaluate disease progression in patients treated with therapeutic anticoagulation vs. prophylactic anticoagulation in noncritical COVID-19 hospitalized patients. METHODS: We performed a retrospective cohort study of adults hospitalized with COVID-19 pneumonia between March 1-May 1, 2020. Inclusion criteria was any adult patient directly admitted to non-intensive care setting for radiologically confirmed COVID-19 pneumonia. T-test was performed for the continuous variables with normal distribution. Wilcoxon-rank-sum test for non-parametric groups. Chi-squared test for categorical variables. P-value <0.05 was considered statistically significant. RESULTS: Overall, 81 (34%) received therapeutic AC, and 159 (66%) subjected received prophylactic AC. The clinical characteristics of the therapeutic group included: average age 57.8 (vs. 55.7), 77.78% male (vs. 72.92%), 40.74% obese (vs. 37.92%), 64.74% had hypertension (vs. 40.88%), 44.44% had Diabetes Mellitus (vs. 37.92%) and 11.11% had chronic kidney disease (vs. 13.84%). Initial inflammatory markers were higher in therapeutic group vs. prophylactic, including D-dimer (845 vs 361ng/dL), Ferritin (918.5 vs. 632ng/mL), and CRP (20 vs. 11.2mg/dL). The average length of stay (LOS) of the therapeutic group was 10 days (vs. 7 for prophylactic), and a higher number of patients required mechanical ventilation (36 vs. 23), and hemodialysis (18 vs. 6). A higher number of adverse events (bleeding) was noticed in the therapeutic group (13.58% vs. 2.52%) with a p-value of <0.001. Higher odds of In-Hospital mortality observed in therapeutic group subjects with Hypertension (OR=5.41), chronic kidney disease (OR= 4.08), and lung disease (OR= 2.87) with a p-value of <0.05. CONCLUSIONS: In noncritically ill patients with COVID-19, treatment with therapeutic AC was related to greater LOS, requiring mechanical ventilation, hemodialysis, and adverse effects compared to prophylactic AC. We also observed a significantly higher D-dimer, ferritin, and CRP in the therapeutic group. RCT performed by ACTIV-4a investigators demonstrated increased organ support-free days in the therapeutic group, contrary to our study, which showed increased dependence of respiratory support and hemodialysis. Our therapeutic group patients appear to have higher comorbidities and significantly elevated initial inflammatory markers compared to the prophylactic group, which may explain these differences. CLINICAL IMPLICATIONS: Finally, our study supports the use of therapeutic anticoagulation depending on the patient overall clinical scenario. DISCLOSURES: No relevant relationships by Adebola Adetiloye No relevant relationships by Jennifer Arzu No relevant relationships by Kuldeep Ghosh No relevant relationships by Gabriel Ibarra no disclosure on file for Armeen Poor;No relevant relationships by Ingrid Portillo No relevant relationships by Fernando Quesada Mata No relevant relationships by Natoushka Trenard No relevant relationships by Julio Valencia Manrique

16.
Chest ; 162(4):A2478, 2022.
Article in English | EMBASE | ID: covidwho-2060950

ABSTRACT

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Pneumomediastinum is the presence of air or other gas in the mediastinum which can be due to trauma related to mechanical ventilation or spontaneous in preexisting lung diseases. Here, we present the case of Covid-19 pneumonia, who developed pneumomediastinum without any trauma or other risk factors. CASE PRESENTATION: A 56-year-old male COVID unvaccinated with a history of essential hypertension presented to the ED with shortness of breath and worsening cough for one week. He was living with his father, who was admitted to the ICU and receiving treatment for COVID pneumonia. The patient appeared to be in respiratory distress. His initial vital signs were temperature of 99.6 F, respiratory rate of 26 breaths per minute, blood pressure 125/71 mm Hg, heart rate 109 beats per minute with a regular rhythm, and oxygen saturation of 50% while he was breathing ambient air. Pulmonary examination revealed use of respiratory accessory muscle and widespread bilateral coarse rhonchi on auscultation. The rest of the physical examination was within normal limits. RT- PCR COVID -19 test was positive. The blood gas analysis reported respiratory alkalosis. Inflammatory markers were elevated: erythrocyte sedimentation rate (35.2 mg/L), C-Reactive Protein (17.70 mg/dL), Ferritin (1108.1 ng/mL), Lactate Dehydrogenase (813 U/L), Lactate (2.4 mg/dL), D-Dimer (35.20 mg/L) and Troponin High Sensitivity-236.6 ng/L. His CBC, electrolytes, and kidney function were normal. Chest X-ray showed Pneumomediastinum with dense basilar predominant consolidation. CT Angio Chest with contrast reported Pneumomediastinum likely from the left central airway source and bilateral dense ground glass consolidation. An echocardiogram showed an ejection fraction of 60-65%, no valvular abnormalities. He was placed on vapotherm(Oxygen 40L/min) with 100% FiO2. He was given Dexamethasone 6mg for ten days, Remdesivir, Barcitinib, and a 7-day course of Azithromycin and Ceftriaxone for community-acquired pneumonia. He was advised to practice prone positioning for 12 hours or more per day. Pulmonology, Infectious Disease, and Cardiology were consulted. Gradually, his oxygen requirement was weaned down and Pneumomediastinum resolved on serial chest x rays. He was discharged on home oxygen in a clinically stable condition. DISCUSSION: Pneumomediastinum in viral pneumonia is rare. The exact mechanism is unknown. Covid-19 pneumonia causes diffuse alveolar wall damage, which might cause air leakage into the mediastinum. The development of pneumomediastinum is an ominous sign in these patients. Fortunately, our patient did not worsen and was weaned off high flow oxygenation requirement. CONCLUSIONS: Few isolated reported cases of pneumomediastinum in a COVID-19 patient have been associated with life-threatening complications. It should be used as a prognostic marker, and close monitoring of these patients is advisable. Reference #1: Damous, S.H.B., dos Santos Junior, J.P., Pezzano, Á.V.A. et al. Pneumomediastinum complicating COVID-19: a case series. Eur J Med Res 26, 114 (2021) DISCLOSURES: No relevant relationships by Saad Ansari No relevant relationships by Akshit Chitkara No relevant relationships by Sudeshna Ghosh No relevant relationships by Femina Patel

17.
Chest ; 162(4):A2245, 2022.
Article in English | EMBASE | ID: covidwho-2060918

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SESSION TITLE: Systemic Disease with Diffuse Lung Symptoms Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Rapidly progressive interstitial lung disease (RP-ILD) is a rare and potentially fatal manifestation of dermatomyositis (DM) and has considerable impact in terms of the prognosis. CASE PRESENTATION: A 52-year-old male demonstrated DM-typical rash, fever, mialgias, and mild muscle weakness 3 months after asymptomatic COVID-19 infection. Two weeks later dysphonia and progressive dyspnea appeared. Lung CT scan showed the picture of organizing pneumonia. His COVID-19 PCR test was negative multiple times. Laboratory tests revealed the following numbers: ALT 210 IU/L, AST 748 IU/L, LDH 613 IU/L, CPK 1165 IU/L, ferritin 1145ϻg/l, CRB 11 mg/l. The patient was tested positive for anti-Ro52 antibodies, while anti-synthetase and scleroderma-associated antibodies were not discovered. Anti-melanoma differentiation-associated gene 5 (MDA5) test was not available due to the lack of the necessary test systems in the country. The patient was diagnosed with DM. Combined immunosuppressive therapy was administered, including: oral prednisolone 60 mg per day and 720 mg intravenously, dexamethasone 64-24 mg intravenously per diem, ciclosporin 200 mg и cyclophosphamide 600 mg, and 3 plasmapheresis sessions followed by an intravenous immunoglobulin. As a result of the therapy, muscle weakness disappeared and CPK levels returned to normal limits, however dyspnea progressed and ferritin levels hit 3500ϻg/l. After the following 3 weeks of intensive combined immunosuppressive therapy, the patient demonstrated symptoms of severe respiratory failure (RF). CT scan showed multiple traction bronchiectasis, wide areas of ground glass opacity, pneumomediastinum and subcutaneous emphysema of a neck and supraclavicular regions. Ciclosporin was replaced with tofacitinib with the dose of 10 mg per diem, IL-6 inhibitor (olokizumab 256 mg) was injected intravenously, massive broad-spectrum antibiotic therapy was administered. RF progressed and the patient was put on mechanical ventilation. The patient died of acute RF and sepsis a week later. DISCUSSION: RP-ILD is a common manifestation of severe MDA5+ DM, which is also associated with necrotizing vasculitis and amyopathic/hypomyopathic muscle involvement. In this case acute ILD in a patient with typical DM could also have been provoked by previous COVID-19 infection. CONCLUSIONS: The courses of disease for COVID-19 and MDA5+ DM have several similarities, which means it can be the same for their pathogenesis and clinical manifestations. In spite of early screening and intensive immunosuppressive therapy in such cases, the prognosis of patients with DM and RP-ILD is still poor and is associated with high mortality. Reference #1: Wang G, Wang Q, Wang Y, et al. Presence of Anti-MDA5 Antibody and Its Value for the Clinical Assessment in Patients With COVID-19: A Retrospective Cohort Study. Front Immunol. 2021 Dec 20;12:791348. doi: 10.3389/fimmu.2021.791348. PMID: 34987516;PMCID: PMC8720853. DISCLOSURES: No relevant relationships by Lidia Ananyeva No relevant relationships by Maria Aristova No relevant relationships by Liudmila Garzanova No relevant relationships by Anna Khelkovskaya-Sergeeva No relevant relationships by Dmitry Kulikovsky

18.
Chest ; 162(4):A1810, 2022.
Article in English | EMBASE | ID: covidwho-2060868

ABSTRACT

SESSION TITLE: Diagnosis of Lung Disease through Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Idiopathic pulmonary hemosiderosis (IPH) is a rare pulmonary disease often resulting in diffuse pulmonary fibrosis. The majority of diagnoses present in infanthood with limited studies demonstrating late onset disease in patients older than 30 years. The mainstay of treatment is immunosuppressive therapy including systemic corticosteroids. Here we present a unique case of IPH in an unvaccinated individual with COVID-19 pneumonia. CASE PRESENTATION: Our patient was a 31 year-old male with a history of IPH diagnosed in early childhood with past hospitalizations for DAH and progressive pulmonary fibrosis for which he was treated with corticosteroids and cyclophosphamide years prior to this admission. He presented with six days of progressive shortness of breath and respiratory distress. He tested positive for COVID-19 four days prior to presentation. He was unvaccinated for COVID-19. Initial oxygen saturation was found to be 56% and non-invasive mechanical ventilation was started. CT angiography of the chest revealed diffuse ground glass opacities, bilateral consolidative changes, and redemonstration of pulmonary fibrosis with extensive honeycombing. Lab results were remarkable for elevated inflammatory enzymes including ferritin 1,335 ng/mL, lactate dehydrogenase 1,369 units/L, and C-reactive protein 6.5 ml/dL. Patient was started on intravenous glucocorticoids, IL-6 inhibitor, remdesivir. Work up for bacterial superinfection was unremarkable. His hospitalization was complicated by acute kidney injury, elevated liver enzymes, and anxiety. Despite the immunosuppressive therapy, the patient continued to have refractory hypoxemia. Due to his persistent hypoxemia, the family was contacted regarding the impending need for endotracheal intubation. They ultimately declined and the patient succumbed to his respiratory failure. DISCUSSION: Idiopathic pulmonary hemosiderosis remains to be a largely unstudied and rare disease with catastrophic respiratory sequela. There remains a scarcity of evidence surrounding the most effective treatment of these patients, although limited studies have shown mortality benefit with immunosuppressive therapy. In patients with IPH an insult such as COVID-19 infection could prove fatal. Preventative measures such as vaccination is vital in the protection of these patients. Further research regarding pathogenesis and treatment mechanisms for IPH is an aim of future study. CONCLUSIONS: Idiopathic Pulmonary Hemosiderosis is a rare but deadly disease often complicated by diffuse alveolar hemorrhage and pulmonary fibrosis. Considering the underlying pulmonary compromise in these patients, secondary insult from infection can have catastrophic outcomes. Reference #1: Saha B. K. (2021). Idiopathic pulmonary hemosiderosis: A state of the art review. Respiratory medicine, 176, 106234. https://doi.org/10.1016/j.rmed.2020.106234 Reference #2: Ioachimescu, O. C., Sieber, S., & Kotch, A. (2004). Idiopathic pulmonary haemosiderosis revisited. The European respiratory journal, 24(1), 162–170. https://doi.org/10.1183/09031936.04.00116302 Reference #3: Thornton, G. & Alotaibi, M. (2016). 979: IDIOPATHIC PULMONARY HEMOSIDEROSIS IN ADULT PATIENTS: AN EPIDEMIOLOGIC ANALYSIS. Critical Care Medicine, 44 (12), 321-321. doi: 10.1097/01.ccm.0000509655.03624.6e. DISCLOSURES: No relevant relationships by Allison Kunze No relevant relationships by Mohammed Siddiqui

19.
Chest ; 162(4):A1163-A1164, 2022.
Article in English | EMBASE | ID: covidwho-2060782

ABSTRACT

SESSION TITLE: Studies on COVID-19 Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: To evaluate factors associated with early versus late mortality in hospitalized patient with COVID-19. METHODS: This observational study analyzed data of patients who died from COVID-19 at Ben Taub Hospital, a tertiary care County teaching hospital, between from March 2020 to February 2022. Demographic, comorbidities, laboratory values as well as COVID-19 treatments were examined. Patients were divided into two groups: those who had early mortality and those with late mortality (death ≤7 days or >7 days of admission, respectively). RESULTS: 212 patients with COVID-19 died during that period. Of these, 46 patients had early mortality and 166 patients had late mortality. 19/46 (41.3%) of the patients in early mortality group died within 72 hours of presentation. There were no differences between the two groups with regards to age, gender, ethnicity, or body mass index. Both groups were similar with regards to history of tobacco use, hypertension, diabetes mellitus, coronary artery disease, congestive heart failure, cerebrovascular accident, atrial fibrillation, obstructive airway disease, cancer, liver cirrhosis and human immunodeficiency virus infection. There were no differences with regards to COVID vaccination status between the two groups. Peak D dimer, peak C-reactive protein, peak ferritin, peak lactate dehydrogenase and lymphocyte nadir during the hospital course were also similar between the two groups. Patients in the early mortality group had shorter time from symptom onset to admission {3.91 days (SD 5.63) in early vs 6.85 days (SD 8.01) in late}. There were no differences between the two groups regarding use of mechanical ventilation. Patients with late mortality were more likely to have received systemic steroids (90.9% vs 60.9%), anticoagulation (94.6% vs 65.2%), remdesivir (75.3% vs 32.6%), inhaled epoprostenol (50.6% vs 19.6%) compared to early mortality, respectively. In addition to severity of symptoms and clinical condition at the outset of the disease, early death may have been related to not receiving some of these medications.1 CONCLUSIONS: Early mortality in patients with COVID-19 is associated with shorter time to symptoms onset and the lower likelihood to have received systemic steroids, systemic anticoagulation, remdesivir and inhaled epoprostenol. CLINICAL IMPLICATIONS: Early recognition and intervention may prevent early mortality in COVID-19 patients. Reference: Sun, Q., Qiu, H., Huang, M. et al. Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province. Ann. Intensive Care 10, 33 (2020). https://doi.org/10.1186/s13613-020-00650-2 DISCLOSURES: No relevant relationships by Muhammad Adrish Advisory Committee Member relationship with AstraZeneca, Genentech, GSK, Mylan, Sanofi Please note: 2020-2021 by Nicola Hanania, value=Consulting fee Consultant relationship with AstraZeneca, Genentech, GSK, Mylan, Sanofi Please note: 2020-2021 by Nicola Hanania, value=Consulting fee Advisory Committee Member relationship with Regeneron, Amgen, and Teva Please note: 2020-2021 by Nicola Hanania, value=Consulting fee Consultant relationship with Regeneron, Amgen, and Teva Please note: 2020-2021 by Nicola Hanania, value=Consulting fee Removed 08/02/2022 by Nicola Hanania Research support relationship with Boehringer Ingelheim, GSK, Novartis Please note: 2020-2021 by Nicola Hanania, value=Grant/Research Support Research support relationship with Sanofi Genzyme and Genentech Please note: 2020-2021 by Nicola Hanania, value=Grant/Research Support No relevant relationships by Stephanie Stalcup

20.
Chest ; 162(4):A1120, 2022.
Article in English | EMBASE | ID: covidwho-2060774

ABSTRACT

SESSION TITLE: Critical Gastrointestinal Case Reports SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Histoplasma capsulatum is a dimorphic fungus most commonly encountered as an opportunistic infection in immunosuppressed patients, particularly those with HIV/AIDS. However, patients immunosuppressed from other causes can also be at risk. Here is presented the case of a patient on multi-immunosuppressant therapy as treatment for Crohn's disease, who developed disseminated histoplasmosis. CASE PRESENTATION: A 44-year-old male with a past medical history of Crohn's disease (previously been on azathioprine, adalimumab and currently on Prednisone therapy), recently started on infliximab infusion for uncontrolled symptoms of IBD, diabetes mellitus, hypothyroidism, and COVID-19 infection (not requiring oxygen therapy) one month prior to the current admission initially presented to the hospital with chief complaints of exacerbated weakness, myalgias, fevers and diarrhea for 5 days;Symptoms of weakness, myalgias began after first infusion of infliximab and it got progressively worse after the 2nd infusion 2 weeks prior to the admission. White Blood Cell count was 1.1 K/uL, platelet count was 7 K/uL, hemoglobin was 7.9 g/dL. CRP was elevated to 142 mg/L, and ferritin was elevated to 39,000 ug/L. CT abdomen and pelvis demonstrated probable rectosigmoid colitis and splenomegaly. Subsequent chest x-ray demonstrated bilateral opacities with haziness over bilateral lung fields. Respiratory viral panel, stool panel, blastomyces antigen, cryptococcal antigen, toxoplasma antibodies, HIV antibody, CMV PCR, and blood cultures were unrevealing. Urinary histoplasma antigen was positive, and BD-glucan was elevated to over 500 ng/L. EBV panel was positive for reactivation, with EBV DNA 2.02 IU/mL. He was subsequently started on amphotericin B lipid complex, with itraconazole destination therapy. He was treated empirically for pneumocystis jiroveci pneumonia (PJP) with sulfamethoxazole-trimethoprim due to him being on chronic Prednisone therapy. Echocardiogram demonstrated left ventricular ejection fraction (LVEF) of 40%, with diffuse hypokinesis and wall motion abnormalities, posing some question of myocarditis. He was later discharged home in an improved state. DISCUSSION: Disseminated histoplasmosis in the setting of Crohn's disease on chronic immunosuppressive therapy has been very rarely reported,(1) with similar reports in patients on immunosuppressive therapy in the setting of rheumatologic disease being slightly more common.(2) The most commonly involved areas in gastrointestinal histoplasmosis are the terminal ileum and colon,(3) with this patient's rectosigmoid colitis and symptomatology being consistent with this pattern. The patient's myocarditis is also consistent with disseminated histoplasmosis infection. CONCLUSIONS: Clinicians should maintain suspicion for opportunistic infections in patients on immunosuppressive therapy in the setting of critical illness. Reference #1: Bhut, B., Kulkarni, A., Rai, V. et al. A rare case of disseminated histoplasmosis in a patient with Crohn's disease on immunosuppressive treatment. Indian J Gastroenterol 37, 472–474 (2018). https://doi.org/10.1007/s12664-018-0886-1 Reference #2: Wood KL, Hage CA, Knox KS, et al. Histoplasmosis after treatment with anti-tumor necrosis factor-alpha therapy. Am J Respir Crit Care Med. 2003;167(9):1279-1282. doi:10.1164/rccm.200206-563OC Reference #3: Galandiuk S, Davis BR. Infliximab-induced disseminated histoplasmosis in a patient with Crohn's disease. Nat Clin Pract Gastroenterol Hepatol. 2008;5(5):283-287. doi:10.1038/ncpgasthep1119 DISCLOSURES: no disclosure on file for Donald Dumford;No relevant relationships by Abhilash Bhat Marakini No relevant relationships by Palak Rath No relevant relationships by Sterling Shriber

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