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1.
Laryngo- Rhino- Otologie ; 101:S245, 2022.
Article in English | EMBASE | ID: covidwho-1967656

ABSTRACT

Introduction Cervical lymphadenopathy is a common finding in the pediatric population and manifests itself uni- or bilaterally. The causes of an acute cervical lymphadenopathy in general pediatric practice are commonly infections (bacterial or viral). Uncommon causes are immunological diseases such as Kawasaki syndrome and Kikuchi-Fujimoto disease. A progression of the lymph node swelling could lead to abscess. Methods We present a clinical case and a systematic literature research on PubMed was performed. Results A 9-year-old patient who developed a high fever 3 days apart with right cervical lymphadenitis and restricted neck mobility was reported to our hospital. The imaging revealed a lymphadenitis on the right side of the neck with increased inflammation parameters and negative blood cultures. Despite the intensive treatment, the patients condition was worsening and was transferred to a pediatric intensive care unit as an emergency, where a previous SARS- CoV- 2 infection was diagnosed as the cause of the symptoms and treated accordingly. Conclusions Patients infected from COVID-19 disease report commonly ENT symptoms as loss of smell and taste, nasal obstruction with rhinorrhea and a sore throat. Cervical lymphadenopathy was less common finding. Our research did not come across any description of unilateral lymphadenopathy as an initial symptom of a PIMS. The sonographic evaluation of the cervical lymph nodes is essential in the diagnosis of lymphadenitis colli and decisive for the indication of surgical procedures.

2.
Laryngo- Rhino- Otologie ; 101:S180, 2022.
Article in English | EMBASE | ID: covidwho-1967655

ABSTRACT

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

3.
Gastroenterology ; 162(7):S-1376-S-1377, 2022.
Article in English | EMBASE | ID: covidwho-1967452

ABSTRACT

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

4.
Gastroenterology ; 162(7):S-846, 2022.
Article in English | EMBASE | ID: covidwho-1967375

ABSTRACT

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

5.
Journal of the American College of Surgeons ; 233(5), 2021.
Article in English | EMBASE | ID: covidwho-1965238

ABSTRACT

The proceedings contain 629 papers. The topics discussed include: barriers to Covid-19 vaccination in underserved minorities: impact of health care access and sociodemographic perspectives;concomitant cholecystectomy during initial bariatric surgery does not increase risk of postoperative complications or bile duct injuries;identifying behavioral facilitators to weight loss after bariatric surgery: are there differences between Medicaid and non-Medicaid patients?;impact of post-discharge phone calls on nonurgent hospital returns;laparoscopic heller myotomy is associated with fewer postoperative complications compared to the thoracoscopic approach: a NSQIP study;population-wide analysis of the effect of bariatric surgery on idiopathic intracranial hypertension in obese patients;reducing operating room inefficiencies via a novel surgical app shortens the duration of laparoscopic Roux-en-y gastric bypass;subtotal gastrectomy vs gastroenterostomy in duodenal obstruction secondary to peptic ulcer disease: results of a retrospective nationwide study;and enhanced recovery after bariatric surgery: further reduction in opioid use with the introduction of dexmedetomidine and transverse abdominis plane block.

6.
Cureus ; 14(6): e26172, 2022 Jun.
Article in English | MEDLINE | ID: covidwho-1964579

ABSTRACT

Traumatic macroglossia is a rare condition characterized by a sudden edematous swelling of the tongue due to trauma that can progress into upper airway obstruction and asphyxia. We are presenting a case of a 20-year-old female with medical history significant for Rett syndrome who developed severe tongue swelling after multiple attempts of intubation secondary to low Glasgow Coma Scale (GCS) from a high dose of benzodiazepines. Traumatic macroglossia in this case was worsened further by uncontrolled bruxism. Multiple approaches were made to control the situation including placement of bite block, use of paralytics, and steroids. Multiple cases were reported about traumatic macroglossia but our case was unique in the sense that our patient did not respond well to conservative medical therapy and surgical approach was not possible as it was set to be done in a tertiary center; however, transferring the patient was not possible with the COVID-19 pandemic as hospitals were on diversion.

7.
Health and Human Rights ; 24(1):77, 2022.
Article in English | ProQuest Central | ID: covidwho-1957760

ABSTRACT

There must be accountability for the acute and longer-term impacts on Palestinian health that flow from the bombings in Gaza and violence in the West Bank and East Jerusalem. Israel has not been held to account for the recent escalation of violence or for the willful obstruction of the passage of essential care and resources that would protect the Palestinian people from COVID-19. Israel has also not been held to account for creating and perpetuating the conditions that have led to the chronic degradation of the Palestinian health system and the poor health of Palestinians. States that act to degrade the health of whole populations must not be permitted to continue doing so with impunity. It is time to end our tolerance for companies and institutions that are complicit with or support the structural violence of colonization and racism that is denying the good health of Palestinians a right that all Palestinians are entitled to enjoy. Strengthening health accountability toward people living in conflict settings can open new avenues for assuring good health, ending oppression and violence, and building peace. As a global health community, we must raise our collective voices and reproach censorship and attempts to silence us.

8.
Journal of Clinical Urology ; 15(1):81-82, 2022.
Article in English | EMBASE | ID: covidwho-1957017

ABSTRACT

Introduction: There is growing recognition that bladder outlet obstruction (BOO) surgery can often be safely performed as a day case procedure. The BOO surgery day case rate (DCR) is a Getting It Right First Time (GIRFT) quality metric. Patients awaiting BOO surgery represent the largest group awaiting elective surgical treatment in urology. This unmet need has expanded considerably due to the Covid-19 pandemic. Patients and Methods: Model Hospital (MH) is a datadriven improvement tool for English NHS trusts, which utilises routinely collected national level data. MH describes performance metrics for transurethral resection of prostate, laser prostatectomy, prostatic urethral lift, and bladder neck incision. MH data were analysed for all 115 trusts performing BOO surgery over 12 months to October 2021. Associations between service delivery and outcome metrics were tested. Results: Table 1 shows national Trust-level metrics for DCR, length of stay (LOS), 30-day readmission rate (30D), annual centre volume (ACV), and waiting list time (WLT). Analysis indicated no significant association between any of the following;DCR and 30D (Spearman rank correlation coefficient (rs)=-0.085, p=0.37), ACV and 30D (rs=- 0.019, p=0.84), DCR and WLT (rs=0.16, p=0.096). Conclusion: There is wide variation in DCR and WLT nationally. The absence of association between DCR and 30D suggests that many trusts can safely increase DCR for BOO surgery. Optimising DCR could help to facilitate the post-Covid Elective Recovery for surgery. The lack of association between DCR and WLT, however, suggests that further resource constraints beyond elective inpatient bed availability influence the provision of BOO surgery.

9.
European Stroke Journal ; 7(1 SUPPL):331, 2022.
Article in English | EMBASE | ID: covidwho-1928137

ABSTRACT

Background and aims: RES-Q Registry is the first stroke database in Romania. The aim is to map key performance indicators for quality of stroke care and to improve stroke management Methods: Each center registers all stroke patients hospitalized in march, yearly. Results: The number of participated centers has increased from 10 in 2017 to 36 in 2021. In five years we have registered 8467 patients. The median age was 71.46 years, median NIHSS at admittance 7.8 points, 82.8% ischemic strokes. Despite improvement in revascularization procedures (intravenous thrombolysis increased from 2.27% in 2017 to 10.56 in 2021, and mechanical thrombectomy from 0,1% to 1,7%) median Modified Rankin Score at discharge did not change significantly and mortality has increased (from 15.09% in 2017 to 19.03% in 2021). A reason for increased mortality is due to Covid-19 pandemic (poor access to primary care, more severely ill, increased door to needle time due to epidemiologic circuits), but beside this, there are unsolved problems, such as the very low percentage (below 1%) of decompressive hemicraniectomy, the reduced capacity to actively detect atrial fibrillation ( 36.9% of patients are still screened for AF only by repeated ECG), the low percentage of carotid imaging (56.7%) and revascularization procedures (less than 7% of symptomatic carotid stenosis). Conclusion: For a better prognosis of stroke we need to increase the number of properly financed stroke units, the educational activities, and to elaborate and implement a national stroke plan.

10.
European Stroke Journal ; 7(1 SUPPL):295, 2022.
Article in English | EMBASE | ID: covidwho-1928071

ABSTRACT

Background and aims: The initiation of a global mass vaccination against COVID-19 seems to decrease mortality and hospitalization for vaccinated people. However, side effects may occur. This short review illustrates some cases of vascular complications following the COVID-19 vaccination, affecting young people with ischemic, embolic complications or a combination of the two. Patients and methods: Observation 1: a 46 years old woman consulted for a sudden left sided hemiparesis seven days following the second dose of covid-19 vaccine. The initial brain scan was normal and she received thrombolytic treatment. Control scan showed signs of ischemic stroke of right superficial cerebral artery with haemorrhagic transformation. Supra-aortic ultrasound was performed showing a fresh mobile thrombus with complete obstruction of the right internal carotid artery. Observation 2: a 52 year old patient admitted for accute dyspnea, three days after receiving the third dose of covid-19 vaccine. CT angiography revealed a thrombosis of left pulmonary artery. Five days later, an ischemic vascular accident occurs confirmed by CT scan, so we made a supra-aortic ultrasound revealing a thrombosis of right proximal internal carotid artery. Discussion and results: Incidence of vascular complications due to the covid 19 vaccination is discussed with possible hypotheses. Conclusions: COVID-19 vaccines are considered safe since the proven benefits of vaccination in protecting against COVID-19. Nonetheless, health professionals must be aware of all possible complications, early diagnosis and quick initiation of the appropriate treatment may enhance the outcome. (Figure Presented).

11.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927848

ABSTRACT

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

12.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927832

ABSTRACT

Introduction: Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystem disorder characterized by asthma, prominent peripheral blood eosinophilia, and small-vessel vasculitis. We report a case of EGPA in an adolescent with uncontrolled asthma who was receiving montelukast. Case: A 12-year-old boy who is known to have asthma and allergic rhinitis which were previously controlled on ICS, intranasal steroids, and prolonged use of montelukast for 4 years. He presented with cough and nasal blockage for 2 months. He also reported an increase in the frequency of asthma attacks and received multiple courses of systemic steroids. Subsequently, his asthma controller medications were upgraded to ICS/LABA few weeks prior to admission. His symptoms were also associated with weight loss, diarrhoea and haematochezia. He was vitally stable and maintained oxygen saturation on room air. Physical examination revealed nasal polyps, purple skin flat lesions on palms and feet (Figure1), and bilateral crackles on chest auscultation. His blood investigations were significant for leukocytosis with marked eosinophilia (11x103/uL, (51%)), high inflammatory markers and total-IgE (1975 kU/L). Initial chest XR showed bilateral interstitial thickening and small pleural effusions (Figure2). Chest CT showed centrilobular nodules and peripheral ground-glass opacities, tree-in-bud appearance with no peripheral sparing in addition to moderate pericardial effusion and bilateral mild pleural effusion (Figure3). Sinus CT showed extensive sino-nasal polyposis with pansinusitis (Figure4). Initial echocardiography showed moderate pericardial effusion with normal biventricular function. Patient was started on IV furosemide. During his hospitalization, patient developed chest pain. His serial troponin was rising and LV contractility was depressed. ECG showed ST-segment depression. Therefore, EGPA with cardiac involvement was suspected. Cardiac MR showed features of a peri-myocarditis. IVIG was commenced for suspicion of coronary artery involvement, which was later disputed by cardiac cath. He was also started on IV pulse steroids at a dose of 30 mg/kg for 3 days which resulted in dramatic decrease in troponin level, eosinophil count and CRP. Skin biopsy, which was later performed after administration of steroids, showed perivascular non-necrotizing granulomas. His ANA, ANCA and COVID-19 PCR came negative. Serum chemistries and urine microscopy were unremarkable. Patient was later started on Rituximab with significant clinical, serological and radiological (Figure5,6) improvement after 10-months of follow-up. Discussion: EGPA is rare but should be considered in children with uncontrolled asthma, eosinophilia and rhino-sinusitis. This case shows the importance of being aware that montelukast could cause EGPA, in spite of the uncertainty about its mechanism. (Figure Presented).

13.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927754

ABSTRACT

RATIONALE: INNA-051 is a Toll-like receptor (TLR) 2/6 agonist delivered via intranasal spray, being developed for treatment of respiratory viral diseases. Pre-clinical studies demonstrate that INNA-051 and analogues are effective against a variety of respiratory viruses including SARS-CoV- 2, influenza, and rhinovirus. INNA-051 induces a tissue-localized innate immune response with cytokine expression and infiltration of innate immune cells into the nasal epithelium that play a key role in viral clearance. The primary objective of this study (ACTRN12621000607875p) was evaluation of safety and tolerability in healthy adults. METHODS: This was a randomized, doubleblind, placebo-controlled, Phase 1 study of single and multiple ascending INNA-051 intranasal doses, with the total dose split evenly across both nostrils. Sixty-four participants ages 18-55 were enrolled, with 5 cohorts (6 active:2 placebo/cohort) receiving single doses of 20μg, 60μg, 150μg, 300μg, or 600μg, and 3 cohorts (6 active:2 placebo/cohort) receiving 4 total doses of 60μg, 150μg, and 300μg administered every third day. Assessments included adverse events, clinical laboratories, peak inspiratory nasal flow (PINF), and peak expiratory flow (PEF).RESULTS: Sixtyfour participants (36 males:28 females) ages 19-55 years were enrolled. Preliminary blinded results demonstrate that INNA-051 was well tolerated across all single and multiple dose cohorts. Adverse events were predominantly mild, limited to the nasopharynx, and resolved within 24-48 hours. Across single dose cohorts, the most frequent events were nasal congestion/blockage (n=20), nasal erythema/inflammation (n=19), rhinorrhea (n=13) and headache (n=11). Except for the 20-μg cohort with only 2 reports of rhinorrhea, all other single dose cohorts had a similar incidence of the other adverse events with no obvious dose relationship. Across all 3 multiple dose cohorts, nasal erythema/inflammation (n=42) was most frequently reported, followed by nasal congestion/blockage (n=26), rhinorrhea (n=9), and headache (n=9), with no dose-dependent relationship. No participants withdrew from the study due to adverse events. There were no clinically significant changes in clinical chemistry and hematology laboratories across all single and multiple dose cohorts. No consistent decrease in post-dose PNIF assessments were observed, and there were no changes in PEF assessments to suggest lower respiratory tract airway response to intranasal INNA- 051.CONCLUSIONS: Intranasal INNA-051 was well tolerated up to single doses of 600μg and multiple doses of 300μg. Mild, self-limited nasal adverse events as described are possible indicators of tissue-localized innate immune response by INNA-051. Investigation of cytokine levels and gene expression of the intranasal epithelium are needed to specifically determine TLR2/6 engagement by INNA-051.

14.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927748

ABSTRACT

RATIONALE The COVID-19 pandemic has disrupted national spirometric surveillance of active and former U.S. coal miners since March 2020. Consequently data collected by the Health Resources and Services Administration (HRSA)-funded Black Lung Clinics Program (BLCP) represents the only major source of recent health data on U.S. former coal miners. Using the first available year of national BLCP data we examined associations between mining region and radiographic disease and lung function impairment. METHODS We analyzed pre-bronchodilator spirometry and International Labour Office chest radiograph classifications from miners seen across 15 BLCP grantees from July 1 2020 to June 30 2021. We calculated percent predicted (PP) and lower limits of normal (LLN) for forced expiratory volume in one second (FEV1) forced vital capacity (FVC) and FEV1/FVC ratio. We determined prevalence of patterns of spirometric abnormality (restrictive obstructive/mixed) and moderate to severe impairment (FEV1<70PP). We classified miners who worked the majority of their coal mining career in Kentucky Virginia or West Virginia as Central Appalachian miners. We examined associations between region worked and lung function impairment using logistic regression. RESULTS The 2,891 miners were predominantly non- Hispanic white (98.1%) and male (99.4%) with mean age 66 years (SD9.3). Mean coal mining tenure was 26 years (SD10.7) and 66% (n=1,900) were Central Appalachian miners. Thirty-seven percent had never smoked. Among those with chest radiographs (n=2,464 85%) Central Appalachian miners had a significant three-fold increase in progressive massive fibrosis (PMF) prevalence compared to miners who worked elsewhere in the U.S. (9% vs 3% p<.0001). Smoking history and spirometry were available in 66% (n=1,918). Of these 40% of never-smokers had abnormal spirometry (obstruction/mixed 10%;restriction 30%);among ever-smokers, 54% had abnormal spirometry (obstruction/mixed 27%;restriction 27%). Abnormal FEV1 was present in 30% of never smokers and 42% of ever-smokers. Mean FEV1PP was significantly lower among Central Appalachian miners compared to miners from other regions. Controlling for age, tenure, and pack-years, Central Appalachian miners had significantly elevated odds of having FEV1 impairment compared to non-Central Appalachian miners (OR 1.31, 95%CI 1.06,1.62). A subanalysis controlling for category of radiographic disease showed that odds of impairment remained elevated among Central Appalachian miners (OR 1.24, 95%CI 0.97,1.60). CONCLUSIONS Controlling for smoking, age, and tenure, former miners who worked most of their career in Central Appalachia have significantly increased odds of disabling impairment. These findings highlight the important role of HRSA-funded black lung clinics in understanding work-related lung disease among U.S. coal miners.

15.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927746

ABSTRACT

With the spread of the novel coronavirus disease 2019 (COVID-19) pandemic, an alarming number of patients now present with acute respiratory distress syndrome (ARDS). Conservative fluid management with diuresis in the ARDS patients improves lung function and decreases ventilator-dependent days. Several cardiac manifestations have been reported in COVID-19 patients including rhythm disorders, myocarditis, Takotsubo cardiomyopathy and myocardial infarction. A 65-year-old Asian female with a history of hypertension presented to the emergency department with cough, worsening dyspnea and palpitations of one-week duration. Investigations at admission were significant for a positive COVID-19 polymerase chain reaction test with an electrocardiogram (EKG) (Figure 1 Panel-A) revealing inferior ST-elevations. Troponin-T was elevated to 1162 ng/L with bedside echocardiogram revealing inferior hypokinesis. Due to concerns for acute ST-elevation myocardial infarction (STEMI), the patient underwent cardiac catheterization with no obvious coronary artery occlusion. A ventriculogram revealed apical ballooning and the patient was treated for COVID-19 induced Takotsubo cardiomyopathy. The patient developed worsening respiratory distress on hospitalization day 3 requiring oxygen supplementation with a high-flow nasal cannula. Conservative fluid regimen and diuretic therapy were being administered when the patient developed ventricular fibrillation and suffered a cardiac arrest. After successful resuscitation, a repeat EKG (Figure 1 Panel-B) demonstrated new anterior and inferior ST-elevations. The patient required increasing vasopressor support, and a repeat cardiac catheterization to rule out coronary artery thromboembolism induced STEMI was negative. A right heart catheterization revealed elevated SVR with decreased cardiac index. The patient clinically deteriorated despite negative fluid balance with recurrent malignant arrhythmias. A bedside echocardiogram performed revealed persistent apical hypokinesis and systolic anterior motion of anterior mitral leaflet (Figure 1 Panel-C) with flow acceleration at left ventricular outflow tract (LVOT) (Figure 1 Panel-D). Due to concerns of cardiogenic shock secondary to Takotsubo cardiomyopathy with dynamic LVOT obstruction physiology, the patient was treated with liberal intravenous fluid resuscitation and successfully weaned from vasopressor therapy. Although she was successfully extubated 2 days later, the patient, unfortunately, passed away later from a thromboembolic stroke. Severe COVID-19 infections are associated with catecholamine surge which may precipitate Takotsubo cardiomyopathy in the susceptible patient population. Female patients with Takotsubo cardiomyopathy are at increased risk of developing dynamic LVOT obstruction. In these patients, management of shock and ARDS can be challenging as the use of inotropic agents may result in hemodynamic instability. Our patient was successfully hemodynamically stabilized using fluid resuscitation once the inotropic support was withdrawn after identifying dynamic LVOT obstruction.

16.
Palliative Medicine ; 36(1 SUPPL):46-47, 2022.
Article in English | EMBASE | ID: covidwho-1916792

ABSTRACT

Background/aims: Radiotherapy is an effective palliative treatment for metastatic disease. The current COVID-19 pandemic has led us to consider shorter courses, new guidelines and prioritize cases clinically urgent. The purpose of this study is to analyze our practice in palliative treatment, new potential strategies and hypofractionation. Methods: 252 patients who receive palliative radiation treatment from March 2020 to March 2021 were reviewed. We analyze how the treatment line has been modified throughout the 1 year of the pandemic and other items related to the different therapeutic options as mortality, reirradiation, primary localization and intention. Results: Median age was 68 years (range 33-95y), 66% males, 34% females. Main primary tumors were 30% lung, 12% prostate and 10% breast. 65% patients had painful bone metastases, 15% brain metastases, 14% cord compression, 4% bleeding and 2% superior vena cava obstruction. Advanced disease was detected in 12% as debut. Half of patients were treated in the two first months of the pandemic than later. Treatment provided was: 8 patients required reirradiation. Currently, 66% died. Conclusions: Radiotherapy plays a critical role improving quality of life in patients with advanced disease, even in the midst of the COVID-19 pandemic. During the first months of confinement, short radiation therapy cycles prevailed over the long ones, as the normal schemes of fractionation coinciding with a greater number of sessions gained importance as time went on. (Table Presented).

17.
Nephrology Dialysis Transplantation ; 37(SUPPL 3):i68-i69, 2022.
Article in English | EMBASE | ID: covidwho-1915664

ABSTRACT

BACKGROUND AND AIMS: During the time of the COVID-19 pandemic, multiple treatment options have been investigated, even though their efficacy and secondary effects remain insufficiently known. We report the case of a vitamin C induced oxalate nephropathy in a COVID-19 patient with preexisting chronic kidney disease (CKD) resulting in irreversible acute renal failure. Vitamin C, also known as ascorbic acid, has been used as an anti-inflammatory therapy for COVID-19, but review of the literature shows similar cases of acute kidney injury (AKI), raising concern. METHOD: We report the case of a 73-year-old Caucasian woman admitted for hyperthermia and digestive disorders. She had recently started a first-line chemotherapy for multiple myeloma with partial response. She also displayed preexisting stage 4 CKD (eGFR 18.50 mL/min/1.73 m2 using CKD-EPI) of unknown aetiology. She was tested positive for SARS-CoV2 by nasopharyngeal swab and soon transferred to the intensive care unit. She received intravenous corticosteroids using dexamethasone 6 g/24 h for 10 days and a piperacillin + tazobactam probabilistic antibiotherapy. She also received high doses (15 g/24 h) of vitamin C for three consecutive days. No monoclonal antibodies were prescribed due to a previous vaccination with a positive serology upon admission. Although the patient recovered from respiratory tract infection, her kidney function progressively deteriorated with serum creatinine levels rising up to 8.06 g/dL, leading to her admission in our nephrology department. The patient was initially treated with high doses of diuretics for anasarca and an abdominal CT excluded urinary tract obstruction with normal kidney size and aspect. Urinary analysis showed protein to creatinine (p/c) ratio of 1348 g/g, and presence of urinary light chains. Her monoclonal spike was measured at 2.3 g/L and her kappa/lambda fraction was 1.74. Intermittent haemodialysis was initiated, and a kidney biopsy was performed. RESULTS: Histology revealed hundreds of intratubular calcium oxalate crystals, with severe and diffuse acute tubular necrosis and interstitial edema. There was no amyloidosis, no sign of active glomerular disease and no interstitial fibrosis. Immunofluorescence (IgA, IgG, IgM, C1Q, C3, kappa and lambda) was negative. We concluded to oxalate nephropathy. After a 2-month follow-up, the patient remains dialysis dependent. Vitamin C is a precursor of oxalate and has been shown to cause secondary oxaluria, particularly with high-dose regimens in patients with altered renal function. Given the histological findings evocative of acute oxalate nephropathy, the accountability of high doses of vitamin C should be considered. No other cause of hyperoxaluria was identified in our patient beside broad spectrum antibiotic use, which could decrease intestinal bacterial oxalate degradation. In particular, there was no malabsorption The limitation of our report is the unknown cause of preexisting CKD;therefore, we cannot rule out preexisting hyperoxaluria. Also, no dosage of serum vitamin C and oxalate levels were performed during follow-up. Finally, our patient had other possible causes AKI, such as recent SARS-CoV2 infection, or linked to multiple myeloma, but these were considered unlikely given the proper haematological response to treatment and non-evocative biopsy. The rationale for vitamin C use in COVID-19 is based on in vitro studies showing its antioxidant, anti-inflammatory, anticoagulant and immune modulatory properties. There lack large clinical studies, and the literature shows conflicting results. Multiple cases of acute oxalate nephropathy were described. CONCLUSION: Vitamin C is an anti-inflammatory treatment used in COVID-19 that can lead to secondary hyperoxaluria with significant and irreversible AKI. Due to the severity of AKI in patients with preexisting CKD, we believe renal function should be considered before using high doses of vitamin C. Larger controlled trials are needed both to establish the clinical benefit of vitamin C and further describe its potential ephrotoxicity.

18.
ASAIO Journal ; 68(SUPPL 1):28, 2022.
Article in English | EMBASE | ID: covidwho-1913084

ABSTRACT

Introduction: Massive bleeding on extracorporeal membrane oxygenation (ECMO) is associated with multiple coagulation defects, including depletion of coagulation factors and development of acquired von Willebrand syndrome (AVWS). The use of recombinant factors, in particular recombinant activated factor VII (rFVIIa, Novoseven), to treat severe refractory hemorrhage in ECMO has been described. However, the use of multiple recombinant factors has been avoided in large part due to concern for circuit complications and thrombosis. Here, we describe the safe and effective administration of rFVIIa and recombinant von Willebrand factor complex (vWF/ FVIII, Humate-P) via post-oxygenator pigtail catheter on VA-ECMO for the treatment of massive pulmonary hemorrhage. Case Description: A 21-month-old (13.4 kg) girl with a recent history of COVID-19 infection presented to an outside hospital with parainfluenza bronchiolitis resulting in acute refractory hypoxemic respiratory failure (oxygenation index 58), refractory septic shock, and myocardial dysfunction. She was cannulated to VA-ECMO and subsequently diagnosed with necrotizing pneumonia from Pseudomonas and herpes simplex infections. Her course was complicated by a large left-sided pneumatocele and bronchopleural fistula requiring multiple chest tubes. She also had right mainstem bronchus obstruction from necrotic airway debris and complete right lung atelectasis. She was noted to have prolonged episodes of mucosal and cutaneous bleeding (oropharynx, chest tube insertion sites, peripheral IV insertion sites) associated with absent high molecular weight von Willebrand multimers consistent with AVWS. Tranexamic acid infusion was initiated and bivalirudin anticoagulation was discontinued. VA-ECMO flows were escalated to 140-160 ml/kg/min to maintain circuit integrity and meet high patient metabolic demand in the absence of anticoagulation. On ECMO day 26, she underwent bronchoscopy to clear necrotic debris from her airway to assist with lung recruitment. The procedure was notable for mucosal bleeding requiring topical epinephrine and rFVIIa. Post-procedure, she developed acute hemorrhage from her right mainstem bronchus, resulting in significant hemothorax (estimated 950 ml) with mediastinal shift, increased venous pressures, desaturation and decreased ECMO blood flow rate, necessitating massive transfusion of 2,050 ml (150 ml/kg) of packed red blood cells, platelets, plasma and cryoprecipitate. An airway blocker was placed in the mid-trachea to control bleeding. In addition to transfusion of appropriate blood products and continuation of tranexamic acid infusion, she was given both rFVIIa (100mcg/kg) and vWF-FVIII (70 units vWF/kg loading dose on the day of hemorrhage, followed by 40 units vWF/kg every 12 hours for 3 additional doses). Both products were administered over 10 minutes through a post-oxygenator pigtail to allow the product to circulate throughout the patient prior to entering the ECMO circuit. The circuit was closely monitored during administration and no changes to circuit integrity were noted in the subsequent hours while hemostasis was achieved. The ECMO circuit remained without thrombosis for 9 days after the bleeding event. Discussion: Balancing anticoagulation and hemostasis is a central challenge in maintaining ECMO support, especially given the prevalence of acquired coagulopathies such as AVWS. For our patient, AVWS contributed to mucosal bleeding necessitating cessation of anticoagulation and utilization of a high ECMO blood flow strategy to minimize circuit clot burden. This was further complicated by absent native lung function and minimal myocardial function, resulting in complete dependence on ECMO. An acute massive pulmonary hemorrhage was treated with multiple recombinant factors (rFVIIa and vWF/FVIII), that are often avoided on ECMO. To minimize clotting risk to the circuit and to maximize transit of these factors to our patient, we added a post-oxygenator pigtail for administration. While this approach was the result of extreme circumstances, th use of a post-oxygenator pigtail for administration of recombinant factors may represent a viable strategy for refractory hemorrhage while on ECMO.

19.
European Journal of Molecular and Clinical Medicine ; 9(3):10378-10386, 2022.
Article in English | EMBASE | ID: covidwho-1913069

ABSTRACT

Background:Mucormycosis has been increasingly described in patients with covid 19 2nd wave (delta variant) which is a highly contagious disease caused by SARS-COV-2 is the leading cause of global pandemic. AIM AND OBJECTIVES: To evaluate etiology, indications, management options and complications in patients managed with endoscopic and external maxillectomy after mucormycosis, to evaluate the incidence and distribution of cases who had extensive mucormycosis and to evaluate the outcome of the management options. Materials and Methods: This is a prospective study done in 30 cases at a tertiary care centre.All the patients were subjected to detailed history taking, clinical examination, endoscopic, radiological, pathological, microbiological investigations after taking informed consent. Patients with age group(30yrs -70yrs) who presented with ROM with extensive maxillary sinus involvement and destruction of different walls of the maxillary sinus were managed with different types of maxillectomies. Results: In this study, 30 cases of post covid rhinoorbital mucormycosis who presented to our hospital were studied, among male 24(80%) & females6 (20%).12 patients (40%) were in 5th to 6th decade and 9 patients (30%) in 4th to 5th decade.Main presenting features were unilateral cheek pain, cheek swelling, nasal obstruction, loosening of teeth, tooth ache, cheek numbness, headache, periorbital edema, visual disturbances being present in 95% of the patients.5% presented with epistaxis, ptosis, diplopia alone.90% patients were known case of diabetes milletus,10% are denovo diabetes.All the patients were subjected to routine blood investigations, microbiological, radiologicalinvestigations.(CT, MRI contrast- PNS, Orbit & Brain).Most commonly seen in males 80%. 1 patient had to undergo orbital exenteration,3 patients underwent palatal resection. Conclusion: Debridement of sinuses is necessary in all cases of mucormycosis so that the fungal reservoir could be removed and the antifungal therapy can reach the viable areas. Therefore the management of mucormycosis is individualised to each patient based on the extension of the disease and overall general conditon of the patient.

20.
Marmara Medical Journal ; 35(2):244-248, 2022.
Article in English | Web of Science | ID: covidwho-1897061

ABSTRACT

Objective: COVID-19 pandemic has infected the entire world and causes obsolete morbidity and mortality. While respiratory symptoms are the most frequently reported, several recent studies revealed that gastrointestinal symptoms are not uncommon. Our aim in this observational study is to reveal the gastrointestinal symptoms of COVID-19 patients. Patients and Methods: Data of COVID-19 patients with gastrointestinal symptoms were recorded and retrospectively analyzed during their hospital follow-up period. 82 patients participated in the study and later on had a positive polymerase chain reaction (PCR) test. Gender, age, systemic and gastrointestinal complaints, medical and surgical disease history, laboratory results, thorax computer tomography (CT) findings, and characteristics of gastrointestinal system (GIS) symptoms of patients were also recorded. Data were analyzed by statistical software. Results: The most common typical symptoms of COVID-19 patients were cough, anosmia, debility, and shortness of breath. Further, most of the gastrointestinal symptoms found in COVID-19 patients were nonspecific abdominal pain. Lymphopenia and elevated liver transaminases were the most common findings of the tests. Patients with diarrhea indicated watery diarrhea. Two patients also had ileus, they healed spontaneously without surgical intervention. Furthermore, all patients were discharged without any problems. Conclusion: Gastrointestinal symptoms are typical in COVID-19 patients. However, these symptoms do not seem to have a detrimental effect on the progression of the disease. In our study group, there was no need for surgical intervention, but COVID-19 patients with gastrointestinal symptoms should be treated by a multidisciplinary approach.

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