Drug induced vasculitis , Thiazide or COVID-vaccine ? : A case report and literature review (preprint)

A middle-aged woman with history of the administration of COVID-19 vaccine and valve replacement surgery before her symptoms, was admitted with bilateral palpable purpuric lesions in the lower extremities and headache . Based on the initial diagnosis of vasculitis , corticosteroid therapy was initiated and resolved the skin lesion

Benefits of 1-Yr Home Training With Functional Electrical Stimulation Cycling in Paraplegia During COVID-19 Crisis.

ABSTRACT: The purpose of this observational study was to report the experience of a 1-yr home training with functional electrical stimulation cycling of a person with T4 American Impairment Scale A paraplegia for 9 yrs, homebound due to the COVID-19 health crisis. The 40-yr-old participant had a three-phase training: V1, isometric stimulation; V2, functional electrical stimulation cycling for 3 sessions/wk; and V3, functional electrical stimulation cycling for 2-4 sessions/wk. Data on general and physical tolerance, health impact, and performance were collected. Borg Scale score relating to fatigue was 10.1 before training and 11.8 after training. The average score for satisfaction at the end of sessions was 8.7. Lean leg mass increased more than 29%, although total bone mineral density dropped by 1.6%. The ventilatory thresholds increased from 19.5 to 29% and the maximum ventilatory peak increased by 9.5%. Rosenberg's Self-esteem Scale score returned to its highest level by the end of training. For the only track event on a competition bike, the pilot covered a distance of 1607.8 m in 17 mins 49 secs. When functional electrical stimulation cycling training is based on a clear and structured protocol, it offers the person with paraplegia the opportunity to practice this activity recreationally and athletically. In times of crisis, this training has proven to be very relevant.

Leg paralysis after AstraZeneca COVID-19 vaccination diagnosed as neuralgic amyotrophy of the lumbosacral plexus: a case report.

The ongoing global administration of vaccines for coronavirus disease 2019 (COVID-19) means that increasing numbers of patients are likely to present with post-vaccination complications. We describe the first reported case of neuralgic amyotrophy (NA) involving the lumbosacral plexus occurring after AstraZeneca COVID-19 vaccination. The patient presented with acute-onset leg paralysis following administration of the vaccine. Based on the clinical, electrodiagnostic, and radiologic findings, the patient was diagnosed with post-vaccination NA. We speculate that the COVID-19 vaccine elicited an immune-mediated inflammatory response to the injected antigen due to inflammatory immunity in a patient with predisposed susceptibility to NA.

Acute lower limb ischemia in an ICU admitted patient diagnosed with covid 19: a case report (preprint)

Thromboembolic events have been reported in hospitalized patient since beginning of the covid 19 pandemic. This study reports an ICU admitted patient with lower extremity arterial thrombosis diagnosed with covid 19.

Supply Chain Management for Extreme Conditions: Research Opportunities (preprint)

Large companies were concerned about their supply chains with environmental and social sustainability and disruption from natural disasters, conflict, and trade disagreements even before the advent of Covid-19. The additional challenges presented by Covid-19 in 2020 are “extreme” in being distinct from supply chain risk in that not just particular companies, but also entire societies are affected. Therefore, it is appropriate to rethink supply chain management (SCM) for research and practice to cope with extreme conditions, now and in the future, whether due to pandemics, war, climate change, or biodiversity collapse. In this essay, we first present the widespread challenges, along with some of the responses. We then list research opportunities for supply chain management in extreme conditions. These opportunities pertain to retailers’ survival in the face of highly successful e-commerce giants and the mixed use of robots and human workers. There are also opportunities to share supply-chain capacity in distribution and coopetition regarding medically necessary items such as anti-virals or vaccines. The growing role of government in supporting business, including the creation of industry commons, also presents avenues for further research.

Judging Under Extreme Conditions: A Court's Role During a National Crisis (preprint)

Debating the role of a court during a national crisis is not a novel scholarly exercise. Several before have done so – and several others will follow. Despite the multitude of opinions on the topic, we are still not one step closer to resolving this issue as we were when these discussions first took place decades ago. The COVID-19 pandemic has given us another occasion to revisit the question. However, unlike the last time when this topic was the focus of discussion in the wake of the attacks of 9/11, the pandemic has taken place in the backdrop of a global decline in the quality of democracy and in an era in which courts have begun assuming a more active role in democratic societies. This allows us an opportunity to rethink some pre-existing notions. To add to it, legal academia has witnessed both a comparative and an interdisciplinary turn which helps reconsider this fundamental question using new insights and reference frames. This article is another addition to the long line of opinions on a court's role during a national crisis. Nonetheless, in contrast to its predecessors, this article addresses this quandary from bottom-up and aims to construct a template for a court to operate in a national crisis that aspires to be applicable across different legal systems and social-political-economic environments.

Sudden Onset of Myelitis after COVID-19 Vaccination: An Under-Recognized Severe Rare Adverse Event (preprint)

Myelitis has been reported as a complication of COVID-19 infection. However, it has rarely been reported as a complication of COVID-19 vaccination, and this may be the first case report following an mRNA vaccine. A 63 yo, otherwise healthy male, received his second dose of the Moderna vaccine on 08 April 2021. He had some initial pain and soreness at the injection site. Seventeen hours post dose, he reported pain and numbness in both calves which progressed to lower back pain, paresthesia in both feet, and pain in lower extremities. Over the day post- vaccination the patient’s condition worsened and he was unable to walk and unable to urinate voluntarily. On the second day post- vaccination he presented to the Emergency Department and was admitted to the University of Iowa hospital unable to walk with severe pain in lower back, legs and feet, and numbness in buttocks. Laboratory findings were unremarkable and lumbar puncture was not diagnostic. MRI revealed increased T2 cord signal seen in the distal spinal cord and conus. Initial treatment included IV Immunoglobulin for 2 days, followed by methylprednisolone 1000 mg/day IV for 5 days. Discharge from the hospital occurred on 16 April 2021 to inpatient rehabilitation. Treatment consisted of oral prednisone 60 mg/day with a tapering schedule. The patient slowly improved and was able to ambulate unassisted at 25 days post -vaccination. This case represents one of the first cases of myelitis reported in the literature after COVID-19 mRNA vaccination. As of 27 April 2021 the FDA VAERS system has 45 reports of transverse myelitis after COVID-19 vaccination (21 after Moderna vaccine, 19 were after Pfizer vaccine, and 5 occurred after Janssen vaccine).

Effectiveness of a telerehabilitation program for COVID-19 survivors (TERECO) on exercise capacity, pulmonary function, lower limb muscle strength, and quality of life: a randomized controlled trial (preprint)

Objectives To investigate superiority of a telerehabilitation program for Covid-19 (TERECO) over no rehabilitation with regard to functional exercise capacity, lower-limb muscle strength (LMS), pulmonary function, health-related quality of life (HRQOL), and perceived dyspnoea. Design Parallel-group randomised controlled-trial with 1:1 block-randomisation. Setting Three major hospitals from Jiangsu and Hubei provinces, China. Participants 120 Covid-19 survivors with modified Medical Research Council (mMRC) dyspnoea score of 2-3 who had been discharged from hospital were randomised. 61 were allocated to the control group and 59 to the TERECO group. Intervention The control group received educational instructions. The TERECO group participated in a 6-week home-based, pulmonary rehabilitation program delivered via smartphone and monitored with chest-worn heart rate telemetry. Exercise types comprised breathing control and thoracic expansion, aerobic exercise, and LMS exercise. Outcomes Primary outcome was 6-minute walking distance (6MWD) in metres. Secondary outcomes were LMS measured as squat time in seconds; pulmonary function assessed by spirometry with parameters being forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), FEV1/FVC, maximum voluntary ventilation (MVV), and peak expiratory flow; HRQOL measured with SF-12 physical component score (PCS) and mental component score (MCS); and mMRC dyspnoea, favourable outcome (no dyspnoea). Outcomes were assessed at 6 weeks (post-treatment) and 28 weeks (follow-up). Results 120 patients were randomised, 15 (12.5%) were lost to follow-up at study endpoint. No serious adverse events occurred. 38 participants in the TERECO group complied with the exercise protocol (64.41% of randomized). The adjusted between-group difference in change in 6MWD from baseline was 65.45 metres (95% CI 43.8-87.1, p<0.001) at post-treatment and 68.62 metres (95% CI 46.39-90.85, p<0.001) at follow-up. Treatment effects for LMS were 20.12 seconds (95% CI 12.34-27.9, p<0.001) post-treatment and 22.23 seconds (95% CI 14.24-30.21, p<0.001) at follow-up. No group differences were found for lung function apart from post-treatment MVV (10.57 litres/minute, 95% CI 0.26-17.88, p=0.005). Increase in SF-12 PCS was greater in the TERECO group with treatment effects estimated as 3.79 (95% CI 1.24-6.35, p=0.004) at post-treatment and 2.69 (95% CI 0.06-5.32, p=0.045) at follow-up. No significant between-group differences were found for improvements in SF-12 MCS. At post-treatment 90.4% endorsed a favourable outcome for mMRC dyspnoea in the TERECO group vs. 61.7% in control (adjusted RR 1.46, 1.17-1.82, p=0.001). Conclusions This trial demonstrated superiority of TERECO over no rehabilitation for 6MWD, LMS, and SF-12 PCS. We found no persistent effects on pulmonary function, SF-12 MCS, and perceived dyspnoea. Trial registration Chinese Clinical Trial Registry: ChiCTR2000031834, 11 Apr 2020, URL: http://www.chictr.org.cn/showproj.aspx?proj=52216 KEY POINTS What is already known Many Covid-19 survivors discharged from hospital have reduced exercise capacity, impaired pulmonary function, muscle weakness, and reduced quality of life, all of which might be addressed with pulmonary rehabilitation. However, evidence on effective pulmonary rehabilitation measures for this population is currently lacking. As delivery of conventional rehabilitation services is furthermore limited due to pandemic control measures, telerehabilitation programs represent a possible alternative. What the study adds We developed a telerehabilitation program for Covid-19 survivors (TERECO program) that is delivered via smartphone and can be carried out at home. Our study suggests that TERECO was safe and participants of the TERECO program had improved exercise capacity, lower-limb muscle strength, and physical quality of life. No relevant group differences were found for lung function, self-reported breathlessness, and mental quality of life. The TERECO program is inexpensive and could be implemented on a large scale to improve physical health of Covid-19 survivors after discharge from hospital.

Acute transverse myelitis after SARS-CoV-2 infection: a rare complicated case of rapid onset paraplegia.

A 63-year-old Caucasian male, known case of controlled type 2 diabetes, chronic renal failure, and ischemic heart disease, was presented with weakness and loss of movement in lower limbs, an absent sensation from the chest below, constipation, and urinary retention. About 4 days before these symptoms, he experienced a flu-like syndrome. Suspicious for COVID-19, his nasopharyngeal specimen's reverse transcription-polymerase chain reaction (RT-PCR) resulted positive. Chest X-ray and HRCT demonstrated severe pulmonary involvement. Immediately, he was admitted to the emergency ward, and the treatment was started according to the national COVID-19 treatment protocol. Subsequently, diagnostic measures were taken to investigate the patient's non-heterogeneous peripheral (spinal) neuromuscular manifestations. Brain CT scan and MRI were normal, but spinal MRI with gadolinium contrast showed extensive increased T2 signal involving central gray matter and dorsal columns, extended from C7 to T12 with linear enhancement in the sagittal plane, posteriorly within the mid and lower thoracic cord. The CSF specimen demonstrated pleocytosis, positive RT-PCR for SARS-CoV-2, and elevated IgG index. Clinical presentation, MRI, CSF, and laboratory findings prioritized the acute transverse myelitis (ATM) as a probable complication of COVID-19 infection over other differential diagnoses. Intravenous methylprednisolone and, subsequently, IV human immunoglobulin were added to the treatment regimen. In the end, the complete resolution of dysesthesia, urinary retention, and constipation were achieved. After continuous and extended respiratory and motor rehabilitation programs, he was discharged asymptomatic.

Complete recovery from COVID-19 of a kidney-pancreas transplant recipient: potential benefit from everolimus?

We present a kidney-pancreas transplant recipient who achieved complete recovery from COVID-19. A 45-year-old patient with T3 paraplegia underwent kidney-pancreas transplantation 18 years ago, followed by a subsequent kidney transplant 9 years ago, and presented with fever, hypoxia and hypotension after exposure to two confirmed cases of COVID-19. History of solid organ transplant, pre-existing renal impairment, asthma and an elevated D-dimer were identified as established risk factors for severe COVID-19. Supportive management was provided, baseline immunosuppression with everolimus was continued, and oral prednisolone was increased. A complete recovery was observed. Given the favourable outcome despite risk factors for severe COVID-19, we identify and review the potential mitigating roles of immunosuppression and mammalian target of rapamycin (mTOR) inhibitors in this disease. Further investigation is required to establish whether mTOR inhibitors could be used as therapeutic agents to treat COVID-19, or as alternative immunosuppression implemented early in the COVID-19 disease course.

Emergency surgical management of cervical spine fracture-dislocation with acute paraplegia in COVID-19 (Coronavirus disease 2019)-suspected patient: first experience from a German spine centre.

PURPOSE: We present an organized hospital plan for the management of Coronavirus disease (COVID-19) patients requiring emergency surgical interventions. To introduce a multidisciplinary approach for the management of COVID-19-infected patients and to report the first operated patient in the Corona unit. METHODS: A detailed presentation of the hospital plan for a separate Corona unit with its intensive care unit and operating rooms. Description of the management of the first spine surgery case treated in this unit. RESULTS: The Corona unit showed a practical approach for the management of an emergency cervical spine fracture-dislocation with acute paralysis. The patient is 92-year-old female. The mechanism of injury was a simple fall during the stay in the internal medicine department where the patient was treated in the referring hospital. The patient had no other injuries and was awake and oriented. The patient did not have the clinical symptom of COVID-19, and the test result of COVID-19 done in the referring hospital was not available on admission in our emergency room. Education of the medical staff and organization of the operating theatre facilitated the management of the patient without an increased risk of spreading the infection. CONCLUSIONS: The current COVID-19 pandemic requires an extra-ordinary organization of the medical and surgical care of the patients. It is possible to manage an infected or a potentially infected patient surgically, but a multidisciplinary plan is necessary to protect other patients and the medical staff.

Incidence of Venous Thromboembolism Among Patients with Severe COVID-19 Requiring Mechanical Ventilation Compared to Other Causes of Respiratory Failure: A Prospective Cohort Study (preprint)

Background: Previous studies have suggested that COVID-19 pneumonia is associated with an increased risk of venous thromboembolism (VTE). This study aimed to investigate the incidence of VTE among mechanically ventilated adults with COVID-19 pneumonia, relative to among patients with respiratory failure related to other causes.Methods: Between June 2, 2020 and August 11, 2020, this prospective study enrolled critically ill adults with suspected COVID-19 pneumonia who required mechanical ventilation within 24 h after hospital admission. The patients were followed until death or hospital discharge. Sequential ultrasonography screening of the lower extremities and catheter insertion sites, as well as testing for plasma biochemical markers, were performed at the intensive care unit admission, day 3, day 7, and day 14. The primary outcome was a composite of deep venous thrombosis, pulmonary embolism, and thrombosis at the central catheter insertion sites. Findings: We enrolled 70 patients, including 57 patients with COVID-19 and 13 patients without COVID-19, and all patients completed follow-up. The incidence of the primary outcome was higher among patients with COVID-19 than among patients with respiratory failure related to other etiologies (36·8% vs. 0%, p=0·023). Multivariate regression analysis revealed that VTE was independently associated with a COVID-19 diagnosis (odds ratio: 6·28, 95% confidence interval: 1·19–68·07) and D-dimer concentration (1-ng/mL increase, odds ratio: 1·15, 95% confidence interval: 1·05–1·30).Interpretation: The incidence of VTE was higher among critically ill mechanically ventilated patients, relative to among patients with respiratory failure related to other causes. Funding: Fundo de Incentivo à Pesquisa e Ensino, Hospital de Clínicas de Porto Alegre.Declaration of Interests: The authors declare that they have no competing interests.Ethics Approval Statement: The ethics committee of the Hospital de Clínicas de Porto Alegre approved the study protocol (2020-0194). All participants or their legal representatives provided informed consent by phone.

The Pricing Relationships between Oil and Renewable Firms under Extreme Conditions: The Effects of Negative WTI Prices (Online Appendix 3/3) (preprint)

We test for the existence of volatility spillovers and co-movements among energy-focused corporations during the outbreak of the COVID-19 pandemic, inclusive of the April 2020 events where West Texas Intermediate (WTI) oil future prices became negative. Employing the spillover index approach of Diebold and Yilmaz [2012]; as well as developing a DCC-FIGARCH conditional correlation framework and using estimated spillover indices built on a generalised vector autoregressive framework in which forecast-error variance decompositions are invariant to the variable ordering, we examine the sectoral transmission mechanisms of volatility shocks and contagion throughout the energy sector. Among several results, we find positive and economically meaningful spillovers from falling oil prices to both renewable energy and coal markets. However, this result is only found for the narrow portion of our sample surrounding the negative WTI event. We interpret our results being directly attributed to a sharp drop in global oil, gas and coal demand, rather than because of a sudden increase in oil supply. While investors observed the US fracking industry losing market share to coal, they also viewed renewables as more reliable mechanism to generate long-term, stable and low-cost supply.

The Pricing Relationships between Oil and Renewable Firms under Extreme Conditions: The Effects of Negative WTI Prices (preprint)

We test for the existence of volatility spillovers and co-movements among energy-focused corporations during the outbreak of the COVID-19 pandemic, inclusive of the April 2020 events where West Texas Intermediate (WTI) oil future prices became negative. Employing the spillover index approach of Diebold and Yilmaz [2012]; as well as developing a DCC-FIGARCH conditional correlation framework and using estimated spillover indices built on a generalised vector autoregressive framework in which forecast-error variance decompositions are invariant to the variable ordering, we examine the sectoral transmission mechanisms of volatility shocks and contagion throughout the energy sector. Among several results, we find positive and economically meaningful spillovers from falling oil prices to both renewable energy and coal markets. However, this result is only found for the narrow portion of our sample surrounding the negative WTI event. We interpret our results being directly attributed to a sharp drop in global oil, gas and coal demand, rather than because of a sudden increase in oil supply. While investors observed the US fracking industry losing market share to coal, they also viewed renewables as a more reliable mechanism to generate long-term, stable and low-cost supply.

Is COVID-19 a risk factor of DVT in orthopaedic trauma surgery? A prospective study (preprint)

Objective: The aim of this prospective study was to evaluate the radiological and laboratory parameters of patients diagnosed with COVID-19 who underwent surgery for a lower extremity fracture in our COVID-19 care units in terms of DVT.Patients and Methods: Patients who were operated on due to lower extremity fracture between 10 March and 1 May and diagnosed with COVID-19 were evaluated prospectively. Patients’ age, gender, affected side, fracture location, fracture type, COVID-19  radiological or clinical symptoms and Doppler USG and biochemical markers screening for DVT were evaluated.Results: Thirty patients, ages 39-88, were included in the study. Preoperative D-dimer value of the patients was mean 5.9 mg / L. In all the patients, the D-dimer level was above the normal range. The mean troponin value was 0.025 ng / mL preoperatively. The troponin value was found to be normal in 8 patients and above the normal value in 22 patients. On physical examination, DVT findings were present in 1 patient and DVT was detected in 2 patients on doppler ultrasound.Conclusion: It can be recommended that extra attention should be given to vascular complications in COVID-19 positive trauma patients, as both the effect of trauma itself increases hypercoagulability and COVID-19 disease seems to have the potential to increase hypercoagulability.