Intracranial Pressure Dynamics and Cerebral Vasomotor Reactivity in Coronavirus Disease 2019 Patient With Acute Encephalitis.

We describe the intracranial pressure dynamics and cerebral vasomotor reactivity in a coronavirus disease 2019 patient with acute encephalitis treated with cerebrospinal fluid drainage and therapeutic plasma exchange. DATA SOURCES: Coronavirus disease ICU, Uppsala University Hospital, Sweden. STUDY SELECTION: Case report. DATA EXTRACTION: Radiology, intracranial pressure, intracranial compliance (correlation between intracranial pressure amplitude and mean intracranial pressure), cerebral vasomotor reactivity (pressure reactivity index), arterial blood pressure, cerebrospinal fluid chemistry, and treatment. DATA SYNTHESIS: None. CONCLUSIONS: This is the first reported case of intracranial pressure monitoring in a patient with acute encephalitis following coronavirus disease 2019. Intracranial pressure data exhibited a high incidence of plateau waves with intracranial pressure insults above 40 mm Hg that required cerebrospinal fluid drainage. Intracranial compliance was low, and pressure reactivity was intact. It is probable that the combination of low intracranial compliance and intact pressure autoregulation explain the high degree of plateau intracranial pressure waves and intracranial pressure variability. This case illustrates that it could be of value to consider intracranial pressure monitoring in selected coronavirus disease 2019 patients with suspicion of increased intracranial pressure to be able to confirm and treat intracranial hypertension if needed. In this patient, therapeutic plasma exchange was safe and efficacious as the level of neuroinflammation decreased and the patient regained consciousness.

The performance of point-of-care antibody test for COVID-19 diagnosis in a tertiary hospital in Bandung, Indonesia.

INTRODUCTION: We aim to describe the performance of combined IgM and IgG point-of-care antibody test (POC-Ab) (Wondfo®) compared to real-time reverse transcriptase (rRT-PCR) (Allplex™ 2019-nCoV Assay) in detecting coronavirus disease 2019 (COVID-19). METHODOLOGY: We compared POC-Ab with rRT-PCR results among patients in a tertiary hospital from January to March 2020 in Bandung, Indonesia. We selected presumptive COVID-19 patients with positive rRT-PCR consecutively and 20 patients with negative rRT-PCR results were selected randomly from the same group of patients as controls. We described the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) with corresponding 95% confidence interval using serum and capillary blood samples. We also tested POC-Ab using non-COVID-19 (confirmed dengue and typhoid) patients' sera. RESULTS: Twenty-seven patients with positive rRT-PCR result and 20 negative controls were included (68.1% males, mean age 46 (SD: 15.4)). Using the serum, the sensitivity of the POC-Ab was 63.0% (42.4-80.6), specificity was 95.0% (75.1-99.9), PPV was 94.4% (72.7-99.8), NPV was 65.5% (45.7-82.1). A subset of 20 patients was tested using a capillary blood sample. The accuracy of the capillary blood sample is lower compared to serum (50.0% vs. 78.7%). None of the non-COVID-19 sera tested were reactive. CONCLUSIONS: POC-Ab for COVID-19 has a high specificity with no false-positive result in non-COVID-19 sera. Therefore, it can be used to guide diagnostic among symptomatic patients in resource limited settings. Given its low sensitivity, patients with high suspicion of COVID-19 but non-reactive result should be prioritized for rRT-PCR testing.

Performance of Low-Dose Chest CT as a Triage Tool for Suspected COVID-19 Patients.

PURPOSE: To investigate the role of low-dose chest computed tomography (CT) imaging in the triage of patients suspected of coronavirus disease 2019 (COVID-19) in an emergency setting. MATERIALS AND METHODS: Data from 610 patients admitted to our emergency unit from March 20, 2020, until April 11, 2020, with suspicion of COVID-19 were collected. Diagnostic values of low-dose chest CT for COVID-19 were calculated using consecutive reverse-transcription polymerase chain reaction (RT-PCR) tests and bronchoalveolar lavage (BAL) as reference. Comparative analysis of the 199 COVID-19 positive versus 411 COVID-19 negative patients was done with identification of risk factors and predictors of worse outcome. RESULTS: Sensitivity and specificity of low-dose CT for the diagnosis of COVID-19 respectively ranged from 75% (150/199) to 88% (175/199) and 94% (386/411) to 99% (386/389), depending on the inclusion of inconclusive results. On multivariate analysis, a higher body mass index (BMI), fever, and dyspnea on admission were risk factors for COVID-19 (all p-values < 0.05). The mortality rate was 12.6% (25/199). Higher age and high levels of C-reactive protein (CRP) and D-dimers were predictors of worse outcome (all p-values < 0.05). CONCLUSION: Low-dose chest CT has a high specificity and a moderate to high sensitivity in symptomatic patients with suspicion of COVID-19 and could be used as an effective tool in setting of triage in high-prevalence areas.

Case Report: Posterior Reversible Leukoencephalopathy Syndrome (PRES) as a Biologically Predictable Neurological Association in Severe COVID-19. First Reported Case From Australia and Review of Internationally Published Cases.

Reports of different types of neurological manifestations of COVID-19 are rapidly increasing, including changes of posterior reversible leukoencephalopathy syndrome (PRES). Here we describe the first reported case of COVID-19 and PRES in Australia diagnosed on basis of MRI brain imaging and confirmed clinically by presence of confusion, delirium, headaches, also associated with hypertension and blood pressure variability and stable long-term kidney problems. He made full recovery as his blood pressure was controlled and clinical status was supported with appropriate supportive therapy. Although traditionally a rare condition, PRES is likely to be more common among patients with COVID-19 pathobiology there is Renin downregulation of ACE2 receptors, involvement of Renin-Angiotensin-Aldosterone system, endotheliitis, cytokine storm, and hyper-immune response. Thus we advocate clinical suspicion and early brain imaging with MRI brain among vulnerable patients with known co-morbidities, and diagnosed with COVID-19 given that hypertension and blood pressure variability are often exacerbated by acute SARS-CoV-2 immune reactions. Such acute hypertensive encephalopathy was able to be reversed with timely supportive therapy ensuring re-hydration and re-establishment of blood pressure control.

Paraneoplastic cerebellar degeneration as a presenting manifestation of non-Hodgkin's lymphoma.

BACKGROUND: Paraneoplastic Cerebellar degeneration (PCD) is one of the classical paraneoplastic syndromes (PNS) which is characterised by subacute onset, progressive cerebellar ataxia and is usually associated with small cell lung carcinoma, adeno carcinoma of breast and ovary followed by Hodgkin's lymphoma. OBJECTIVE: We herein report a case of subacute onset, progressive cerebellar ataxia in a 37-year-old female, who on evaluation was found to have non-Hodgkin's lymphoma and experienced good clinical response to treatment. DISCUSSION: As compared to solid tumours, chances of association of PNS with Lymphomas is quite low and there are only few case reports in the literature showing association of PCD with non-Hodgkin's lymphoma. As PCD is one of the classical PNS, it is very important to identify subtle cerebellar manifestations in an otherwise apparently normal individual, as early diagnosis and aggressive treatment can immensely improve the mortality and morbidity associated with this syndrome. CONCLUSION: This case signifies the importance of suspecting PNS as an important differential diagnosis in a young patient presenting with subacute onset progressive cerebellar ataxia and evaluating her extensively for malignancy in spite of no paraneoplastic antibody been detected as early diagnosis and treatment can lead to gratifying response. We do agree that 2 weeks follow up is a short time interval to determine whether the response was sustained or not, for which a long term follow up is required.

Should CT be used for the diagnosis of RT-PCR-negative suspected COVID-19 patients?

INTRODUCTION: The diagnosis of patients with Coronavirus disease 2019 (COVID-19) suspicion but negative reverse transcriptase-polymerase chain reaction (RT-PCR) test is challenging. OBJECTIVE: We aimed to investigate the diagnostic value of chest computed tomography (CT) in RT-PCR-negative patients with suspected COVID-19. MATERIALS AND METHODS: The study included patients who were admitted to our hospital with the suspicion of COVID-19 between 1 April 2020 and 30 April 2020 and tested negative after RT-PCR test, and underwent CT for further diagnosis. Initial CT findings were classified as typical, indeterminate, and atypical for COVID-19, and negative for pneumonia. Incidental findings on CT were noted. RESULTS: Of the 338 patients with a mean age of 57 years (min 18 years-max 96 years), 168 (49.70%) were male and 170 (50.29%) were female. The most common symptoms were cough (58.87%), fever (40.82%), and dyspnea (39.34%). The CT findings were typical for COVID-19 in 109 (32.24%) patients, indeterminate in 47 (13.90%) patients, and atypical in 77 (22.78%) patients. The CT findings of 105 (31.06%) patients were negative for pneumonia. Incidental lung nodules suspicious of malignancy were identified in seven patients. Seventy-seven patients (22.78%) had extrapulmonary incidental findings CONCLUSION: The diagnostic value of CT in RT-PCR-negative patients with suspected COVID-19 is not very high. Based on clinical, laboratory, and chest x-ray findings, it may be more appropriate to refer patients to CT after the first triage, when necessary.

Evaluation of Hypertriglyceridemia in Critically Ill Patients With Coronavirus Disease 2019 Receiving Propofol.

OBJECTIVES: To report the prevalence of, and evaluate risk factors for, the development of hypertriglyceridemia (defined as a serum triglyceride level of > 400 mg/dL) in patients with coronavirus disease 2019 who received propofol. DESIGN: Single-center, retrospective, observational analysis. SETTING: Brigham and Women's Hospital, a tertiary academic medical center in Boston, MA. PATIENTS: All ICU patients who with coronavirus disease 19 who received propofol between March 1, 2020, and April 20, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The major outcome of this analysis was to report the prevalence of, and risk factors for, the development of hypertriglyceridemia in patients with coronavirus disease 19 who received propofol. Minor outcomes included the development of acute pancreatitis and description of propofol metrics. Of the 106 patients that were included, 60 (56.6%) developed hypertriglyceridemia, with a median time to development of 46 hours. A total of five patients had clinical suspicion of acute pancreatitis, with one patient having confirmatory imaging. There was no difference in the dose or duration of propofol in patients who developed hypertriglyceridemia compared with those who did not. In the patients who developed hypertriglyceridemia, 35 patients (58.5%) continued receiving propofol for a median duration of 105 hours. Patients who developed hypertriglyceridemia had elevated levels of inflammatory markers. CONCLUSIONS: Hypertriglyceridemia was commonly observed in critically ill patients with coronavirus disease 2019 who received propofol. Neither the cumulative dose nor duration of propofol were identified as a risk factor for the development of hypertriglyceridemia. Due to the incidence of hypertriglyceridemia in this patient population, monitoring of serum triglyceride levels should be done frequently in patients who require more than 24 hours of propofol. Many patients who developed hypertriglyceridemia were able to continue propofol in our analysis after reducing the dose.

Prevalence and outcome of dysnatremia in patients with COVID-19 compared to controls.

OBJECTIVE: The pandemic of coronavirus disease (COVID-19) has rapidly spread globally and infected millions of people. The prevalence and prognostic impact of dysnatremia in COVID-19 is inconclusive. Therefore, we investigated the prevalence and outcome of dysnatremia in COVID-19. DESIGN: The prospective, observational, cohort study included consecutive patients with clinical suspicion of COVID-19 triaged to a Swiss Emergency Department between March and July 2020. METHODS: Collected data included clinical, laboratory and disease severity scoring parameters on admission. COVID-19 cases were identified based on a positive nasopharyngeal swab test for SARS-CoV-2, patients with a negative swab test served as controls. The primary analysis was to assess the prognostic impact of dysnatremia on 30-day mortality using a cox proportional hazard model. RESULTS: 172 (17%) cases with COVID-19 and 849 (83%) controls were included. Patients with COVID-19 showed a higher prevalence of hyponatremia compared to controls (28.1% vs 17.5%, P < 0.001); while comparable for hypernatremia (2.9% vs 2.1%, P = 0.34). In COVID-19 but not in controls, hyponatremia was associated with a higher 30-day mortality (HR: 1.4, 95% CI: 1.10-16.62, P = 0.05). In both groups, hypernatremia on admission was associated with higher 30-day mortality (COVID-19 - HR: 11.5, 95% CI: 5.00-26.43, P < 0.001; controls - HR: 5.3, 95% CI: 1.60-17.64, P = 0.006). In both groups, hyponatremia and hypernatremia were significantly associated with adverse outcome, for example, intensive care unit admission, longer hospitalization and mechanical ventilation. CONCLUSION: Our results underline the importance of dysnatremia as predictive marker in COVID-19. Treating physicians should be aware of appropriate treatment measures to be taken for patients with COVID-19 and dysnatremia.

Prevalence and outcome of dysnatremia in patients with COVID-19 compared to controls.

OBJECTIVE: The pandemic of coronavirus disease (COVID-19) has rapidly spread globally and infected millions of people. The prevalence and prognostic impact of dysnatremia in COVID-19 is inconclusive. Therefore, we investigated the prevalence and outcome of dysnatremia in COVID-19. DESIGN: The prospective, observational, cohort study included consecutive patients with clinical suspicion of COVID-19 triaged to a Swiss Emergency Department between March and July 2020. METHODS: Collected data included clinical, laboratory and disease severity scoring parameters on admission. COVID-19 cases were identified based on a positive nasopharyngeal swab test for SARS-CoV-2, patients with a negative swab test served as controls. The primary analysis was to assess the prognostic impact of dysnatremia on 30-day mortality using a cox proportional hazard model. RESULTS: 172 (17%) cases with COVID-19 and 849 (83%) controls were included. Patients with COVID-19 showed a higher prevalence of hyponatremia compared to controls (28.1% vs 17.5%, P < 0.001); while comparable for hypernatremia (2.9% vs 2.1%, P = 0.34). In COVID-19 but not in controls, hyponatremia was associated with a higher 30-day mortality (HR: 1.4, 95% CI: 1.10-16.62, P = 0.05). In both groups, hypernatremia on admission was associated with higher 30-day mortality (COVID-19 - HR: 11.5, 95% CI: 5.00-26.43, P < 0.001; controls - HR: 5.3, 95% CI: 1.60-17.64, P = 0.006). In both groups, hyponatremia and hypernatremia were significantly associated with adverse outcome, for example, intensive care unit admission, longer hospitalization and mechanical ventilation. CONCLUSION: Our results underline the importance of dysnatremia as predictive marker in COVID-19. Treating physicians should be aware of appropriate treatment measures to be taken for patients with COVID-19 and dysnatremia.

Chronic comorbidities and clinical outcomes in patients with and without COVID-19: a large population-based study using national administrative healthcare open data of Mexico.

Coronavirus disease 2019 (COVID-19) was rapidly expanded worldwide within a short period. Its relationship with chronic comorbidities is still unclear. We aimed to determine the effects of chronic comorbidities on clinical outcomes of patients with and without COVID-19. This was an analysis of 65,535 patients with suspicion of viral respiratory disease (38,324 SARS-CoV-2 positive and 27,211 SARS-CoV-2 negative) from January 01 to May 12, 2020 using the national administrative healthcare open data of Mexico. SARS-CoV-2 infection was confirmed by reverse-transcriptase-polymerase-chain-reaction. General characteristics and chronic comorbidities were explored. Clinical outcomes of interest were hospital admission, pneumonia, intensive care unit admission, endotracheal intubation and mortality. Prevalence of chronic comorbidities was 49.4%. Multivariate logistic regression analysis showed that the effect of age, male sex, bronchial asthma, diabetes mellitus and chronic kidney disease on clinical outcomes was similar for both SARS-CoV-2 positive and negative patients. Adverse clinical outcomes were associated with the time from symptoms onset to medical contact, chronic obstructive pulmonary disease, hypertension and obesity in SARS-CoV-2 positive patients, but with cardiovascular disease in SARS-CoV-2 negative patients (p value < 0.01 for all comparisons). Chronic comorbidities are commonly found in patients with suspicion of viral respiratory disease. The knowledge of the impact of comorbidities on adverse clinical outcomes can better define those COVID-19 patients at higher risk. The different impact of the specific type of chronic comorbidity on clinical outcomes in patients with and without SARS-CoV-2 infection requires further researches. These findings need confirmation using other data sources.

Cutaneous Manifestations in Four Patients with COVID-19.

As the numbers of SARS-CoV-2 infections increased globally, reports of cutaneous manifestations started to emerge. We describe several patients with COVID-19 who presented with skin changes. We noted such manifestations in four out of 110 patients (3.63%) and describe the clinical situation of each of these patients. Each patient had either a maculopapular or a urticariform rash. These manifestations have a broad differential diagnosis and it was difficult to exclude drug reactions. We hope to raise awareness of this possible manifestation of COVID-19 in order to raise suspicion of this diagnosis among clinicians when they encounter patients with fever and rash. Larger series that also include patients with mild disease and skin biopsies may be useful. LEARNING POINTS: Cutaneous manifestations can occur as part of COVID-19, so clinicians should be suspicious of this diagnosis in patients with fever and rash.The differential diagnosis is large and drug reactions are difficult to rule out.

COVID-19 mimics on chest CT: a pictorial review and radiologic guide.

Chest imaging is often used as a complementary tool in the evaluation of coronavirus disease 2019 (COVID-19) patients, helping physicians to augment their clinical suspicion. Despite not being diagnostic for COVID-19, chest CT may help clinicians to isolate high suspicion patients with suggestive imaging findings. However, COVID-19 findings on CT are also common to other pulmonary infections and non-infectious diseases, and radiologists and point-of-care physicians should be aware of possible mimickers. This state-of-the-art review goal is to summarize and illustrate possible etiologies that may have a similar pattern on chest CT as COVID-19. The review encompasses both infectious etiologies, such as non-COVID viral pneumonia, Mycoplasma pneumoniae, Pneumocystis jiroveci, and pulmonary granulomatous infectious, and non-infectious disorders, such as pulmonary embolism, fat embolism, cryptogenic organizing pneumonia, non-specific interstitial pneumonia, desquamative interstitial pneumonia, and acute and chronic eosinophilic pneumonia.

False-negative results of initial RT-PCR assays for COVID-19: A systematic review.

BACKGROUND: A false-negative case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is defined as a person with suspected infection and an initial negative result by reverse transcription-polymerase chain reaction (RT-PCR) test, with a positive result on a subsequent test. False-negative cases have important implications for isolation and risk of transmission of infected people and for the management of coronavirus disease 2019 (COVID-19). We aimed to review and critically appraise evidence about the rate of RT-PCR false-negatives at initial testing for COVID-19. METHODS: We searched MEDLINE, EMBASE, LILACS, as well as COVID-19 repositories, including the EPPI-Centre living systematic map of evidence about COVID-19 and the Coronavirus Open Access Project living evidence database. Two authors independently screened and selected studies according to the eligibility criteria and collected data from the included studies. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. We calculated the proportion of false-negative test results using a multilevel mixed-effect logistic regression model. The certainty of the evidence about false-negative cases was rated using the GRADE approach for tests and strategies. All information in this article is current up to July 17, 2020. RESULTS: We included 34 studies enrolling 12,057 COVID-19 confirmed cases. All studies were affected by several risks of bias and applicability concerns. The pooled estimate of false-negative proportion was highly affected by unexplained heterogeneity (tau-squared = 1.39; 90% prediction interval from 0.02 to 0.54). The certainty of the evidence was judged as very low due to the risk of bias, indirectness, and inconsistency issues. CONCLUSIONS: There is substantial and largely unexplained heterogeneity in the proportion of false-negative RT-PCR results. The collected evidence has several limitations, including risk of bias issues, high heterogeneity, and concerns about its applicability. Nonetheless, our findings reinforce the need for repeated testing in patients with suspicion of SARS-Cov-2 infection given that up to 54% of COVID-19 patients may have an initial false-negative RT-PCR (very low certainty of evidence). SYSTEMATIC REVIEW REGISTRATION: Protocol available on the OSF website: https://tinyurl.com/vvbgqya.

COVID-19 in Children With Cancer: A Single Low-Middle Income Center Experience.

BACKGROUND: Coronavirus disease-2019 (COVID-19) could be associated with morbidity and mortality in immunocompromised children. OBJECTIVE: The objective of this study was to measure the frequency of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among hospitalized children with cancer and to detect the associated clinical manifestations and outcomes. METHODOLOGY: A prospective noninterventional study including all hospitalized children with cancer conducted between mid-April and mid-June 2020 in Ain Shams University Hospital, Egypt. Clinical, laboratory, and radiologic data were collected. SARS-CoV-2 infection was diagnosed by reverse transcription polymerase chain reaction tests in nasopharyngeal swabs. RESULTS: Fifteen of 61 hospitalized children with cancer were diagnosed with SARS-CoV-2. Their mean age was 8.3±3.5 years. Initially, 10 (66.7%) were asymptomatic and 5 (33.3%) were symptomatic with fever and/or cough. Baseline laboratory tests other than SARS-CoV-2 reverse transcription polymerase chain reaction were not diagnostic; the mean absolute lymphocyte count was 8.7±2.4×109/L. C-reactive protein was mildly elevated in most of the patients. Imaging was performed in 10 (66.7%) patients with significant radiologic findings detected in 4 (40%) patients. Treatment was mainly supportive with antibiotics as per the febrile neutropenia protocol and local Children Hospital guidance for management of COVID-19 in children. CONCLUSIONS: Pediatric cancer patients with COVID-19 were mainly asymptomatic or with mild symptoms. A high index of suspicion and regular screening with nasopharyngeal swab in asymptomatic hospitalized cancer patients is recommended.

Acute arterial occlusion of the lower limb as the main clinical manifestation in a patient with Covid-19 - Case Report.

INTRODUTION: COVID-19 infection may predispose to venous and arterial thromboembolism due to excessive inflammation, hypoxia, immobilization and disseminated intravascular coagulation; however, there are few reports of lower limb ischemia as the main manifestation of the disease. PRESENTATION OF CASE: Male patient, 69 years old, asthmatic, ex-smoker and bearer of systemic arterial hypertension, has been admitted to the emergency department with sudden onset of pain in the right lower limb (RLL), associated with cyanosis and reduced temperature of the limb. He has been tested for COVID-19 in the OR with positive result for IGG and IGM. Computed tomography angiography (AngioCT) was performed, showing signs of arterial embolization to both limbs, right internal iliac artery, and superior mesenteric artery. Faced with the threat of limb loss and the absence of signs and symptoms of visceral ischemia, the patient underwent full anticoagulation and RLL thromboembolectomy and tricompartmental fasciotomy. He was discharged after 7 days of hospitalization and demonstrated no other signs and symptoms of COVID-19, following outpatient follow-up. DISCUSSION: COVID-19 is associated with high risk of thrombotic complications being related to the clinical severity of the patient, with few studies that show symptoms of sudden pain in the lower limb without other complaints. CONCLUSION: Individuals infected with COVID-19 are at risk for arterial thromboembolic events, and knowledge of such cases is essential in order to create specific protocols for prophylaxis of thrombotic events in these patients, in addition to increasing the suspicion of infection in individuals with acute arterial occlusion, mostly during pandemic times.

Diagnostic accuracy of initial chest radiograph compared to SARS-CoV-2 PCR in patients with suspected COVID-19.

OBJECTIVE: The chest radiograph (CXR) is the predominant imaging investigation being used to triage patients prior to either performing a SARS-CoV-2 polymerase chain reaction (PCR) test or a diagnostic CT scan, but there are limited studies that assess the diagnostic accuracy of CXRs in COVID-19.To determine the accuracy of CXR diagnosis of COVID-19 compared with PCR in patients presenting with a clinical suspicion of COVID-19. METHODS AND MATERIALS: The CXR reports of 569 consecutive patients with a clinical suspicion of COVID-19 were reviewed, blinded to the PCR result and classified into the following categories: normal, indeterminate for COVID-19, classic/probable COVID-19, non-COVID-19 pathology, and not specified. Severity reporting and reporter expertise were documented. The subset of this cohort that had CXR and PCR within 3 days of each other were included for further analysis for diagnostic accuracy. RESULTS: Classic/probable COVID-19 was reported in 29% (166/569) of the initial cohort. 67% (382/569) had PCR tests. 344 patients had CXR and PCR within 3 days of each other. Compared to PCR as the reference test, initial CXR had a 61% sensitivity and 76% specificity in the diagnosis of COVID-19. CONCLUSION: Initial CXR is useful as a triage tool with a sensitivity of 61% and specificity of 76% in the diagnosis of COVID-19 in a hospital setting. ADVANCES IN KNOWLEDGE: .Diagnostic accuracy does not differ significantly between specialist thoracic radiologists and general radiologists including trainees following training.There was a 40% prevalence of PCR positive disease in the cohort of patients (n = 344) having CXR and PCR within 3 days of each other.Classic/probable COVID-19 was reported in 29% of total cohort of patients presenting with clinical suspicion of COVID-19 (n = 569).Initial CXR is useful as a triage tool with a sensitivity of 61% and specificity of 76% in the diagnosis of COVID-19 in a hospital setting.

Phlegmasia cerulea dolens associated with acute coronavirus disease 2019 pneumonia despite supratherapeutic warfarin anticoagulation.

Patients with acute coronavirus disease 2019 (COVID-19) respiratory infection are associated with concomitant thromboembolic complications and a hypercoagulable state. Although these mechanisms are not completely understood, unique alterations in the serum markers for hemostasis and thrombosis have been detected. A high index of suspicion is required by vascular surgeons for patients presenting with this novel virus. We present the case of a 51-year-old man with acute COVID-19 pneumonia who developed phlegmasia cerulea dolens despite chronic warfarin therapy and a supratherapeutic international normalized ratio.

Patient and Provider Risk in Managing ST-Elevation Myocardial Infarction During the COVID-19 Pandemic: A Decision Analysis.

BACKGROUND: The optimal treatment strategy for treating ST-segment-elevation myocardial infarction (STEMI) in context of the coronavirus disease 2019 (COVID-19) pandemic is unclear given the potential risk of occupational exposure during primary percutaneous coronary intervention (PPCI). We quantified the impact of different STEMI treatment strategies on patient outcomes and provider risk in context of the COVID-19 pandemic. METHODS: Using a decision-analytic framework, we evaluated the effect of PPCI versus the pharmaco-invasive strategy for managing STEMI on 30-day patient mortality and individual provider infection risk based on presence of cardiogenic shock, suspected coronary territory, and presence of known or presumptive COVID-19 infection. RESULTS: For patients with low suspicion for COVID-19, PPCI had mortality benefit over the pharmaco-invasive strategy, and the risk of cardiac catheterization laboratory provider infection remained very low (<0.25%) across all subgroups. For patients with presumptive COVID-19 with cardiogenic shock, PPCI offered substantial mortality benefit to patients relative to the pharmaco-invasive strategy (7.9% absolute decrease in 30-day mortality), but also greater risk of provider infection (2.3% absolute increase in risk of provider infection). For patients with presumptive COVID-19 with nonanterior STEMI without cardiogenic shock, PPCI offered a 0.4% absolute mortality benefit over the pharmaco-invasive strategy with a 0.2% greater absolute risk of provider infection, and the tradeoff between patient and provider risk with PPCI became more apparent in sensitivity analysis with more severe COVID-19 infections. CONCLUSIONS: Usual care with PPCI remains the appropriate treatment strategy in the majority of cases presenting with STEMI in the setting of the COVID-19 pandemic. However, utilization of a pharmaco-invasive strategy in selected patients with STEMI with presumptive COVID-19 and low likelihood of mortality from STEMI and use of preventive strategies such as preprocedural intubation in high risk patients when PPCI is the preferred strategy may be reasonable to reduce provider risk of COVID-19 infection.

Deep vein thrombosis in hospitalized patients with coronavirus disease 2019.

OBJECTIVE: The pandemic of coronavirus disease 2019 (COVID-19) has caused devastating morbidity and mortality worldwide. In particular, thromboembolic complications have emerged as a key threat for patients with COVID-19. We assessed our experience with deep vein thrombosis (DVT) in patients with COVID-19. METHODS: We performed a retrospective analysis of all patients with COVID-19 who had undergone upper or lower extremity venous duplex ultrasonography at an academic health system in New York City from March 3, 2020 to April 12, 2020 with follow-up through May 12, 2020. A cohort of hospitalized patients without COVID-19 (non-COVID-19) who had undergone venous duplex ultrasonography from December 1, 2019 to December 31, 2019 was used for comparison. The primary outcome was DVT. The secondary outcomes included pulmonary embolism, in-hospital mortality, admission to the intensive care unit, and antithrombotic therapy. Multivariable logistic regression was performed to identify the risk factors for DVT and mortality. RESULTS: Of 443 patients (COVID-19, n = 188; and non-COVID-19, n = 255) who had undergone venous duplex ultrasonography, the COVID-19 cohort had had a greater incidence of DVT (31% vs 19%; P = .005) than had the non-COVID-19 cohort. The incidence of pulmonary embolism was not significantly different statistically between the COVID-19 and non-COVID-19 cohorts (8% vs 4%; P = .105). The DVT location in the COVID-19 group was more often distal (63% vs 29%; P < .001) and bilateral (15% vs 4%; P < .001). The duplex ultrasound findings had a significant impact on the antithrombotic plan; 42 patients (72%) with COVID-19 in the DVT group had their therapy escalated and 49 (38%) and 3 (2%) had their therapy escalated and deescalated in the non-DVT group, respectively (P < .001). Within the COVID-19 cohort, the D-dimer level was significantly greater in the DVT group at admission (2746 ng/mL vs 1481 ng/mL; P = .004) and at the duplex examination (6068 ng/mL vs 3049 ng/mL; P < .01). On multivariable analysis, male sex (odds ratio [OR], 2.27; 95% confidence interval [CI], 1.06-4.87; P = .035), intensive care unit admission (OR, 3.42; 95% CI, 1.02-11.44; P = .046), and extracorporeal membrane oxygenation (OR, 5.5; 95% CI, 1.01-30.13; P = .049) were independently associated with DVT. CONCLUSIONS: Given the high incidence of venous thromboembolic events in this population, we support the decision to empirically initiate therapeutic anticoagulation for patients with a low bleeding risk and severe COVID-19 infection. Duplex ultrasonography should be reserved for patients with a high clinical suspicion of venous thromboembolism for whom anticoagulation therapy could result in life-threatening consequences. Further study of patients with COVID-19 is warranted to elucidate the etiology of vascular thromboembolic events and guide the prophylactic and therapeutic interventions for these patients.

The Role of the Computed Tomography (CT) Thorax in the Diagnosis of COVID-19 for Patients Presenting with Acute Surgical Emergencies. A Single Institute Experience.

The current Coronavirus disease 2019 (COVID-19) pandemic has had a huge impact on emergency surgical services in the UK. The Royal College of Surgeons (RCS) published guidelines about COVID-19 pandemic in March, 2020 to aid decision making for the surgeons. These guidelines recommended that all patients requiring urgent surgery should have reverse transcriptase polymerase chain reaction (RT-PCR) and/or computed tomography (CT) thorax pre-operatively. However, it is currently unclear whether the use of CT thorax is a sensitive and specific diagnostic test. The objective of this study was to find out whether CT thorax is a reliable and accurate test in the diagnosis of COVID-19 compared to RT-PCR. This is particularly important in surgical patients where there is no time to wait for RT-PCR results. A prospective cohort study of patients presented with acute surgical emergencies at a University Teaching Hospital was conducted. Data was collected from March 23, to May 15, 2020, during the peak of the crisis in the UK. All adult patients presented with operable general surgical emergencies were considered eligible. Another group of patients, admitted with acute medical emergencies but with suspected COVID-19 infection, was used for comparison. Data was manually collected, and sensitivity, specificity and predictive value were calculated using the MedCalc statistical software version 19.2.6. Standard reporting for COVID-19 infection for CT chest based on guidelines from British Society of Thoracic Imaging (BSTI) and Radiological Society of North America (RSNA) was used. Patients who had their CT thorax reported as typical or classic of COVID 19 (high probability) were treated as infected cases with extra precautions in the wards and surgical theatres as suggested by health and safety executive (HSE). These patients had serial RT-PCR during their admissions or in the post-operative phase, if the first swab was negative. For the study, 259 patients were considered eligible for inclusion from both groups. Patients admitted for acute surgical emergencies were treated according to RCS guidelines and subjected to RT-PCR test and/or CT scan of the thorax. There were 207 patients with high clinical suspicion of COVID-19. Of those 207 patients, 77 patients had CT thorax with radiographic features consistent with COVID-19 pneumonia. However, only 40 patients had a positive RT-PCR result. CT thorax was normal in 130 patients, out of which 29 patients were found to have COVID-19 diagnosis after swab test. Sensitivity of CT scan to diagnose COVID-19 infection was found to be 58% (95% CI; 45.48% to 69.76%) whilst specificity was 73% (95% CI; 64.99% to 80.37%) with a negative predictive value of 77.69% (95% CI; 72.17% to 82.39%). CT scan was found to be a reliable tool in the diagnosis of COVID-19. With a negative predictive value of up to 82.4%, CT thorax can play an important role to help surgeons in their decision making for asymptomatic suspected cases of COVID-19. However, over-reliance on CT scan which also has a high false positive rate for diagnosis of COVID-19 infections can lead to overtreatment, overuse of resources and delays in decision-making process. Hence, results should be interpreted with caution and correlated with clinical presentation and swab test results.