Effect of pulmonary rehabilitation program on post hospitalization severe COVID-19 patients (Experimental study)

Background: COVID-19 infection was discovered to be the major global cause of a serious respiratory illness toward the end of 2019. The majority of COVID-19 patients experience mild disease, while about 14% go on to have severe disease and 6% end up in critical condition. An evidence-based standard of therapy called pulmonary rehabilitation includes exercise-training, education, and behavior modification to help people had a lung illness feel better physically and mentally. Aim(s): current study aimed to evaluate the effect of pulmonary rehabilitation program on severe post covid19 patients (post hospitalization) regarding pulmonary function tests and dyspnea score. Method(s): Randomized control experimental study design enrolled 100 patients of post hospitalization due to severe COVID 19 infection. Dyspnea score, Spirometry and 6-minute walk test were performed upon discharge. Pulmonary rehabilitation program in the form of respiratory exercises and walking exercise was done to 50 patients. Follow up assessment of the same parameters was done 6 weeks after the program. Other 50 patients had no pulmonary rehabilitation program to them. Result(s): Post COVID-19 cases in the experimental group show much improvement in percentage of normal breathing score (mMRC) 30% versus no cases in control group. In addition, the experimental group showed a significant higher percentage of normal spirometry findings (66% versus 28% in control group). As regards oxygen saturation, 6MWT score and distance, it showed a higher mean after practicing the exercise program. Conclusion(s): pulmonary rehabilitation program was effective in achieving much improvement in recovery of severe cases of COVID 19 infection.Copyright © 2021 Muslim OT et al.

COVID-19 and hepatic injury: cellular and molecular mechanisms in diverse liver cells.

The coronavirus disease 2019 (COVID-19) represents a global health and economic challenge. Hepatic injuries have been approved to be associated with severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection. The viral tropism pattern of SARS-CoV-2 can induce hepatic injuries either by itself or by worsening the conditions of patients with hepatic diseases. Besides, other factors have been reported to play a crucial role in the pathological forms of hepatic injuries induced by SARS-CoV-2, including cytokine storm, hypoxia, endothelial cells, and even some treatments for COVID-19. On the other hand, several groups of people could be at risk of hepatic COVID-19 complications, such as pregnant women and neonates. The present review outlines and discusses the interplay between SARS-CoV-2 infection and hepatic injury, hepatic illness comorbidity, and risk factors. Besides, it is focused on the vaccination process and the role of developed vaccines in preventing hepatic injuries due to SARS-CoV-2 infection.

Is nano-biofortification the right approach for malnutrition in the era of COVID-19 and climate change?

Human health may depend on the environment and its compartments, which may include climatic factors. These climatic factors and their changes might impact on human health particularly the outbreak of pandemics like COVID-19. The combined stress resulted from climate changes and COVID-19 could be noticed in several countries especially in the developing countries. Malnutrition is considered one of the most important problems in the developing countries in particular under the droughts, flooding, and other climatic events. Malnutrition was aggravated under COVID-19 outbreak in these countries due to the closure of borders between countries, the crisis of global trade, and the global food insecurity. The biofortification process is the sustainable solution to overcome malnutrition, which included very recently using nano-nutrients as called nano-biofortification. The approach of nano-biofortification is a promising tool in producing biofortified edible plants, otherwise this tool still needs more studies to answer the open questions like which nano-nutrients can be used in nano-biofortification? Which recommended doses and crops are considered suitable candidates?

Impact of cytokine storm and systemic inflammation on liver impairment patients infected by SARS-CoV-2: Prospective therapeutic challenges.

Coronavirus disease 2019 (COVID-19) is a devastating worldwide pandemic infection caused by a severe acute respiratory syndrome namely coronavirus 2 (SARS-CoV-2) that is associated with a high spreading and mortality rate. On the date this review was written, SARS-CoV-2 infected about 96 million people and killed about 2 million people. Several arguments disclosed the high mortality of COVID-19 due to acute respiratory distress syndrome or change in the amount of angiotensin-converting enzyme 2 (ACE2) receptor expression or cytokine storm strength production. In a similar pattern, hepatic impairment patients co-infected with SARS-CoV-2 exhibited overexpression of ACE2 receptors and cytokine storm overwhelming, which worsens the hepatic impairment and increases the mortality rate. In this review, the impact of SARS-CoV-2 on hepatic impairment conditions we overviewed. Besides, we focused on the recent studies that indicated cytokine storm as well as ACE2 as the main factors for high COVID-19 spreading and mortality while hinting at the potential therapeutic strategies.

DIFFUSE ALVEOLAR HEMORRHAGE AS A CONSEQUENCE OF MICROSCOPIC POLYANGIITIS DUE TO COVID-19

SESSION TITLE: Fellows' COVID-19 SESSION TYPE: Fellow Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a small vessel vasculitis of which microscopic polyangiitis (MPA) is a subset. They are known to cause life threatening renal failure and/or pulmonary hemorrhage. Viruses are a known trigger of vasculitis, including MPA. (1) We present a case of MPA caused by COVID-19 presenting as diffuse alveolar hemorrhage (DAH) CASE PRESENTATION: 55 year old female with a past medical history of hemorrhagic stroke, hypertension & asthma who presented with respiratory distress & severe hypoxemia. At the time of intubation, a moderate amount of blood was suctioned from her endotracheal tube. She was profoundly hypoxemic & required 100% FiO2 and PEEP 18 cmH2O. A SARS CoV2 PCR test was positive. Other admission laboratory values were significant for a creatinine of 4.9 mg/dL (baseline: 0.8mg/dL), hemoglobin of 8 g/dL (baseline: 11.8g/dL), ferritin 569 ng/mL, D-dimer 3.18 ug/mL, CRP 62.8 mg/L, ESR 118 mm/hr. Chest X-ray showed dense bilateral airspace opacities. A CT scan showed extensive bilateral consolidations with air bronchograms that were not typical for a COVID-19 pneumonia (Image 1) except in the apices where these dense consolidations had a peripheral pattern. She was admitted to the medical ICU where she continued to have bleeding into her endotracheal tubing. Bronchoscopy showed blood in the airways diffusely with no focality to the bleeding. A bronchoalveolar lavage was performed of two separate lobes, and was notable for progressively bloody aliquots consistent with DAH. Because of concern for a pulmonary-renal syndrome, rheumatologic testing was performed. She was empirically treated with high dose intravenous steroids and plasmapheresis. Unfortunately, profound hypoxia persisted and family elected to withdraw life-sustaining therapies. Two days after her death, serologies revealed a mildly positive ANA and a strongly positive anti-MPO ANCA, suggesting the diagnosis of MPA. DISCUSSION: While the primary signs and symptoms of COVID-19 are fever, cough, and dyspnea, other reported manifesations include kawasaki-like disease in children (2) and cutaneous manifestations such as livedo reticularis (3). We believe that in our case the patient’s infection with COVID-19 & its subsequent increased inflammatory state led to her developing MPA vasculitis with subsequent pulmonary-renal syndrome complicated by diffuse alveolar hemorrhage, rapidly progressive renal failure and ultimately death. Her clinical and serologic picture were consistent with a diagnosis of microscopic polyangiitis. It is unclear whether our patient had a smoldering vasculitis that was triggered by the hyper-inflammatory nature of COVID-19 or whether this virus caused a vasculitis de novo. CONCLUSIONS: With vasculitis potentially being one of COVID-19's presenting symptoms, prompt diagnosis and intervention is essential in improving outcomes. Reference #1: Yates M, Watts R. ANCA-associated vasculitis. Clin Med (Lond). 2017;17(1):60-64. doi:10.7861/clinmedicine.17-1-60 Reference #2: Viner RM, Whittaker E. Kawasaki-like disease: emerging complication during the COVID-19 pandemic [published online ahead of print, 2020 May 13]. Lancet. 2020;10.1016/S0140-6736(20)31129-6. doi:10.1016/S0140-6736(20)31129-6 Reference #3: Sachdeva M, Gianotti R, Shah M, et al. Cutaneous manifestations of COVID-19: Report of three cases and a review of literature [published online ahead of print, 2020 Apr 29]. J Dermatol Sci. 2020;S0923-1811(20)30149-3. doi:10.1016/j.jdermsci.2020.04.011 DISCLOSURES: no disclosure on file for Christopher Damiano;No relevant relationships by Elie Fares, source=Web Response no disclosure on file for Catherine Kuntz;No relevant relationships by Kriti Pathak, source=Web Response

MYASTHENIA GRAVIS CRISIS TRIGGERED BY COVID-19

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: It is known that viral infections increase the risk of a crisis in patients with known myasthenia gravis (1). While COVID-19 has been associated with an array of neurologic complications including encephalopathy, strokes, and seizures (2), there have been no published reports of new or exacerbated neuromuscular conditions as a result of said infection. We present a case of myasthenia gravis crisis precipitated by COVID-19 infection. CASE PRESENTATION: 79 year old female patient with a past medical history of myasthenia gravis, mixed connective tissue disease-associated ILD on home oxygen, heart failure with a reduced ejection fraction, and a history of VTE on Apixaban who presented with dry cough, nausea, and diarrhea. She was found to have worsening of her chronic hypoxic respiratory failure on admission, requiring high flow nasal cannula. She tested positive for COVID-19. Her admission ABG showed a Pa O2 77 mmHg without hypercapnia. Inflammatory markers were elevated;CRP 65 mg/L, LDH 500 IU/L, and d-dimer 3.99 ug/mL. Other admission labs were notable for lactate 5.2 mmol/L, BNP 258 pg/mL. Patient initially improved, but then started exhibiting increasing weakness which similar to her prior myasthenic crises. Her neurological exam became notable for decreased motor strength in neck flexion and extension, diffuse weakness of proximal muscles (3/5 strength in proximal upper extremities, 4+/5 in distal upper extremities, 2/5 in proximal lower extremities, 4/5 in distal lower extremities), with decreased but symmetrical DTRs. Her respiratory status declined, requiring a combination of high flow nasal cannula and non-rebreather mask to maintain adequate oxygenation. Negative inspiratory force measurements were found to be decreased (NIF 20 from normal on admission). She was diagnosed with a myasthenic crisis. She received IVIG without significant improvement and was then transferred to the medical ICU for further management. In the ICU, patient treated with plasmapheresis and initial supported with NIPPV therapy with Bi-level PAP. She unfortunately continued to decline and required intubation for further management. Patient's course was then complicated by an acute stroke and her family elected to pursue comfort care. She passed thereafter. DISCUSSION: While the primary signs and symptoms of COVID-19 are fever, cough, and dyspnea, several neurological manifestations of the disease that have been reported. In our case, this SARS COV-2 virus was the precipitating cause of this patient’s myasthenic crisis. We wonder if experimental therapy with Remdisivir, Convalescent plasma or other immunologic agents could have prevented or shortened the duration of the myasthenic crisis in this patient. CONCLUSIONS: Myasthenia gravis crises can be associated with COVID-19. Prompt detection & diagnosis can help improve outcomes. Reference #1: Gilhus NE, Romi F, Hong Y, Skeie GO. Myasthenia gravis and infectious disease. J Neurol. 2018;265(6):1251-1258. doi:10.1007/s00415-018-8751-9 Reference #2: Haddad S, Tayyar R, Risch L, et al. Encephalopathy and seizure activity in a COVID-19 well controlled HIV patient [published online ahead of print, 2020 May 16]. IDCases. 2020;21:e00814. doi:10.1016/j.idcr.2020.e00814 DISCLOSURES: no disclosure on file for Christopher Damiano;No relevant relationships by Elie Fares, source=Web Response no disclosure on file for Catherine Kuntz;No relevant relationships by Kriti Pathak, source=Web Response No relevant relationships by Ralph Tayyar, source=Web Response