Hemofiltration as an Alternative for IL-6 Inhibitors in COVID-19 Cytokines Storm Associated with Underlaying Bacterial Infections: A Review Article.

SARS-CoV-2 causes mostly mild cases. However, a considerable number of patients develop fatal acute respiratory distress syndrome due to the cytokine storm and imbalanced immune response. Several therapies depending on immunomodulation have been used, including glucocorticoids and IL-6 blockers. However, their efficacy is not perfect with all patients and patients with concomitant bacterial infections and sepsis. Accordingly, studies on different immunomodulators, including extracorporeal techniques, are crucial to save this category of patients. In this review, we overviewed the different immunomodulation techniques shortly, with a brief review of extracorporeal methods.

Egyptian Consensus on the Role of Lung Ultrasonography During the Coronavirus Disease 2019 Pandemic.

Background & Aims: Coronavirus disease 2019 (COVID-19) is a global health problem, presenting with symptoms ranging from mild nonspecific symptoms to serious pneumonia. Early screening techniques are essential in the diagnosis and assessment of disease progression. This consensus was designed to clarify the role of lung ultrasonography versus other imaging modalities in the COVID-19 pandemic. Methods: A multidisciplinary team consisting of experts from different specialties (ie, pulmonary diseases, infectious diseases, intensive care unit and emergency medicine, radiology, and public health) who deal with patients with COVID-19 from different geographical areas was classified into task groups to review the literatures from different databases and generate 10 statements. The final consensus statements were based on expert physically panelists' discussion held in Cairo July 2021 followed by electric voting for each statement. Results: The statements were electronically voted to be either "agree," "not agree," or "neutral." For a statement to be accepted to the consensus, it should have 80% agreement. Conclusion: Lung ultrasonography is a rapid and useful tool, which can be performed at bedside and overcomes computed tomography limitations, for screening and monitoring patients with COVID-19 with an accepted accuracy rate.

Neutralizing antibody responses in asymptomatic close contacts of COVID-19 patients and in asymptomatic healthcare workers.

The identification of novel antibodies that could neutralize SARS-CoV-2 is one of the novel approaches to use in combating COVID-19. This study aimed to explore the level of neutralizing antibodies (NAbs) in asymptomatic close contacts of COVID-19 patients and asymptomatic healthcare workers. In vitro qualitative detection of serum antibodies of participants from both populations was done using an anti-SARS-CoV-2 immunoassay. The study included 107 participants, of which 59.8% were healthcare workers and 40.2% were family contacts of confirmed COVID-19 cases. Their median age was 22 years. The percentage of positivity and median titer for NAbs were significantly higher among family contacts than mong healthcare workers (P = 0.013 and < 0.001, respectively). We also measured C-reactive protein (CRP) levels and the median value of CRP was significantly higher in the family members who had been in contact with COVID-19 patients than in healthcare workers (P < 0.001). In the family contact group, there was a significant negative correlation between the absolute lymphocyte count and CRP (r = -0.409, P = 0.034). There was no significant correlation between neutralizing antibody titers and either CRP or absolute lymphocyte count (P > 0.05 for both). In conclusion, the indication of elevated NAb titers in asymptomatic family contacts could help lay the groundwork for further studies to explore the potential utility of these antibodies to provide future immunity from infection within a family as well as for potential use in general during passive antibody therapies for COVID-19 patients.

Prevalence and patterns of symptoms of dysautonomia in patients with long-COVID syndrome: A cross-sectional study.

BACKGROUND: The association between autonomic dysfunction and long-COVID syndrome is established. However, the prevalence and patterns of symptoms of dysautonomia in long-COVID syndrome in a large population are lacking. OBJECTIVE: To evaluate the prevalence and patterns of symptoms of dysautonomia in patients with long-COVID syndrome. METHODS: We administered the Composite Autonomic Symptom Score 31 (COMPASS-31) questionnaire to a sample of post-COVID-19 patients who were referred to post-COVID clinic in Assiut University Hospitals, Egypt for symptoms concerning for long-COVID syndrome. Participants were asked to complete the COMPASS-31 questionnaire referring to the period of more than 4 weeks after acute COVID-19. RESULTS: We included 320 patients (35.92 ± 11.92 years, 73% females). The median COMPASS-31 score was 26.29 (0-76.73). The most affected domains of dysautonomia were gastrointestinal, secretomotor, and orthostatic intolerance with 91.6%, 76.4%, and 73.6%, respectively. There was a positive correlation between COMPASS-31 score and long-COVID duration (p < 0.001) and a positive correlation between orthostatic intolerance domain score and post-COVID duration (p < 0.001). There was a positive correlation between orthostatic intolerance domain score and age of participants (p = 0.004). Two hundred forty-seven patients (76.7%) had a high score of COMPASS-31 >16.4. Patients with COMPASS-31 >16.4 had a longer duration of long-COVID syndrome than those with score <16.4 (46.2 vs. 26.8 weeks, p < 0.001). CONCLUSIONS: Symptoms of dysautonomia are common in long-COVID syndrome. The most common COMPASS-31 affected domains of dysautonomia are gastrointestinal, secretomotor, and orthostatic intolerance. There is a positive correlation between orthostatic intolerance domain score and patients' age.

Serial ultrasonographic monitoring of diaphragmatic and mid-upper arm muscle thickness in mechanically ventilated respiratory patients: A single-center observational study.

INTRODUCTION: Muscle monitoring during mechanical ventilation (MV) is gaining great interest nowadays; however, a proper monitoring tool is not well-established yet. OBJECTIVES: To assess the role of ultrasound in muscle monitoring during MV in respiratory patients. METHODS: Eligible 68 mechanically ventilated patients were consecutively enrolled. Serial ultrasound measurements of diaphragmatic thickness at the end of inspiration (Tdi) and mid-upper arm (MUA) muscle thickness were recorded every other day till weaning. Before discharge, functional status score (FSS) was assessed. RESULTS: Tdi decreased in 72.1%, did not change in 13.2% and increased in 14.7% of the patients. MUA muscle thickness decreased in 47.17% and did not change in others. Significant correlation between Tdi and MUA muscle thickness change was found (r = 0.404, P = 0.001); however, MUA muscle thickness change could not predict Tdi change (B = 0.067, P = 0.059). Diaphragmatic and MUA thickness change showed significant negative correlation with ICU stay (r = -0.260, -0.647, P = 0.032, <0.001) and MV duration (r = -0.335, -0.596, P = 0.005, <0.001), respectively. Weaning failure was significantly higher among patients with decreased Tdi (64.28%) and FSS was significantly lower in those with decreased MUA muscle thickness. US measurements of Tdi and MUA muscle thickness showed excellent intra-observer (ICC = 0.996, 0.999, P < 0.001) and inter-observer agreement (ICC = 0.992, 0.998, P < 0.001), respectively. CONCLUSION: Sonographic muscle monitoring during MV is promising. Changes in the diaphragmatic thickness during MV are common and weakly related to those of peripheral muscles. Early decreased muscle thickness heralds poor weaning and functional outcome.

Six-minute walk test before and after large-volume paracentesis in cirrhotic patients with refractory ascites: A pilot study.

BACKGROUND/AIMS: Functional impairment is common among cirrhotic patients with refractory ascites, and improvement in functional impairment is an expected issue after paracentesis. The six-minute walk test (6MWT) is considered an objective test for functional activity. No published data have evaluated the 6MWT among cirrhotic patients with refractory ascites before and after large-volume paracentesis. The research aim was to assess the feasibility of performing the 6MWT among cirrhotic patients who had refractory ascites before and after large-volume paracentesis. MATERIALS AND METHODS: Thirty-one cirrhotic inpatients with refractory ascites were subjected to pulmonary function tests (forced expiratory volume in one second [FEV1], forced vital capacity [FVC], FEV1/FVC) and diffusion lung capacity for carbon monoxide (DLCO) before and 48 h after therapeutic large-volume paracentesis. Dyspnoea as assessed by the Borg scale and functional capacity as assessed by the 6MWT were also evaluated. RESULTS: Prior to paracentesis, the mean values of FVC and FEV1 were lower than the predicted values, and a significant increase was observed after paracentesis. There was improvement in the mean DLCO values after paracentesis (P < 0.05). Regarding the 6MWT, significant increases in the walked distance (6MWD) (310.7 ±â€¯73 vs. 348.7 ±â€¯72.3 m) and oxygen saturation after paracentesis (P = 0.001) were observed. Significant improvement in the dyspnoea scale also occurred after paracentesis (P = 0.001). A significant positive correlation between the 6MWD before paracentesis and serum albumin levels was demonstrated (r = 0.373, P = 0.039). CONCLUSION: We found a decrease in pulmonary function and the 6MWD in patients who had refractory ascites, which improved significantly following large-volume paracentesis. The 6MWT is useful in detecting impaired functional capacity among cirrhotic patients.

Association between hand grip strength with weaning and intensive care outcomes in COPD patients: A pilot study.

BACKGROUND: In COPD, weight loss and muscle wasting contribute significantly to morbidity, disability, and handicap. Dominant-handgrip strength for evaluation of muscle strength has not been tested as a parameter to predict outcome of weaning from mechanical ventilation (MV). OBJECTIVES: To evaluate the association between handgrip strength and the duration and success of weaning and extubation outcome. MATERIALS AND METHODS: This prospective study included 34 COPD patients requiring MV for at least 48 hours. Recovery from sedation and muscle relaxants was assessed before recruitment. Serial meseaurment of handgrip strength were assessed by trained personnel. RESULTS: There was a significant negative correlation between baseline hand grip and duration of MV (P = .047, r = -.343). The mean day 5 hand grip was significantly lower in person who died compared to survivors (5.7 ± 5.5 vs 18.2 ± 14.5, P = .044). The mean day 5 hand grip was significantly lower in patients who needed reintubation compared to those in patients who did not need reintubation (2.8 ± 2 vs 17.2 ± 13.9, P = .029). There was no significant difference in the mean baseline, day 2, day 3, day 4 and day 5 hand grip in weaning success compared to those in failure (P > .05). CONCLUSION: Handgrip strength may be good predictor for duration of MV, extubation outcome, ICU mortality and prognosis.

Obstructive sleep apnea: Influence of hypertension on adiponectin, inflammatory markers and dyslipidemia.

Obstructive sleep apnea (OSA) is a common but often unrecognized condition with potentially serious complications. The aim of this study was to explore the possible mechanisms linking hypertension (HT), a common cardiovascular disease (CVD), with obstructive sleep apnea (OSA) by investigating the levels of morning and evening serum adiponectin, inflammatory markers (TNF-α, IL-6), and lipid profiles in OSA patients with and without HT. Four groups were enrolled in this case-control analytic study: control, OSA, OSA+HT, and HT groups, each of which included 22 subjects. The results revealed low morning and evening serum adiponectin levels in patients with OSA and OSA+HT compared with their control and HT counterparts. Serum adiponectin levels declined progressively with increasing severity of OSA. Also, morning adiponectin levels were significantly decreased at the same time that a loss of the normal diurnal rhythm was observed in the OSA and OSA+HT groups. Both TNF-α and IL-6 levels were significantly increased in the OSA and OSA+HT groups compared with levels in the control and HT groups. Altered lipid profiles was noticed in the same groups. These findings were more pronounced in the OSA+HT than in the OSA group. In conclusion, the biochemical findings of this study demonstrate predominantly low adiponectin levels, increased levels of inflammatory markers, and atherogenic lipid profiles in OSA patients with HT compared with those of the other patients studied. This highlights the possible contributing role of these factors to the pathogenesis of HT as a common cardiovascular complication in OSA patients.

Diagnostic Role of RASSF1A and p16INK4a Promoter Gene Hypermethylation in Serum DNA of Lung Cancer Patients: Clinicopathological Significance.

The most common inactivation mechanism of tumor suppressor genes, RASSF1A and p16INK4a, in lung cancer is hypermethylation. We detected the methylation status of RASSF1A and p16INK4a in serum of lung cancer patients using methylation-specific PCR and analyzed their clinicopathological significance. Each of RASSF1A and p16INK4a hypermethylation was detected in 31.1% cancer patients but not in benign lung lesion patients. Hypermethylation was preferentially observed in small cell lung cancer (SCLC) for RASSF1A (50%), but not for p16INK4a. In non-small cell lung cancer (NSCLC), RASSF1A and p16INK4a hypermethylation were found in 27% and 37.8% respectively. Hypermethylation of RASSF1A was not correlated with clinicopathological character. While, p16INK4a hypermethylation was associated with age >60 years, smoking and squamous cell carcinoma (SCC) (P = 0.033), but not with gender and pathological stages of NSCLC. Sensitivity and specificity of each gene were 31.1% and 100% respectively and the sensitivity improved with evaluation of a combination of the two genes (55.6%). These findings suggest that serum RASSF1A and p16INK4a hypermethylation are promising diagnostic method for detection of lung cancer. As regard the clinicopathological characteristics, p16INK4a hypermethylation may provide a more specific approach than RASSF1A hypermethylation.

B-lines: Transthoracic chest ultrasound signs useful in assessment of interstitial lung diseases.

OBJECTIVE: This prospective study was conducted to evaluate the value of sonographic B-lines (previously called "comet tail artifacts"), which are long, vertical, well-defined, hyperechoic, dynamic lines originating from the pleural line in assessment of interstitial lung diseases (ILD) and compare them with the findings of chest high-resolution computed tomography (HRCT) and pulmonary function tests (PFTs). MATERIALS AND METHODS: Sixty-one patients with ILD underwent transthoracic lung ultrasound for assessment of the presence of B-lines and the distance between them. These findings were compared with that of chest HRCT (ground glass, reticular, nodular or honey combing) and PFT as forced vital capacity (FVC), total lung capacity (TLC), diffusion capacity for carbon monoxide (DLCO) and partial arterial oxygen pressure (PaO2). RESULTS: All patients had diffuse bilateral B-lines. The distance between each of the two adjacent B lines correlated with the severity of the disease on chest HRCT where B3 (the distance was 3 mm) correlated with ground glass opacity and B7 (the distance was 7 mm) correlated with extensive fibrosis and honey combing. Also, the distance between B-lines inversely correlated with FVC (r = -0.848, P < 0.001), TLC (r = -0.664, P < 0.001), DLCO (r = -0.817, P < 0.001) and PaO2 (r = -0.902, P < 0.001). CONCLUSION: B-lines that are lung Ultrasound signs seem to be useful in the assessment of ILD.

Surfactant protein D, soluble intercellular adhesion molecule-1 and high-sensitivity C-reactive protein as biomarkers of chronic obstructive pulmonary disease.

OBJECTIVE: The aim of this study was to estimate the serum levels of surfactant protein D (SP-D), soluble intercellular adhesion molecule-1 (sICAM-1), and high-sensitivity C-reactive protein (hs-CRP) in patients with chronic obstructive pulmonary disease (COPD) and to assess the correlation of these indices with COPD severity. SUBJECTS AND METHODS: This analytic cross-sectional study was carried out on 64 COPD male patients, and 26 apparently healthy age-matched males as a control. Chest X-ray, spirometry and arterial blood gases were done for only COPD patients. Serum levels of SP-D, sICAM-1 and hs-CRP were determined by enzyme-linked immunosorbent assay in both patient and control groups. RESULTS: The serum levels of SP-D, sICAM-1 and hs-CRP were significantly higher in COPD patients than controls (p < 0.001 for each). Also, these biomarkers were significantly higher in stages III and IV compared to either stage I or II (p < 0.01 for each). SP-D was significantly positively correlated with sICAM-1 and hs-CRP (r = 515, p < 0.001; r = 501, p < 0.001, respectively) and negatively correlated with PaO2 (r = -0.651, p < 0.001) and all parameters of spirometry. CONCLUSION: SP-D, sICAM and hs-CRP were significantly higher in COPD patients in comparison with controls. Moreover, SP-D, sICAM-1, and hs-CRP were significantly negatively correlated with FEV1%. Accordingly, estimation of these biochemical indices may be used as biomarkers for assessment of COPD severity.

Spontaneous bacterial empyema in patients with liver cirrhosis in Upper Egypt: prevalence and causative organisms.

BACKGROUND: Spontaneous bacterial empyema (SBEM) is a complication in cirrhotic patients, in which a preexisting pleural effusion becomes infected. PURPOSE: The purpose was to determine the prevalence and causative organisms of SBEM among cirrhotic patients with hydrothorax. MATERIALS AND METHODS: This descriptive, cross-sectional study included 901 cirrhotic patients. All patients underwent clinical evaluation, liver function tests, chest X-ray, abdominal and chest ultrasonography, and pleural and peritoneal fluids study (when detected) including polymorphonuclear (PMN) leukocyte count, biochemical analysis, and culture by two methods: conventional and modified (inoculation of 10 mL of pleural or peritoneal fluid into a blood culture bottle). Diagnostic criteria for SBEM included positive pleural fluid culture and a PMN count of >250 cells/mm(3) or, if a negative culture, a pleural fluid PMN count of >500 cells/mm(3) and the absence of pneumonia on chest radiography. RESULTS: Of 901 cirrhotic patients, 16 cases of SBEM were diagnosed. The prevalence of SBEM was 1.8 % in cirrhotic patients and 26.2 % in patients with cirrhosis and hydrothorax. Pleural fluid culture was found to be positive by the conventional method in four (25 %) cases and by modified methods in 11 (68.8 %) cases. Escherichia coli was the most frequently isolated pathogen (six cases). The mortality rate of SBEM was 25 %. CONCLUSIONS: SBEM is a frequent complication in cirrhotic patients with hydrothorax. E. coli is the most frequent organism responsible for SBEM. The modified method of pleural fluid culture is more sensitive than the conventional method for diagnosis of SBEM.

Evaluation of recently validated non- invasive formula using basic lung functions as new screening tool for pulmonary hypertension in idiopathic pulmonary fibrosis patients.

BACKGROUND: A prediction formula for mean pulmonary artery pressure (MPAP) using standard lung function measurement has been recently validated to screen for pulmonary hypertension (PH) in idiopathic pulmonary fibrosis (IPF) patients. OBJECTIVE: To test the usefulness of this formula as a new non invasive screening tool for PH in IPF patients. Also, to study its correlation with patients' clinical data, pulmonary function tests, arterial blood gases (ABGs) and other commonly used screening methods for PH including electrocardiogram (ECG), chest X ray (CXR), trans-thoracic echocardiography (TTE) and computerized tomography pulmonary angiography (CTPA). MATERIALS AND METHODS: Cross-sectional study of 37 IPF patients from tertiary hospital. The accuracy of MPAP estimation was assessed by examining the correlation between the predicted MPAP using the formula and PH diagnosed by other screening tools and patients' clinical signs of PH. RESULTS: There was no statistically significant difference in the prediction of PH using cut off point of 21 or 25 mm Hg (P = 0.24). The formula-predicted MPAP greater than 25 mm Hg strongly correlated in the expected direction with O2 saturation (r = -0.95, P < 0.000), partial arterial O2tension (r = -0.71, P < 0.000), right ventricular systolic pressure measured by TTE (r = 0.6, P < 0.000) and hilar width on CXR (r = 0.31, P = 0.03). Chest symptoms, ECG and CTPA signs of PH poorly correlated with the same formula (P > 0.05). CONCLUSIONS: The prediction formula for MPAP using standard lung function measurements is a simple non invasive tool that can be used as TTE to screen for PH in IPF patients and select those who need right heart catheterization.

A prospective study of antituberculous drug-induced hepatotoxicity in an area endemic for liver diseases.

PURPOSE: Identification of risk factors associated with antituberculosis drug-induced hepatotoxicity (anti-TB-DIH) is important, especially in endemic area for TB and liver disease. This study assessed the incidence and risk factors of anti-TB-DIH in upper Egyptian patients treated for active pulmonary and extra-pulmonary TB. METHODS: A total of 100 consecutive TB patients were prospectively followed up both clinically and biochemically before and during their course of anti-TB therapy with daily doses of isoniazid, rifampin, ethambutol, and pyrazinamide, or streptomycin. RESULTS: Anti-TB-DIH developed in 15 (15%) patients within 15-60 days (median: 30 days) from the onset of therapy. Liver function normalized in 10 (60%) patients within 2 weeks from cessation of therapy. No recurrence of DIH was observed after reintroduction of therapy. Only 1 patient died from fulminant hepatic failure despite discontinuation of all anti-TB drugs. By univariate analysis, patients with anti-TB-DIH had more pre-existing liver disease (P = 0.024; OR: 3.60; 95% CI: 1.16-11.18), lower body mass index (BMI; P = 0.037; OR: 3.73; 95% CI: 1.04-10.56), lower serum albumin (P = 0.035; OR: 3.31; 95% CI: 1.04-10.56), and more extensive disease (P = 0.033; OR: 3.50; 95% CI: 1.11-11). Age, gender, raised baseline transaminases level, inclusion of pyrazinamide, and inactive hepatitis B or C carrier state were not significant risk factors of DIH. Using multivariate regression analysis, only pre-existing liver disease and lower BMI of 20 kg/m(2) or less were independent predictors of DIH (P = 0.024 and P = 0.047, respectively). CONCLUSION: Anti-TB-DIH is not uncommon, needs early recognition and treatment, and is more in patients with pre-existing liver disease and low BMI.