Bradycardia in Patients With COVID-19: A Calm Before the Storm?

Cardiac manifestations of coronavirus disease 19 (COVID-19), including arrhythmia, have been described in the literature. However, to our knowledge, association of COVID-19 with bradycardia has not been reported. This case study describes sinus bradycardia as a potential manifestation of COVID-19. This is a retrospective case series of four patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, admitted to St. Luke's University Health Network ICU between 24 March 2020 and 5 April 2020. Medical records of these patients were reviewed using the EPIC electronic health record system. Demographic, clinical, laboratory, and treatment data were reviewed against periods of bradycardia in each patient. The patient group comprised two males and two females. Two patients had pre-existing cardiovascular (CV) comorbidities but no history of arrythmias. Heart rates ranged between 66 and 88 beats/min on admission. The lowest rates during bradycardia were between 42 and 49 beats/min. The onset of sinus bradycardia in patients 1, 2, and 3 were day nine, 15, and five of illness, respectively. Patient 4 had three episodes of bradycardia, starting on day 10 of illness. Patients' bradycardia episodes lasted one to 14 days. During bradycardia, maximum body temperatures ranged between 99.9 and 100.2 degree Fahrenheit. Patients 2, 3, and 4 required vasopressors to maintain mean arterial pressure > 65 mmHg during episodes. All four patients were on propofol at some point during bradycardia with patients 1, 2, and 3 also receiving dexmedetomidine. There was no consistent correlation of these medications with bradycardia. Electrocardiogram (ECG) findings included sinus bradycardia. Prolonged QTc interval observed in patient 2 on admission improved during bradycardia. Transient sinus bradycardia is a possible manifestation of COVID-19 and is important for close CV surveillance. Etiology can be multifactorial, but severe hypoxia, inflammatory damage of cardiac pacemaker cells, and exaggerated response to medications are possible triggers. High levels of pro-inflammatory cytokines may act directly on the sinoatrial (SA) node contributing to the development of bradycardia. This may be a warning sign of the onset of a serious cytokine storm. An increased awareness of possible exaggerated bradycardia response is important to consider with the use of empiric medications which have arrhythmogenic effects.

Virulence characteristics of hcp (+) Campylobacter jejuni and Campylobacter coli isolates from retail chicken.

BACKGROUND: Recently the Type VI secretion system (T6SS), which can play a significant role in bacterial survival and pathogenesis, was reported in Campylobacter spp., having the hcp gene as a key component. METHODS: Campylobacteriosis is associated with the consumption of infected chicken meat. Our study aimed to explore the presence of T6SS in C. jejuni (n = 59) and C. coli (n = 57) isolates, from retail raw chicken and to investigate their pathogenic potential. The hcp gene was used as an indicator for the T6SS presence. RESULTS: Using multiplex PCR we have identified a significantly higher prevalence of hcp in C. coli isolates (56.1%) than in C. jejuni (28.8%) and AFLP analysis of the isolates showed a high degree of genetic similarity between the isolates carrying the hcp gene. Genome sequencing data showed that 84.3% of the C. coli and 93.7% of the C. jejuni isolates had all 13 T6SS open reading frames. Moreover, the virulence characteristics of hcp + isolates, including motility and the ability to invade human intestinal epithelial cells in vitro, were significantly greater than in the control strain C. jejuni 12502; a human isolate which is hcp positive. CONCLUSION: Overall, it was discovered that hcp (+) C. coli and C. jejuni isolated from retail chicken isolates posses genetic and phenotypic properties associated with enhanced virulence. However, since human infections with C. coli are significantly less frequent than those of C. jejuni, the relationship between virulence factors and pathogenesis requires further study.

Prevalence of Campylobacter and Salmonella in raw chicken on retail sale in the republic of Ireland.

To assess the current risks to consumers from Campylobacter and Salmonella in raw chicken products sold in the Republic of Ireland, a retail survey was undertaken to define their prevalence. Samples (n = 510) were analyzed using protocols based on ISO 10272-1:2006 and ISO 6579:2002. Processor codes on pack labels showed that 67% of samples were produced in the Republic of Ireland and 25% in the United Kingdom. Salmonella was present in 5.1% of samples, but the eight serovars found caused less than 7% of human salmonellosis reported in the Republic of Ireland. The results suggest that on-farm controls to limit Salmonella infection of broilers have been successful and that in Ireland raw chicken is not a significant cause of salmonellosis in humans. The overall prevalence of Campylobacter spp. was 84.3%. Isolation by the ISO method found 52.7% of samples to be positive, but overgrowth by contaminants was frequently evident. Therefore, in addition to enrichment, an homogenized sample was plated directly onto modified charcoal cefoperazone deoxycholate agar, and this detected a further 31.6%. Speciation of isolates (n = 426) determined that 67% were Campylobacter jejuni and 32% were Campylobacter coli. These species are the most common cause of campylobacteriosis in man. The results indicate that there is a need for poultry producers to introduce interventions to minimize the exposure of consumers in the Republic of Ireland to Campylobacter spp., as has been successfully done for Salmonella.

Genotypic characterisation and cluster analysis of Campylobacter jejuni isolates from domestic pets, human clinical cases and retail food.

The genetic similarity of Campylobacter jejuni isolates from pets, compared to human clinical cases and retail food isolates collected in Ireland over 2001-2006 was investigated by cluster analysis of pulsed-field gel electrophoresis (PFGE) fingerprinting profiles. Comparison of the PFGE profiles of 60 pet isolates and 109 human isolates revealed that seven (4.1%) profiles were grouped in clusters including at least one human and one pet C. jejuni isolate. In total six (1.6%) of 60 pet and 310 food profiles were in clusters with at least one food and one pet C. jejuni isolate. The detection of only a small number of genetically indistinguishable isolates by PFGE profile cluster analysis from pets and from humans with enteritis in this study suggests that pets are unlikely to be an important reservoir for human campylobacteriosis in Ireland. However, genetically indistinguishable isolates were detected and C. jejuni from pets may circulate and may contribute to clinical infections in humans. In addition, contaminated food fed to pets may be a potential source of Campylobacter infection in pets, which may subsequently pose a risk to humans.

Pulsed field gel electrophoresis typing of human and retail foodstuff Campylobacters: an Irish perspective.

Campylobacter enteritis is a zoonosis, an infectious disease transmissible under normal conditions from vertebrate animals to man, presenting a major global public health burden. In this study, Pulsed Field Gel Electrophoresis (PFGE) was employed to identify common genotypes in a collection of 600 Campylobacter isolates in order to investigate if profiles obtained from retail samples of foodstuffs matched genotypes causing illness in the community in Ireland. The Campylobacters were isolated from retail foodstuffs, and cases of gastroenteritis, over the same 20-month period in three population centres in Ireland. The major observation made was of a high level of PFGE-genotype heterogeneity; 236 SmaI discrete genotypes were found in 507 strains successfully analysed. Analysis of the PFGE profiles revealed 22 common profiles amongst food isolates and those causing enteritis in humans. These cojoint PFGE genotypes indicate that 56 (38%) of the human clinical isolates are genetically related to 129 (36%) of the food isolates. The identification of these recurrent PFGE types, in the sampled Campylobacter coli and Campylobacter jejuni populations, indicates that a high proportion of Campylobacter isolates found in foods of animal origin also occur in patients with symptoms of enteritis. This data adds weight to the epidemiological hypothesis that a high proportion of human Campylobacter cases are contracted via the handling and consumption of contaminated foodstuffs, in particular poultry.

Prevalence of Campylobacter spp. in raw retail poultry on sale in Northern Ireland.

A year-long survey of fresh, retail poultry products on sale in Northern Ireland was undertaken to define the prevalence of Campylobacter spp. by using protocols based on ISO (standard) 10272-1:2006. Incubation at 37 and 42 degrees C was undertaken to increase the diversity of isolates obtained. Overall, 652 isolates were identified as Campylobacter spp. by using PCR and amplified fragment length polymorphic typing. Phenotyping wrongly identified 21% of isolates. Prevalences of Campylobacter found were chicken, 91% (n = 336); turkey, 56% (n = 77); and duck, 100% (n = 17). Prevalence rates for chicken produced in Northern Ireland, Scotland, England, and Wales were similar, with a mean value of 91%. The prevalences in product from the latter two countries were much higher than were found in two United Kingdom-wide surveys of chicken. The incubation temperature did not affect the relative proportions of the species isolated (P > 0.05). Campylobacter jejuni composed 64.6% of isolates, Campylobacter coli, 27.4%, and Campylobacter lari, 1%. Most cases of human campylobacteriosis are caused by C. jejuni and C. coli. The overall Campylobacter prevalence results are consistent with Northern Ireland surveys undertaken since 2000, and indicate that United Kingdom strategies to control Campylobacter in chicken have not had a significant effecton the prevalence of this pathogen in retail products on sale in Northern Ireland.

Endothelial dysfunction in heart failure identifies responders to cardiac resynchronization therapy.

BACKGROUND: The presence of endothelial dysfunction is associated with increased heart failure mortality. Cardiac resynchronization therapy (CRT) improves heart failure outcomes; however, current guidelines do not adequately identify responders to CRT. OBJECTIVE: The purpose of this study was to determine whether endothelial dysfunction can predict response to CRT. METHODS: Brachial artery flow-mediated dilation, a measure of endothelial function, was measured at baseline preimplant and 90 days postimplant in 33 patients undergoing CRT (age 64.2 +/- 16.8 years, left ventricular ejection fraction [LVEF] 25% +/- 9%, QRS duration 158 +/- 25 ms, New York Heart Association class III-IV). RESULTS: Of the 33 patients, 19 (58%) were responders to CRT. Baseline flow-mediated dilation was 4.6% +/- 4.5% in responders and 8.6% +/- 4.2% in nonresponders (P <.01). After 90 days of CRT, responders had significant improvement in LVEF (23% +/- 8% to 30% +/- 9%, P = .03), 6-minute walk distance (756 +/- 213 feet to 1,089 +/- 242 feet, P = .04), and quality of life (52 +/- 22 to 31 +/- 28, P <.005), whereas nonresponders did not show improvement in these measures. The presence of baseline endothelial dysfunction correlated with impaired baseline functional capacity (r = 0.39, P = .03), and improvement in flow-mediated dilation correlated with improvement in 6-minute walk distance (r = 0.34, P = .05). Logistic regression analysis showed that every 1% reduction in baseline flow-mediated dilation correlated with an approximately 5% increased likelihood of response to CRT. The predictive value of baseline endothelial dysfunction was independent of QRS duration, LVEF, or dyssynchrony and provided additive prognostic value. CONCLUSION: The presence of endothelial dysfunction independently identifies CRT responders and provides additive prognostic value for predicting response over current criteria. Addition of endothelial function assessment to current selection criteria may improve the ability to identify CRT responders.

Statin pretreatment is protective despite an association with greater coronary artery disease burden in patients presenting with a first ST-elevation myocardial infarction.

The relationship of chronic pre-event statin use with coronary disease severity at the time of presentation with a first acute ST-elevation myocardial infarction (STEMI) is unknown. A retrospective review was performed of consecutive patients presenting with STEMI and without a prior history of vascular disease, divided into those whom had been treated with statins before presentation (n=50) and those whom were not pretreated (n=231). Patients pretreated with statins were more likely to have left main (24.0% vs 8.3%; P=.001) or 3-vessel disease (44.0% vs 25.1%; P=.007) vs untreated patients. After matching for risk factors, a trend toward higher likelihood of 3-vessel disease persisted in the statin pretreatment group (47.6% vs 28.6%; P=.07). Significantly lower peak troponin-I levels (87.8 mg/dL vs 134.5 mg/dL; P=.006) were found in patients pretreated with statins, suggesting that statin pretreatment is protective in patients with STEMI despite the presence of greater disease burden. This finding supports the concept that statin therapy alters the natural history of coronary artery disease development leading to a first STEMI and is cardioprotective in those patients who experience a first STEMI.

Effect of incubation temperature on isolation of Campylobacter jejuni genotypes from foodstuffs enriched in Preston broth.

Preston broth and agar incubated at either 37 or 42 degrees C have been widely used to isolate campylobacters from foodstuffs. The consequences of using either incubation temperature were investigated. Retail packs of raw chicken (n = 24) and raw lamb liver (n = 30) were purchased. Samples were incubated in Preston broth at 37 and 42 degrees C and then streaked onto Preston agar and incubated as before. Two Campylobacter isolates per treatment were characterized. Poultry isolates were genotyped by random amplification of polymorphic DNA (RAPD), pulsed-field gel electrophoresis (PFGE), and flagellin PCR-restriction fragment length polymorphism, and lamb isolates were genotyped by RAPD only. In total, 96% of the poultry and 73% of the lamb samples yielded campylobacters. The lamb isolates were all Campylobacter jejuni, as were 96% of the poultry isolates, with the remainder being Campylobacter lari. The incubation temperature had no significant effect on the number of positive samples or on the species isolated. However, genotyping of the C. jejuni isolates revealed profound differences in the types obtained. Overall (from poultry and lamb), the use of a single incubation temperature, 37 degrees C, gave 56% of the total number of RAPD C. jejuni genotypes, and hence, 44% remained undetected. The effect was especially marked in the poultry samples, where incubation at 37 degrees C gave 47% of the PFGE genotypes but 53% were exclusively recovered after incubation at 42 degrees C. Thus, the incubation temperature of Preston media selects for certain genotypes of C. jejuni, and to detect the widest range, samples should be incubated at both 37 and 42 degrees C. Conversely, genotyping results arising from the use of a single incubation temperature should be interpreted with caution.