Asystole in COVID-19 Infection: A Case Report

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), has been associated with a broad spectrum of cardiac manifestations ranging from myocardial injury and heart failure to cardiac arrhythmias. In this report, we present a rare case of sinus node dysfunction/asystole in a young patient without any known history of coronary artery disease or cardiac arrhythmias, which necessitated pacemaker placement.

Acute Pericarditis Due to SARS-COV-2 in a Kidney Transplant Recipient

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is highly contagious and typically presents with respiratory complications. Non-respiratory etiology has been increasingly identified in the literature, including cardiac manifestations. Here, we discuss an atypical case recently treated for SARS-CoV-2 presenting with acute pericarditis. Our patient's medical history of autoimmune disease and renal transplant further complicated her care. There is currently no standard of therapy for SARS-CoV-2-related pericarditis. We would like to highlight increased awareness of this rare complication as well as successful treatment regimens for acute management of the disease.

Spontaneous Hyperinflation of an Intragastric Balloon Causing Gastric Outlet Obstruction

A 39-year-old female with a history of obesity (body mass index, BMI = 33.6) had an intragastric balloon (IGB) placed in February 2020 for weight loss. She presented with gastric outlet obstruction after a delay in the removal of her IGB because of the coronavirus disease (COVID) pandemic. Although uncommon, spontaneous hyperinflation of IGBs has been reported and the US FDA also has issued a warning regarding the risk of spontaneous hyperinflation. The etiology of the hyperinflation is unclear, however, gas-forming micro-organism contamination of the IGB fluid has been reported.

COVID-19-Induced Left Sciatic Neuropathy Requiring Prolonged Physical Medicine and Rehabilitation

A growing number of case reports and series have described a wide spectrum of neurological manifestations of COVID-19 disease including encephalopathy, cerebrovascular disease, and Guillain-Barre syndrome (GBS). However, peripheral neuropathy associated with COVID-19 disease has been uncommonly reported. Here, we describe a young patient with a COVID-19 infection who developed unilateral sciatic neuropathy during the course of treatment requiring prolonged physical medicine and rehabilitation stay. She was treated in the intensive care unit (ICU) for hypoxic respiratory failure for 22 days total, during which she was intubated, sedated, and paralyzed for 14 days. She received dexamethasone, convalescent plasma, and remdesivir for COVID-19; she also received ceftriaxone and azithromycin for possible superimposed bacterial pneumonia. The hypoxic respiratory failure was improved progressively, and she was extubated. On day 17 of ICU stay, she reported numbness and weakness in left leg and had 0/5 motor strength at the left ankle in all directions. She was able to move left hip and knee and had decreased sensation to light touch and pain from the level of the left knee to the toes. Imaging of the brain and spine showed no obvious findings that would explain the neurological symptoms. On electromyography (EMG), there was acute denervation in the left tibialis anterior muscle. She required prolonged physical medicine and rehabilitation care, greater than 60 days during which she had some improvement in sensation, but remained without ankle movement for two more months. This could be a rare manifestation of COVID-19-induced sciatic mono-neuropathy given her symptoms, EMG reports, clinical exam, and normal imaging studies.

COVID-19 Vaccination-Induced Rash: Does the Choice of Vaccine Matter?

With the introduction of large-scale vaccination programmes against the coronavirus disease 2019 (COVID-19), the world has now begun to visualise a possible end to the ongoing pandemic. As with any vaccination programme, reports of side effects have begun to emerge in the wake of vaccinations. Initial reports were about mild side effects, such as local inflammation, pain, and fever. However, as a significant number of the population began to receive various COVID-19 vaccines, reports of various other moderate to severe side effects have now started to emerge. Although these side effects seem to be rare, the symptoms can be severe, and information and guidelines on how to manage them are scarce. In this case series, we discuss the incidence of widespread rashes that develop in some individuals after receiving COVID-19 vaccines by both AstraZeneca (AstraZeneca plc, Cambridge, UK) and Pfizer-BioNTech (Pfizer Inc., Brooklyn, NY; BioNTech SE, Mainz, Germany). The systemic skin reaction varied from maculopapular rashes to papules and patches that were widespread and not simply localised to the vaccine injection site. Further clinical information, awareness, and guidelines for practicing clinicians need to be exigently provided as vaccination programmes approach completion and the incidences of moderate to severe side effects of COVID-19 vaccination are becoming more apparent and pervasive.

Biomarkers Predictive of Extubation and Survival of COVID-19 Patients

Purpose

Many patients with COVID-19 who develop acute respiratory distress syndrome (ARDS) require prolonged periods of mechanical ventilation. Mechanical ventilation may amplify ventilator-associated complications and extend resource utilization. A better understanding of prognostic indicators could help in the planning and distribution of resources, particularly in resource-limited areas. We analyzed laboratory studies of intubated COVID-19 patients with the goal of identifying biomarkers that may predict extubation success and survival to discharge.

Methods

A retrospective chart review was performed on all COVID-19 patients requiring mechanical ventilation between January 3, 2020, and January 7, 2020, in a single academic tertiary care center in Northeastern New York State. The electronic medical record was used to collect 14 laboratory variables at three time points: admission, intubation, and extubation (including terminal extubation) for all intubated intensive care unit (ICU) patients treated for COVID-19. Mean laboratory values were analyzed with the Mann-Whitney U test. Categorical variables were analyzed with the two-sample Wilcoxon rank-sum test.

Results

Seventy-two patients met the inclusion criteria. Forty-three patients were male. The mean age was 61 years. The overall mortality was 50%. On admission, intubated patients who survived had significantly higher platelet counts (p=0.024), and absolute lymphocyte counts (ALC; p=0.047). Notably, ferritin (p=0.018) and aspartate transaminase (AST; p=0.0045) levels were lower in survivors.

At the time of intubation, survivors again had a higher platelet count (p=0.024) and ALC (p=0.037) levels. They had a lower D-dimer (p=0.0014), ferritin (p=0.0015), lactate dehydrogenase (LDH; p=0.0145), and AST (p=0.018) compared to intubated patients who died.

At extubation, survivors had higher platelet count (p=0.0002), ALC (p=0.0013), and neutrophil/lymphocyte ratio (NLR; p=0.0024). Survivors had lower d-dimer (p=0.035), ferritin (p=0.0012), CRP (p=0.045), LDH (p=0.002), AST (p<0.001), and ALK (p=0.0048).

Conclusions

Biomarkers associated with increased risk of mortality include platelet count, ALC, lymphocyte percentage, NLR, D-dimer, ferritin, C-reactive protein (CRP), AST, alanine transaminase (ALT), and alkaline phosphatase (ALK). This study provides additional evidence that these biomarkers have prognostic value in patients with severe COVID-19. The goal is to find objective surrogate markers of disease improvement or success of extubation. When considered within the larger body of data, it is our hope that a mortality risk calculator can be generated for intubated COVID-19 patients.

Acute Acalculous Cholecystitis Due to COVID-19, an Unusual Presentation

Although the Coronavirus Disease 2019 (COVID-19) infection mainly affects the lung, its gastrointestinal (GI) involvements are also well-known, especially hepatic involvement presenting as mild to moderate transaminitis. However, COVID-19 infection presenting with gall bladder involvement with acalculous cholecystitis is extremely rare in the medical literature. So far, only two cases have been reported, and herein, we are reporting the third case of a patient who developed COVID-19 presenting as an acute acalculous cholecystitis.

Asystole During Nasopharyngeal Swab: Is COVID-19 to Blame?

The use of nasopharyngeal (NP) swab sampling for the detection of various respiratory pathogens has been a standard procedure in medicine for many years. While this is a fairly common procedure, there has been a significant increase in utilization recently due to the SARS-CoV-2 pandemic. We describe a case of a 40-year-old SARS-CoV-2 positive patient with no prior cardiac history who developed asystole while an NP swab was being used to obtain a sample for a SARS-CoV-2 assay. Return of normal sinus rhythm was achieved with chest compressions alone. The incident was deemed to have been an exaggerated vagal response to intranasal stimulation; better known as the trigeminocardiac reflex. This is the first reported case describing asystole during use of an NP swab. This case occurred in a patient with no known cardiac disease and highlights the potential importance of the arrhythmogenic nature of COVID-19 that could potentiate the vagal response in susceptible individuals undergoing NP sampling.

Hyperlipasemia in absence of acute pancreatitis is associated with elevated D-dimer and adverse outcomes in COVID 19 disease

BACKGROUND

Coronavirus SARS-CoV-2 affects multiple organs. Studies have reported mild elevations of lipase levels of unclear significance. Our study aims to determine the outcomes in patients with COVID-19 and hyperlipasemia, and whether correlation with D-dimer levels explains the effect on outcomes.

METHODS

Case-control study from two large tertiary care health systems, of patients with COVID-19 disease admitted between March 1 and May 1, 2020 who had lipase levels recorded. Data analyzed to study primary outcomes of mortality, length of stay (LOS) and intensive care utilization in hyperlipasemia patients, and correlation with D-dimer and outcomes.

RESULTS

992 out of 5597 COVID-19 patients had lipase levels, of which 429 (43%) had hyperlipasemia. 152 (15%) patients had a lipase > 3x ULN, with clinical pancreatitis in 2 patients. Hyperlipasemia had a higher mortality than normal lipase patients (32% vs. 23%, OR = 1.6,95%CI = 1.2-2.1, P = 0.002). In subgroup analysis, hyperlipasemia patients had significantly worse LOS (11vs.15 days, P = 0.01), ICU admission rates (44% vs. 66%,OR = 2.5,95%CI = 1.3-5.0,P = 0.008), ICU LOS (12vs.19 days,P = 0.01), mechanical ventilation rates (34% vs. 55%,OR = 2.4,95%CI = 1.3-4.8,P = 0.01), and durations of mechanical ventilation (14 vs. 21 days, P = 0.008). Hyperlipasemia patients were more likely to have a D-dimer value in the highest two quartiles, and had increased mortality (59% vs. 15%,OR = 7.2,95%CI = 4.5-11,P < 0.001) and LOS (10vs.7 days,P < 0.001) compared to those with normal lipase and lower D-dimer levels.

CONCLUSION

There is high prevalence of hyperlipasemia without clinical pancreatitis in COVID-19 disease. Hyperlipasemia was associated with higher mortality and ICU utilization, possibly explained by elevated D-dimer.

In-Hospital Cardiac Arrest (IHCA) and Outcomes in Patients Admitted With COVID-19 Infection

During the COVID-19 pandemic, many patients are hospitalized, and those suffering from in-hospital cardiac arrest (IHCA) have been previously reported to have poor outcomes. This is a single-center, retrospective, observational study conducted at the Veterans Affairs Medical Center, Washington, DC, USA. The inclusion criteria were: patients admitted to the hospital with a diagnosis of COVID-19 who underwent cardiopulmonary resuscitation (CPR) for IHCA. Patients were labeled as COVID-19 positive based on a laboratory-confirmed positive polymerase chain reaction test. Patients with do-not-resuscitate (DNR) orders, those who were made comfort care, or enrolled in hospice were excluded. The study was approved by the hospital’s institutional review board. A total of 155 patients with COVID-19 infection were admitted; 145/155 (93.5%) admitted to the medical floor and 10/155 (6.5%) to the medical intensive care unit (MICU). 36/145 (24.8%) floor patients were upgraded to MICU. Of the 46 patients treated in MICU, 17/46 (36.9%) were excluded for DNR status. From the remaining 29/46 (63.1%) patients, 19/29 (65.5%) patients survived, and 10/29 (34.5%) patients had IHCA. All 10/10 (100%) died after CPR without return of spontaneous circulation (ROSC). The initial rhythm was non-shockable in all patients, with pulseless electrical activity (PEA) in 7/10 (70%) and asystole in 3/10 (30%) patients. Patients with COVID-19 infection who had an IHCA and underwent CPR had a 0% survival at our hospital. Discussions on advanced care options, especially CPR, with COVID-19 patients and their families, are important as the overall prognosis after CPR for IHCA is poor.

Cardiovascular Risk Factors and the Severity of COVID-19 Disease

Background and objective Several cardiovascular risk factors have emerged as important determinants of severe illness and death among coronavirus disease 2019 (COVID-19) patients. However, the full impact of these cardiovascular risk factors is still under investigation. This study aimed to investigate the association between patients' level of cardiovascular risk and the severity of COVID-19. Materials and methods This observational study included all adult patients with COVID-19 hospitalized at Sheikh Khalifa Ibn Zaid International University Hospital from March 20 to May 10, 2020. The cardiovascular risk level was assessed by the doctor responsible for each patient based on the 2019 European Society of Cardiology (ESC), the European Atherosclerosis Society (EAS), and the European Association for the Study of Diabetes (EASD) guidelines. We examined the association between the patients' level of cardiovascular risk and their severity of COVID-19 disease by using a logistic regression model. Results Among 133 patients with confirmed COVID-19, 46.6% had a low cardiovascular risk level, 19.5% had a moderate risk level, 15.8% had a high risk level, and 18.1% was found to have a very high risk level. Patients with different cardiovascular risk levels had significantly different rates of complications including secondary infection (p-value: <0.001), acute respiratory distress syndrome (ARDS) (p-value = 0.017), intensive care unit (ICU) admission (p-value: <0.001), and death (p-value: <0.001). A patient's very high cardiovascular risk level versus low, moderate, or high cardiovascular risk level was independently associated with ICU admission [OR = 6.42, 95% CI: (1.45-28.30)]. Conclusion Based on our findings, an increased level of cardiovascular risk among patients was strongly associated with the severity of COVID-19. This study also highlights the need for assessing cardiovascular risk factors in all patients with COVID-19.

Psychological Impact of COVID-19 on Frontline Healthcare Workers in Saudi Arabia

This study assesses the determinants and severity of psychological distress among frontline Ministry of Health workers within Saudi Arabia during the rapid acceleration phase of the coronavirus disease 2019 (COVID-19) epidemic. Moreover, we assess distress sustainability and stress-coping behaviors. We conducted an online national cross-sectional survey. The Kessler Psychological Distress Scale (k10) is a highly reliable instrument used to assess depression and anxiety. We evaluated stress-coping behavior and the persistence of the disorders. Binary logistic regression identified the sociodemographic factors related to severe distress. The prevalence of severe psychological distress among COVID-19 frontline healthcare workers (HCWs) was 27.3%. Factors associated with severe psychological distress in multiple regression analyses were male gender (p < 0.001), working for >45 hours/week (p = 0.009), age of >40 years (p = 0.038), years of experience for more than seven years (p = 0.048), Asir region (p = 0.003), and using psychological services (p < 0.001). The prevalence of severe psychological distress was 27.3%. Factors associated with severe psychological distress in multiple regression analyses were male gender, working >45 hours/week, age, years of experience, region, and using psychological services. The results form a foundation for targeted psychological health support services at the individual and institutional levels to prevent progression to mental illness.

Alectinib continuation during COVID 19 'antiviral' treatment: Risk or benefit?

INTRODUCTION

Serious Acute Respiratory Syndrome Coronavirus 2 (SARSCoV2) has led to COVID 19 pandemic a year ago and it has not been globally taken under control yet. COVID 19 tends to have poorer prognosis in cancer patients. Additionally, we have no well-established guidelines for management of these patients during pandemic, in terms of treatment of 'cancer' and treatment of 'COVID 19'. Tyrosine kinase inhibitors (TKIs) are given without any break in cancer patients to have better survival outcomes in daily routine. However, there is no well-established data to continue or delay ALK inhibitors in lung cancer patients infected with SARS-CoV2. Concomittant use of ALK inhibitors and COVID 19 antiviral treatment is a dilemma because of the lack of data in this area.

CASE REPORT

A 47-year old female metastatic ALK positive nonsquamous cell lung cancer patient on alectinib, a second generation ALK inhibitor was diagnosed with symptomatic COVID 19. She was given favipiravir for COVID 19 while continuing alectinib.Management and outcome: The patient continued alectinib during COVID 19 antiviral treatment without any break. She tolerated 'concomittant' alectinib & favipiravir. She had partial remission after three months of alectinib without any dose adjustment despite active COVID 19 medication.

DISCUSSION

To best of our knowledge, this is the first case who continued alectinib without dose adjustment during antiviral COVID-19 medication without clinically worsening. There is limited data about 'concomittant' use of TKIs and antiviral COVID 19 medication in the literature. There are some case reports, but they generally tended to delay or suspend TKIs during COVID 19 antiviral medication. Our case differs from them in terms of continuation of alectinib without any break or additional side effects during favipiravir for symptomatic COVID 19. We consider that our case might contribute to the literature in terms of management of cancer patients on targeted therapy during COVID 19 antiviral treatment. However, clinical trials are needed in this area.

A Rare Case of SARS-CoV-2-Induced Microscopic Polyangiitis

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection triggers elevated levels of circulating cytokines and immune-cell hyperactivation, called a cytokine storm, which leads to dysregulated immune response not only towards the pathogen itself but also contributes to cellular, vascular injury and multiorgan dysfunction. The cytokine-induced endothelial inflammation and vascular pathology of COVID-19 is well reported in post-mortem biopsies and several cases reporting small, medium and large vessel micro/macro thrombotic events and vasculitis in multiple organs. So far, few cases have been reported with newly diagnosed antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis at the time of acute COVID-19 infection. The exact pathophysiology of SARS-CoV-2 and ANCA-associated vasculitis continues to be studied and reviewed. Here we report a case of a 60-year-old female who presented to our institution with sudden onset of shortness of breath and hemoptysis. A detailed history revealed a recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Labs showed elevated serum creatinine, urine analysis with large blood and nephrotic range proteinuria. CT chest was remarkable for abnormal appearance of the parenchyma bilaterally compatible with a crazy paving pattern, suggesting pulmonary alveolar proteinosis versus diffuse alveolar hemorrhage. Vasculitis was suspected and the patient was started on IV corticosteroids and plasmapheresis. Diagnostic workup was positive for antineutrophil cytoplasmic antibodies-myeloperoxidase (ANCA-MPO), anti-Sjögren's syndrome-related antigen A autoantibodies (anti-SS-A) and antinuclear antibodies (ANA). Renal biopsy confirmed focal segmental necrotizing, crescentic and sclerosing glomerulonephritis, pauci-immune type, anti-MPO antibody/P-ANCA associated. A diagnosis of microscopic polyangiitis was made and she was started on rituximab immunosuppressive therapy following which she showed clinical improvement. In this document, we present a unique case of microscopic polyangiitis possibly induced by SARS-CoV-2 infection confirmed by renal biopsy and clinical presentation. In the current setting of a global pandemic, we strongly recommend that vasculitis be high on the differential diagnosis in patients who are currently infected or had been infected with SARS-CoV-2 and present with acute kidney injury (AKI).

COVID-19 Virus Infection in Three Patients With Hypogammaglobulinemia

The world is experiencing the COVID-19 outbreak and there are no evidence-based treatment strategies available for immunocompromised patients. COVID-19 is a novel beta coronavirus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients with cancer are more susceptible to infection than individuals without cancer due to their impaired humoral and cellular immune function caused by the malignancy itself and chemotherapy. We present three cases of cancer patients with hypogammaglobulinemia with varying clinical outcomes associated with infection. These include one mantle cell lymphoma patient with recurrent respiratory infection requiring intravenous immunoglobulin (IVIG) support and two multiple myeloma patients with continued viral shedding.

Acute Multiple Cerebral Watershed Infarctions as the Initial Presentation of COVID-19 in a Young Male Patient: A Case Report

Cerebrovascular diseases appear to be one of the most serious complications of coronavirus disease 2019 (COVID-19). In this report, we present a case of a 38-year-old male with a past medical history significant only for hypertension, who presented to the emergency department (ED) with confusion and multiple focal neurologic deficits. Brain imaging showed acute multiple cerebral watershed infarctions. Upon further investigation and laboratory workup, the hypercoagulability and vasculitis panels were found to be negative, and other differential diagnoses were ruled out. In light of a number of emerging reports of COVID-19-related ischemic stroke, our patient was also screened for the disease, and surprisingly the test came back positive. We believe this case report will highlight the importance of conducting neurological examinations in COVID-19 patients, since timely workup and prompt interventions may reduce morbidity and mortality.

Cutaneous and Pulmonary Manifestations: COVID-19 Virus or Coccidioidomycosis?

COVID-19 viral pandemic continues to manifest itself in the form of various clinical symptoms. Due to concerns of COVID-19 in the setting of high rates of false-negative, there is increased likelihood of anchoring bias. We present a case of a 48-year-old white female who presented with two weeks of dry cough and diffuse pruritic nodular cutaneous rash. Patient was exposed to a colleague who tested positive for COVID 19. Initial visits were conducted virtually and workup was negative for COVID-19. Patient was offered supportive care; however, her symptoms continued to worsen. Subsequent workup was positive for left lower lobe nodular opacity on the chest X-ray, follow up CT chest showed demonstrated a focal 3.4 cm infiltrate in the left lower lobe pleural base posteriorly, blood workup was positive for eosinophil count, elevated liver enzymes and positive coccidioides antibody IgG and IgM. This case highlights the importance of avoiding anchoring bias when creating differential diagnoses and triaging patients.

Newly Diagnosed Idiopathic Thrombocytopenia Post COVID-19 Vaccine Administration

A few individuals are believed to have developed immune thrombocytopenia (ITP) following the administration of the coronavirus disease 2019 (COVID-19) vaccine. This phenomenon has been reported in a few case reports and also in some recent news articles. In this report, we discuss a case of a 54-year-old Caucasian female who presented to the emergency room with life-threatening thrombocytopenia in the setting of de novo ITP following COVID-19 vaccine administration. Due to the relapsing nature of ITP, it is unclear if the patient has achieved complete remission of the disease.

A Case of Postural Orthostatic Tachycardia Syndrome Secondary to the Messenger RNA COVID-19 Vaccine

Postural orthostatic tachycardia syndrome (POTS) is an impaction of the autonomic nervous system initiating orthostatic tachycardia. There are numerous triggers for POTS including viruses, vaccines, and an autoimmune basis. This case report is clinically relevant to better understand the pathophysiology behind the messenger RNA (mRNA) coronavirus disease 2019 (COVID-19) vaccine and the mechanism that triggers autonomic nervous system dysfunction. Furthermore, the overall goal of this case study is to report a unique side effect associated with the novel mRNA COVID-19 vaccine. A 42-year-old male, with no prior symptoms of sinus tachycardia and presyncope episodes, is diagnosed with POTS secondary to the first dose of the mRNA COVID-19 vaccine. Symptoms to this date include sinus tachycardia, dizziness, headaches, and fatigue that are often triggered after a large meal or standing for a longer duration. Numerous diagnostic tests and images failed to confirm any other diagnosis other than POTS. There was a sequential connection between the onset of symptoms approximately one week after taking the first dose of the mRNA COVID-19 vaccine. Currently, POTS in this patient is controlled by lifestyle modification. This case report has broader implications as it can help us understand how the mRNA vaccine works on the body relative to the immune system. Our theory is that the development of antibodies activates an autoimmune reaction that triggers POTS disease. The prevalence of the POTS dysautonomia post-vaccination will be clearer as more data and research are conducted on the side effects from the innovative mRNA vaccines created to combat severe acute respiratory syndrome coronavirus 2.

Effect of COVID-19-Associated Lockdown on Patients With Diabetic Retinopathy

Purpose To evaluate the effect of the coronavirus disease 2019 (COVID-19)-related lockdown in the management of patients with diabetic retinopathy (DR), including diabetic macular edema (DME), in a tertiary reference center in Greece. Methods In this retrospective study, we first compared the number of patients who were diagnosed with DR or DME in our clinic during the period of the lockdown and during the same period of the previous year. In addition, we included consecutive patients with DR or DME, who were followed up and treated regularly in our clinic and their appointments deferred due to lockdown, so as to compare the visual acuity, fundoscopy, and optical coherence tomography (OCT) findings prior to and post lockdown. Results During the lockdown period, there was a statistically significant decrease in patients with DR and DME as compared to the same period in the previous year. Regarding patients with previously diagnosed DME, there was a statistically significant worsening in their visual acuity and central retinal thickness after lockdown as compared to the last visit before lockdown (p<0.001 for both comparisons). Concerning patients diagnosed with DR and without DME before lockdown, 30% of patients with severe non-proliferative diabetic retinopathy (NDPR) and 8.3% of patients with quiescent proliferative DR (PDR) progressed to active PDR while four out of 107 patients (3.7%) developed DME during the lockdown. Multivariate regression analysis revealed that only the time interval between the last visit before lockdown and the first visit after the lockdown was associated with the best-corrected visual acuity (BCVA) change (p=0.017). Conclusions The COVID-19-related lockdown was related to the postponement in patient care, which resulted in significantly worse visual acuity outcomes in patients with DR.

Effects of COVID-19 pandemic curfew on orthopedic trauma in a tertiary care hospital in Turkey

OBJECTIVE

This study aimed to investigate whether various curfew practices affect trauma prevalence, epidemiological differences among the population admitted to hospital because of trauma, and treatment practices used after trauma.

METHODS

Patients who suffered from fractures or soft-tissue trauma between March 21, 2020, and June 1, 2020, (group pandemic) and during the same period in 2019 (control group) were included in our single-center retrospective study. Each group was also divided into 3 subgroups according to the age of patients (≤ 20 years, 21-64 years, and ≥ 65 years). Data including anatomical region subjected to trauma, place of admission, mechanism of trauma, location of trauma, mode of treatment, type of surgery (if performed), duration of hospitalization (if hospitalized), time elapsed until surgery, and duration of postoperative hospitalization were collected and compared between groups.

RESULTS

A total of 361 patients were admitted to the hospital with new trauma during the pandemic, and 708 patients had been admitted during the same period in 2019. The number of admissions decreased significantly by 50.9% (P < 0.001). The mechanism of trauma that occurred with low energy was significantly increased in the pandemic group (73.9%) compared with the control group (47.6%) (P < 0.001). Similarly, the distribution of trauma throughout the skeletal system, especially in the upper extremity, was significantly increased in the pandemic group (49.9% vs. 30.5%, P < 0.001). However, there was no significant decrease in individuals aged above 65 years (P = 0.115). Similar to the general outlook, the 3 groups differed in terms of the mechanism of trauma, location of trauma, and distribution of the anatomical region subjected to trauma (P < 0.001). Majority of the patients received inpatient treatment in all 3 groups (P < 0.001).

CONCLUSION

The results of this study showed that the pandemic dramatically reduced the number of hospital admissions related to orthopedic trauma. The rate of low energy, upper extremity traumas that occurred indoors increased during the pandemic period compared with that of the previous year. However, the rate of hospital admissions did not differ in the ≥65-year-old subgroup during the pandemic period compared with that of the previous year.

A Young COVID-19-Positive Male Patient Presented With Bilateral Pulmonary Emboli and Multiple Strokes

COVID-19 has been repeatedly related to a variety of extra-pulmonary manifestations since its emergence. COVID-19-positive patients have been shown to develop neurological deficits, deep venous thrombosis, acute kidney injury, acute hepatic injury, and myocarditis, among other conditions. The mechanism of some of these injuries remains unclear, but one factor that has been revealed is hypercoagulability. A hypercoagulable state, whether secondary to dysfunctional coagulation cascades or microvascular angiopathy, has been reported in the literature in COVID-19 patients. We present a case of a patient diagnosed with COVID-19 presented with venous thromboembolism and then shortly developed innumerable strokes.

Stressor Combat Strategies and Motivating Factors Among Health Care Service Providers During COVID-19 Pandemic

Context Since its inception in December 2019 in Wuhan, China, the severe acute respiratory syndrome coronavirus-2, the etiological agent for coronavirus disease 2019 (COVID-19), is spreading rapidly both locally and internationally, and became certified as a pandemic by the World Health Organization (WHO) in March 2020. Working in an environment of high risk, coupled with adherence to quarantine and stressors related to the job, has been found to exacerbate the psychological health of frontline healthcare workers. Aims To assess the perceived stressors, combat strategies, and motivating factors among health care service providers during the COVID-19 pandemic. Setting and design A cross-sectional study was conducted among healthcare workers at a tertiary care hospital in the north-central region of India from May to September 2020. Methods and materials A convenience sample of 150 health care workers was taken. A self-reported pretested structured "COVID 19 staff questionnaire" was used as a study tool. The health care workers (HCWs) included nurses, physicians, laboratory technicians, and radiology technicians who worked in high-risk areas (isolation ward, COVID intensive care unit, emergency department, and outpatient cough outdoor walk-in clinics) during the outbreak constituted our study population.  Statistical analysis used The varying levels of stress or effectiveness of measures were reported as mean and standard deviation, as appropriate. Descriptive statistics were used for data presentation. A Mann-Whitney U test was used to analyse differences between two groups of non-normally distributed data. A p-value of less than 0.05 was considered statistically significant. Results As compared to doctors, paramedical staffs were more stressed with frequent protocol changes (88%), emotional exhaustion (68%), and conflicts with duties (62.7%). The factors like seeing colleague getting better (78.7%) and hoping for financial compensation (49.3%) were reported as stress busters; family compensation in case of death at the workplace and disability benefits in case of disease-related disability development were more effective motivational factors for paramedical staff in case of future outbreaks (p-value <0.05). Conclusions It is needful that secondarily traumatized team members should be always observed, educated, and properly handled. Certain personal coping strategies adopted by health workers should be well addressed and motivated if scientifically sustainable. We have to include psychiatric preparedness and stress monitoring also for health care teams along with emphasizing hygiene, temperature monitoring, and fever management, in planning to fight the pandemic.

Failure of Major Upper Extremity Replantation Due to COVID-19-Related Arterial Thrombosis

Coronavirus disease of 2019 (COVID-19), caused by the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that emerged in Wuhan, was declared a pandemic by the World Health Organization. COVID-19 has many different clinical manifestations. One of them is arterial hypercoagulopathy. Although its mechanism is not fully explained, acute thrombosis and thromboembolism can be seen in patients. In this study, we present a case who was amputated due to the development of arterial thrombosis on the 10th day following infection with coronavirus, despite successful replantation after traumatic above-elbow amputation. After replantation on the seventh day, it was learned that the patient’s husband was positive for COVID-19 and had come to visit the patient. For this reason, we performed reverse transcription polymerase chain reaction (RT-PCR) to confirm the patient’s COVID-19 status. We found that the patient, who was asymptomatic, was positive by RT-PCR for COVID-19. On the 10th day after the operation, it was observed that the blood circulation of the replanted extremity was impaired, although it had been perfect until that day. Emergency embolectomy and vascular reanastomosis were planned for the patient. Although we generally observe thrombosis at an end-to-end anastomosis site, massive axillary arterial thrombosis was detected at the proximal end of the vascular anastomosis. Upon development of tachycardia, hypotension, and metabolic acidosis after embolectomy and vascular reanastomosis, the decision was made to amputate the replanted limb to reduce the risk of life-threatening complications. To our knowledge, this is the first such COVID-19-related complication on upper extremity replantation in the literature.

COVID-19-Induced Bile Duct Casts and Cholangitis: A Case Report

Coronavirus disease 2019 (COVID-19) infection can lead to various complications involving all of the major organ systems. Gastrointestinal manifestations such as nausea, vomiting, and diarrhea are commonly associated with this condition. Biliary complications from COVID-19 constitute an area of active research. In this report, we present a case of secondary sclerosing cholangitis in a critically ill patient (SSC-CIP) associated with COVID-19. A 57-year-old male with a past medical history of hypertension and diabetes presented to the hospital with signs of sepsis. He had abdominal pain, fever, and elevated liver enzymes without an elevated lipase. Abdominal ultrasound and CT scan showed a dilated common bile duct (CBD) with a distal CBD stone. He had experienced a prolonged course of severe critical illness related to COVID-19 prior to this episode, with respiratory failure requiring mechanical ventilation, thromboembolic complications, and he had also required tracheostomy and gastrostomy tube. The patient was diagnosed with cholangitis and was appropriately treated with antibiotics and fluid resuscitation. An endoscopic retrograde cholangiopancreatography (ERCP) was performed. During ERCP, the biliary cast was removed and a bile duct stent was placed. After the procedure, he showed significant improvement and was discharged on an appropriate course of antibiotics. Outpatient ERCP was eventually done to remove the stent and further bile duct casts were removed. The patient was referred for outpatient cholecystectomy.

Critical illness due to COVID-19 can result in SSC-CIP. This can be further complicated by bile duct casts, liver fibrosis, and cirrhosis.

Secondary Immune Thrombocytopenic Purpura Triggered by COVID-19

Multiple infectious causes have been implicated with the development of secondary immune thrombocytopenic purpura (ITP). Nevertheless, new pathogens, including coronavirus disease 2019 (COVID-19), are recently being described in its development. A 41-year-old Hispanic male presented to the Emergency Department with a two-day history of bleeding gums and blood-tinged sputum. A severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) test was positive on admission. Initial laboratory studies showed severe thrombocytopenia of 3x10⁹/L (150-400x10⁹/L) with no abnormal platelets or schistocytes seen on peripheral blood smear, with normal prothrombin time/international normalized ratio (PT/INR), partial thromboplastin time (PTT) and fibrinogen levels. Secondary causes of thrombocytopenia were ruled out. One unit of single donor platelets was transfused and the patient was treated with intravenous dexamethasone for a total of five days and intravenous immunoglobulin (IVIG) for two days. One week after discharge the patient had a recurrence of epistaxis and hematuria requiring a second course of steroids and IVIG and the decision was made to start the patient on eltrombopag 50mg daily, which maintained his platelet counts within normal limits. COVID-19-associated ITP can be severe and life-threatening and hence warrants rapid and prompt management with steroids and IVIG. In refractory cases, thrombopoietin receptor agonists should be used.

Gastrointestinal Symptoms in Association With Hypokalemia Can Be a Predictor of Inferior Outcomes in COVID-19

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus disease-2 (SARS-C0V-2), has affected many lives globally. In Singapore, majority of the infected individuals are foreign workers residing in dormitories. A retrospective review conducted over two weeks (April 13 to April 26, 2020) of migrant workers admitted to a public hospital in Singapore revealed that a significant number of them developed hypokalemia. The purpose of this study was to examine any association that might exist between COVID-19 and hypokalemia. Fifty patients in this study had hypokalemia, translating to a prevalence of 28.4% (95% CI: 21.9-35.7). Gastrointestinal (GI) loss was a significant cause of hypokalemia with a prevalence of GI symptoms in the study group (diarrhea, vomiting, poor oral intake) of 5.7% (95% CI: 2.8-10.2). Clinicians should consider screening for hypokalemia in COVID-19 patients and initiate potassium replacement to mitigate any potential arrhythmias.

Myeloma Cast Nephropathy and COVID-19: A Case Report of Multiple Myeloma Presenting as Acute Kidney Injury in the Setting of COVID-19

A 64-year-old African American male presented to the emergency department with subacute low back pain for two weeks and decreased urine output. He was found to have a potassium level of 9.2 mmol/L and was uremic with a creatinine level of 28.5 mg/dL and blood urea nitrogen (BUN) level of 201 mg/dL. He also tested positive for COVID-19. He was then started on continuous renal replacement therapy (CRRT). His urinalysis showed more than 500 mg/dL of protein. A workup for multiple myeloma was also conducted, and urine protein electrophoresis test was positive for free lambda light chains with a level of 17,700 mg/L and free kappa light chains with a level of 88.30 mg/L with a kappa:lambda free light chain ratio of 0.005. Additionally, serum Bence Jones protein level was elevated at 240 mg/dL, and serum beta-2 microglobulin level was elevated at 31.41 mg/L. An immunoglobulin (Ig) panel also showed low levels of IgG, IgA, and IgM. Kidney biopsy for this patient showed definite cast nephropathy and minimal chronic changes, with only one of over 20 glomeruli sclerosed and minimal interstitial deposits. The patient was started on chemotherapy with cyclophosphamide, bortezomib, and dexamethasone (CyBorD).

BCG Scar Local Skin Inflammation as a Novel Reaction Following mRNA COVID-19 Vaccines in Two International Healthcare Workers

Bacillus Calmette-Guérin (BCG) local scar inflammatory reactions have been mostly associated with Kawasaki disease in children and less commonly with other viral infections (i.e., measles). BCG scar inflammation associated with or following vaccine administration has only been reported with the influenza vaccine. We describe the first reports in the literature of local BCG inflammation following two different available messenger ribonucleic acid (mRNA) anti-severe acute respiratory syndrome coronavirus 2 (anti-SARS-CoV-2) vaccines (mRNA-1273, and BNT162b2) in two young healthy physicians, one from Costa Rica, and another from the United States of America, with normal cell blood counts, flow cytometries, and negative for human immunodeficiency virus (HIV). In both cases, BCG scar inflammation appeared after 24 hours of vaccination of the second dose, without signs of reaction on the injection site, and resolved within four days. Dermoscopic findings in one case showed arborizing and comma-shaped vessels. Pharmacovigilance surveillance of BCG scar reactions following coronavirus disease 2019 (COVID-19) vaccines should be considered particularly in countries where BCG is part of their national immunization programs.

The Role of Computed Tomography and Real-Time Polymerase Chain Reaction in the Diagnosis and Prognostication of COVID-19

With the rapid spread of coronavirus disease 2019 (COVID-19) starting in early 2020, there has been much interest in the applicability of radiologic imaging in managing affected patients. From the initial screening to addressing the extent of pulmonary involvement, CT scans provide great value to hospitals overwhelmed by an influx of patients, including those with suspected COVID-19. Because CTs come at a high financial cost, lower cost real-time polymerase chain reaction (RT-PCR) COVID-19 tests are critical due to their ability to identify asymptomatic carriers and properly handle patients during the ongoing pandemic. However, unlike RT-PCR, CT scans can also provide insight into the progression of the virus. The signs of acute COVID-19 infection include unique patterns of ground-glass opacities (GGO) with vascular thickening, enabling radiologists to diagnose COVID-19 with a high specificity. Additionally, there may be a significant value in the use of CT scans in predicting the outcomes.

Noteworthy Neurological Manifestations Associated With COVID-19 Infection

March 11, 2020 marked the start of the coronavirus disease 2019 (COVID-19) pandemic. COVID-19, caused by severe acute respiratory syndrome coronavirus 2, was being reported as a severe respiratory illness. However, since the recognition of this novel virus, there has been a constant realization that it may present or manifest in a multitude of ways. At first, the typical signs and symptoms were what one would expect from a respiratory virus: cough, shortness of breath, and fever. However, as the disease became more prevalent, neurologic symptoms were reported such as headaches, hypogeusia, and hyposmia. This case report aims to add to the growing body of neurologic manifestations by presenting two cases, Bell’s palsy and Guillain-Barre syndrome. Each case involves flaccid paralysis as the primary presentation.

Telephone Fracture Clinic Consultations: A Satisfactory Solution in Lockdown

Introduction The COVID-19 pandemic was a catalyst to many learning opportunities within clinical practice in the UK. Attempts were made to reduce footfall within all institutions and within the study unit; this led to alterations in fracture clinic provision. An alternative method was developed whereby most of the initial contacts were in person and much of the follow-up was done remotely. The aim of this study was to evaluate patient satisfaction and views on this alteration in service. Methods The first 299 patients who had fracture clinic appointments delivered by telephone consultation at this institution during the pandemic in early 2020 were retrospectively identified and sent a postal survey. Satisfaction levels were assessed through a degree of agreement with statements (nine items), yes/no answers (four questions), and space for comments. Results One hundred and thirty-one survey responses were included (44% response rate). The majority of patients (82%) were satisfied overall with the care they received. Although 78% of patients stated that they preferred a telephone consultation to attend a face-to-face hospital appointment during the pandemic, only 22% stated they would have preferred this in normal (pre-COVID-19) times. Interestingly 62% of patients stated they would be happy for further fracture clinic appointments to be carried out in the same way. Discussion Most of the remote consultations were in follow-up rather than new patients. Patients were adaptable to this alternative method of care delivery. There could be a role for its integration into the options for fracture clinic delivery in the future.

Planning for the Pandemic: A Community Hospital Story

When the Covid 19 pandemic affected New York State, Federal and mostly State, mandates were given to hospitals to prepare for the expected influx of patients. This is a community hospital's planning journey that includes preparing for placing patients, educating caregivers, matching the abilities of the available caregivers with the needs of the patients, securing needed equipment and supplies, and caring for the caregivers. Planning for patient placement resulted in a phased-in guide, accommodating seriously and critically ill affected patients. Education and training were initial and ongoing, rapidly changing as new information became available. Effective care delivery models that focused on team were modified depending on the needs of patients and staff competence. Securing and maintaining equipment and supplies were challenging and caring for the caregivers was a priority. Working as a team, this community hospital developed a road map that was effective in planning for the surge and allowed the hospital to maintain a safe environment for staff and patients who received quality care in difficult time.

COVID-19 and Diabetic Ketoacidosis: Report of Eight Cases

Aim To describe the clinical characteristics and outcome of hospitalized COVID-19 patients with diabetic ketoacidosis (DKA). Methods We report eight cases of diabetic ketoacidosis in COVID-19 who presented to our institution in New Jersey, USA. COVID-19 was diagnosed by nasopharyngeal swab reverse transcription polymerase chain reaction (RT-PCR). The patients' electronic medical records were reviewed. Data on patients' age, sex, ethnicity, laboratory values, glycosylated hemoglobin level, oral antihyperglycemic agents (OHAs), insulin, and clinical outcomes were collected. Results The median age of the patient was 42.5 years, and seven were males and one was female. Out of eight patients, five had type 2 diabetes mellitus (DM), two had undiagnosed DM, and one had type 1 DM. Median value of initial glucose on presentation was 454 mg/dL. Median value of HbA1c on presentation was 11.4% and of anion gap was 26.5 mEq/L. Four patients had large ketonemia, one patient had moderate ketonemia, and three patients had small ketonemia. All the patients were started on standard treatment protocol for DKA with intravenous fluids and IV insulin infusion. Acute kidney injury (AKI) was seen in four patients, and one patient required renal replacement therapy. Out of eight patients, three required mechanical ventilation, and the same three patients died. Conclusion Our case series shows that COVID-19 infection can precipitate DKA in patients with known diabetes mellitus patients or as a first manifestation in undiagnosed DM patients; COVID-19 with DKA is associated with substantial mortality. Further studies are needed to characterize poor risk factors associated with mortality in these patients.

Intracerebral Haemorrhage in an Adolescent With COVID-19 With Acute Kidney Injury: Is the Virus to Blame?

Neurological manifestations in COVID-19 are well described. We describe a 15-year-old girl with acute focal deficit with altered sensorium due to massive right intracerebral hemorrhage following a hypertensive emergency and acute on chronic kidney disease. She was found to be COVID positive by reverse transcription-polymerase chain reaction (RT-PCR). She gradually improved although her neurological deficit in the form of left hemiparesis persisted at discharge. There might be a possible association between intracerebral hemorrhage and COVID-19, although the causation is still not well established.

Purpuric Rash and Thrombocytopenia After the mRNA-1273 (Moderna) COVID-19 Vaccine

The mRNA-1273 vaccine, popularly called the "Moderna vaccine" is being widely administered in the United States for the prevention of COVID-19 infection since December 2020. Mild to moderate intensity side effects like low-grade fever, myalgia, chills and malaise were reported in the trials related to the vaccine. With this case report, we report a case of purpuric rash and thrombocytopenia after receiving the first dose of the m-RNA-1273 vaccine. The patient, in this case, is a 60-year-old male patient who received the first vaccine dose and within two days, he developed diffuse papular rash associated with some thrombocytopenia. He had a history of tobacco use, Hepatitis C liver cirrhosis, chronic kidney disease stage 4, untreated hypertension and systolic congestive heart failure at the baseline. With review of the limited literature related to the vaccine and its side effect profile and with no other etiology explaining the sudden onset of rash, we attribute this thrombocytopenia and purpuric rash as the side effects of the mRNA-1273 vaccine.

Cardiac Troponin I Levels in Hospitalized COVID-19 Patients as a Predictor of Severity and Outcome: A Retrospective Cohort Study

Introduction

The COVID-19 (coronavirus disease) has affected millions of people, wreaking havoc worldwide. World Health Organization (WHO) labelled this disease as a serious threat to public health since its rapid spread from Wuhan, China. The respiratory manifestations of COVID-19 are common, but myocardium involvement causing myocardial injury and rise in cardiac markers is much less discussed.

Materials and methods

We conducted this retrospective cohort study from 1st April 2020 to 1st October 2020. Data was collected from the Hospital Management and Information System (HMIS) based on inclusion criteria. We used the Cox proportional hazard regression model for survival analysis, estimated the probability curves of survival using the Kaplan-Meier method, and contrasted it with the log-rank test.

Results

Among the 466 patients, 280 (69%) were male; the rest were female. The majority were both hypertensive and diabetic, and one-third had a myocardial injury on arrival. The most frequent symptoms in more than half of the patients (51.90%) included a combination of fever, dry cough, and shortness of breath. Out of 466 patients, 266 patients were discharged, and 200 did not survive. In our study, 168 (36.05%) patients had a cardiac injury; among them, 38 (22.61%) were in the discharge group, and the remaining 130 (77.39%) patients were in the nonsurvivor group. Our study results showed that the mortality rate was higher in patients with high cardiac troponin I (cTnI) levels (hazard ratio [HR] 3.61) on admission.

Conclusion

Our result concluded that measuring cTnI levels on presentation could help predict the severity and outcome in COVID-19 patients. It will allow physicians to triage patients and decrease mortality.

A Retrospective Review of Outcomes in Intensive Care Unit Patients Infected With SARS-Cov2 in Correlation to Admission Acute Physiologic Assessment and Chronic Health Evaluation II Scores

Introduction

Coronavirus disease 2019 (COVID-19) has emerged as a global pandemic that has placed an unprecedented burden on intensive care services worldwide. Identification of a reliable risk-stratification tool for COVID-19 patients is necessary for appropriate resource allocation, selection of clinical management pathways, and guidance of goals of care conversations with families and caregivers in the critical care setting. The Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scoring system is one of several predictive models used to classify illness severity and estimate mortality risk on admission to the intensive care unit (ICU). Our retrospective study sought to evaluate the prognostic ability of the APACHE II score in COVID-19 patients according to endpoints of mortality and length of stay (LOS) as well as unfavorable clinical outcomes, including development of acute renal failure (ARF) requiring renal replacement therapy (RRT) and acute venous thromboembolic events (VTE).

Methods

This multicenter retrospective cohort study evaluated a randomized sample of 3,102 patients with confirmed COVID-19 disease admitted to the ICU from January 2020 to May 2020. A total of 395 patients with complete data points for appropriate APACHE II score calculation, absence of the preexisting comorbidities end-stage renal disease, and history of VTE were included. Linear and logistic regression models were employed to evaluate primary outcomes of mortality and LOS as well as secondary outcomes of VTE and ARF requiring continuous renal replacement therapy (CRRT) or hemodialysis (HD).

Key results

Among the 395 patients enrolled, total percent mortality and mean LOS were 37.0% and 12.92 days, respectively. Primary outcome analysis revealed a statistically significant increase in odds of mortality as well as in mean LOS with every additional point increase in APACHE II score from a baseline of zero. Specifically, for every point increase in the APACHE II score, odds of mortality increased by 12% (p value < 0.001), and average LOS increased by 0.2 days (p value < 0.001). In our secondary outcome analysis, 14.43% and 62.2% of the total sample population developed ARF requiring RRT and VTE, respectively. For every additional point increase in APACHE II score from a baseline of zero, odds of requiring CRRT or HD increased by 10% on average (95% CI (1.06, 1.15); p value < 0.001). Similarly, for every additional point increase in the APACHE II score from a baseline of zero, there was a corresponding increase in odds of VTE by 19% (95% CI (1.14, 1.24); p value < 0.001).

Conclusions

The APACHE II score is an effective predictive model of in-hospital mortality and unfavorable clinical outcomes, including prolonged LOS, ARF requiring CRRT or HD, and development of VTE. As therapeutic interventions for COVID-19 evolve, application of this risk-stratification tool may guide clinical management decisions in the critical care setting.

An Unusual Case of Gastrointestinal Bleeding in a Patient With COVID-19

Coronavirus disease 2019 (COVID-19) is predominantly a respiratory disease that often presents with fever, cough, dyspnea, and myalgia or fatigue. Digestive symptoms such as nausea, vomiting, diarrhea, and abdominal pain may accompany respiratory symptoms. However, gastrointestinal (GI) bleeding among COVID-19 patients is a rare and unusual presentation, since these patients are frequently hypercoagulable and are less likely to bleed and more likely to clot. In this report, we present a case of an 80-year-old male with a history of type 2 diabetes mellitus, hypertension, and obesity who presented with GI bleed and was subsequently found to have COVID-19.

A Case of Moderately Severe COVID-19 in a Healthcare Worker in Russia: Virus Isolation and Full Genome Sequencing

The coronavirus disease 2019 (COVID-19) pandemic is probably the most studied one in history from both clinical and molecular-epidemiological perspectives. Nonetheless, data on the correlation between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral genotypes and COVID-19 symptoms caused by them are still scarce. In this report, we present a moderately severe COVID-19 case in a healthcare worker in Moscow, Russia, supplemented with the data on its causative agent's phenotype regarding in vitro and full-genome characterization. The 44-year-old male healthcare worker who had frequent professional contacts with COVID-19 patients was hospitalized with a viral pneumonia diagnosis and soon started to exhibit fever, dry paroxysmal cough, loss of smell, and typical ground-glass opacities found in both lungs on chest CT scans. The COVID-19 diagnosis was verified by real-time quantitative polymerase chain reaction (qRT-PCR), immunochromatography, and immunochemiluminescent assays. The patient was treated with hydroxychloroquine, azithromycin, paracetamol, and enoxaparin, leading to his recovery after two weeks from the disease onset. The virus was successfully isolated from the nasopharyngeal swab sample taken on the fifth day of the disease onset using the Vero E6 cell line and exhibited a pronounced cytopathic effect (CPE) with a viral titer reaching 10⁶ TCID₅₀/ml in the cell culture medium. The full genome sequence of the viral isolate was obtained and 8 nucleotide and 5 amino acid mutations compared to the Wuhan-Hu-1 reference genome were identified. Viral isolate belonged to GR / 20B / B.1.1 genetic lineage (GISAID, Nextstrain, Pangolin nomenclatures, respectively) - the most prevalent genotype found in Russia to date.

The Rapid Development and Early Success of Covid 19 Vaccines Have Raised Hopes for Accelerating the Cancer Treatment Mechanism

The Covid-19 pandemic has brought about rapid change in medical science. The production of new generation vaccines for this disease has surprised even their most optimistic supporters. Not only have these vaccines proven to be effective, but the importance of this disease and pandemic situation also significantly shortened the long-standing process of validating such products. Vaccination is a type of immunotherapy. Researchers have long been looking at vaccines as a possible treatment for cancer (Geynisman et al., 2014). In the same way that vaccines work against infectious diseases, attempts are being made to develop vaccines to identify specific proteins on cancer cells. This helps the immune system recognize and attack cancer cells. Cancer vaccines may help: I) Prevent the growth of cancer cells (Bialkowski et al., 2016), II) Prevent recurrence of cancer (Stanton and Disis, 2015), III) Destroy cancer cells left over from other treatments. The following types of cancer vaccines are being studied: Antigen Vaccines. These vaccines are made from specific proteins or antigens of cancerous cells. Their purpose is to stimulate the immune system to attack cancer cells (Tagliamonte et al., 2014). Whole-Cell Vaccines. A whole-cell vaccine uses the entire cancer cell, not just a specific molecule (antigen), to generate the vaccine. (Keenan and Jaffee, 2012).Dendritic Cell Vaccines. Dendritic cells help the immune system identify abnormal cells, such as cancerous cells. Dendritic cells are grown with cancer cells in the laboratory to produce the vaccine. The vaccine then stimulates the immune system to attack cancer. (Wang et al., 2014; Mastelic-Gavillet et al., 2019). DNA Vaccines. These vaccines are made from DNA fragments of cancer cells. They can be injected into the body to facilitate immune system cells can better respond and kill cancer cells (Gatti-Mays et al., 2017).Other Types of Cancer Vaccines. such as Anti idiotype vaccines. This vaccine stimulates the body to generate antibodies against cancerous cells. An example of an anti-idiotype antibody is Racotumomab or Vaxira (Cancer, 2016). However, conditions and considerations after Corona does not seem to be the same as before. The current pandemic situation has also led to major changes in the pharmaceutical and Vaccine production process and international protocols. Some of the most critical issues that can accelerate the introduction of cancer vaccines are: 1. Typical drug and vaccine development timeline. A typical vaccine needs 5 to 10 years and sometimes longer to design secure funding, and get approval (Figure 1). Less than 10 percent of new drugs, which are entered in the different phases of clinical trials, are advanced to approval by the Food and Drug Administration (FDA)(Cancer, 2020a). However, now the situation is not normal. Dozens of Covid 19 vaccines are starting clinical trials. Some of them use RNA and DNA technology, which delivers the body with missions to produce its antibodies against the virus. There are already at least 254 therapies and 95 vaccines related to Covid-19 being explored. However, it seems that the experiences gained in this pandemic, and advances in technology, may be effective in shortening the production path of other vaccines and drugs and the process of its approval at the national and international levels in the future. In Figure 2, the time course of production of conventional vaccines in comparison with Covid 19 vaccines (Cancer, 2020b) is shown.2. The introduction of messenger RNA (mRNA) technology into the field of prevention and treatment. Over the past decades, this technology has been considered an excellent alternative to conventional vaccination methods. Proper potency and low side effects, the possibility of fast production and relatively low production cost are its advantages. However, until recently, the instability of this molecule has been a major problem in its application. This research was started many years ago by two companies that played a significant role in developing the first Covid vaccines, so BioNTech and Moderna were able to quickly transfer their experience in the field of Covid vaccine development (Pardi et al., 2018; Moderna, 2020). Figure 3 shows how mRNA vaccines work. Bout Pfizer &ndash; BioNTech and Moderna mRNA vaccines were more than 90 % effective in preclinical stages. Millions of doses of these two vaccines are currently being injected into eligible individuals worldwide. 3. Considering the use of artificial intelligence in assessing the effectiveness of vaccines. There are always doubts about the effectiveness of the new drug in treating the disease. Once the vaccine is widely available, we will know more about its effectiveness versus it works under carefully controlled scientific testing conditions. Vaccines will continue to be monitored after use. The data collected helps professionals understand how they work in different groups of people (depending on factors such as age, ethnicity, and people with different health conditions) and also the length of protection provided by the vaccine. Artificial intelligence (AI) is an emerging field, which reaches everywhere and not only as a beneficial industrial tool but also as a practical tool in medical science and plays a crucial role in developing the computation vision, risk assessment, diagnostic, prognostic, etc. models in the field of medicine (Amisha et al., 2019). According to the wide range of AI applications in the analysis of different types of data, it can be used in vaccine production, safety assessments, clinical and preclinical studies and Covid 19 vaccines adverse reactions (CDC, 2019). Indeed, most cancer vaccines are therapeutic, rather than prophylactic, and seek to stimulate cell-mediated responses, such as those from CTLs, capable of clearing or reducing tumor burden. There are currently FDA-approved products for helping cancer treatment such as BREYANZI, TECARTUS and YESCARTA for lymphoma, IMLYGIC for melanoma, KYMRIAH for acute lymphoblastic leukemia, and PROVENGE for prostate cancer. Over the past decade, most of BioNTech&#39;s activities have been in the field of cancer vaccine design and production for melanoma (two clinical trials), breast cancer (one clinical trial), and the rest concerning viral and veterinary vaccines (two clinical trials). Also Maderno company has been working on Individualized cancer vaccines (one clinical trials), and vaccines for viral infections such as Zika and Influenza and veterinary vaccines (several clinical trials) (Pardi et al., 2018). Therefore, it can be said, mRNA technology that has been the subject of much research into the treatment of cancer has been shifted and rapidly used to produce and use the Covid 19 vaccine. The current pandemic situation has necessitated the acceleration of Covid 19 vaccines and drugs and national and international protocols for their approval. If the currently produced vaccines can continue to be as successful as the preclinical and early phase studies, these changes and evolution have raised hopes for accelerating the use of these technologies and mechanisms in the field of cancer and other diseases vaccines, including HIV and influenza.

Immune Thrombocytopenic Purpura in a Patient With SARS-CoV-2 and Epstein-Barr Virus

A 35-year-old female was admitted to the hospital for menorrhagia and fatigue. Initial labs revealed that the patient had severe thrombocytopenia and also tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The main objective in this case is to describe the investigation that eventually led to a diagnosis of idiopathic thrombocytopenic purpura (ITP) in the setting of a SARS-CoV-2 coronavirus disease 2019 (COVID-19) infection and co-infection with Epstein-Barr virus (EBV). The majority of ITP cases are idiopathic and most are diagnosed and managed without hospital admission. Admission and careful management were warranted in this particular case.

Interestingly, however, the patient did not have any respiratory complications associated with COVID-19. She was given 1 unit of platelets and subsequently received intravenous corticosteroids. Platelet counts improved and the patient was discharged with a course of oral prednisone. This case highlights the importance of understanding the differences between primary and secondary ITP. 

Neuroleptic Malignant Syndrome After Re-introduction of Atypical Antipsychotics in a COVID-19 Patient

We present a case of neuroleptic malignant syndrome (NMS) in a 46-year-old white female from a state psychiatric hospital who also tested positive for coronavirus-2019 (COVID-19) (severe acute respiratory syndrome coronavirus, SARS-CoV-2) infection after re-introduction of her home antipsychotics medication. She presented with confusion and altered mental status likely secondary to delirium from COVID-19 infection. Clozapine and risperidone were initially held on admission and restarted after continuing agitation on day two. She began to have increased restlessness with rising creatinine kinase (CK) levels, peaking on day seven with sudden fever, hypertension, and tachycardia. The diagnosis of NMS was confirmed, antipsychotic medication was held, and appropriate treatment was administered. The mechanism explaining the occurrence of NMS in COVID-19 patients is still unclear, but COVID-19 infection may be a risk factor for this presentation. The mechanism of SARS-CoV-2 as a risk factor for NMS is still uncertain and needs to be investigated further. However, if their infection status is known, patients should be given neuroleptics with caution and carefully considered for the development of this rare condition.

Colonic Ileus, Distension, and Ischemia Due to COVID-19-Related Colitis: A Case Report and Literature Review

Coronavirus disease 2019 (COVID-19) predominantly presents with respiratory symptoms, however, the involvement of the gastrointestinal system has also been reported. Isolated gastrointestinal manifestation due to COVID-19 presenting as colonic distension is uncommon. Colonic ileus from COVID-19 infection presents as dilatation on imaging, with the risk of subsequent ischemia and perforation if not recognized and treated promptly. There is no consensus on the treatment modality for COVID-19-related colitis, however, COVID-19-targeted medications in conjunction with surgical intervention have been performed for management. We present a case of a 73-year-old man who presented with abdominal pain, distention, and diarrhea. He tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and was found to have marked dilatation of the colon on imaging. He was initially given convalescent plasma to reduce inflammatory markers, as tocilizumab was contraindicated due to suspected bowel obstruction. Once more stable, he underwent surgical intervention followed by tocilizumab infusion. Pathological specimens of the colon demonstrated hemorrhagic colitis with microthrombi suggestive of COVID-19-related colitis.  Recognizing COVID-19-related colitis allows for timely diagnosis and management with targeted interventions in addition to surgery, which may prevent perforation. We suggest convalescent plasma followed by the formation of colostomy and finally infusion of tocilizumab as a feasible option for the treatment of COVID-19-related colitis. However, further research is needed in order to fully understand this entity and provide guidance for its management.

Multiple Arterial Thrombosis in a COVID Patient With No Known Comorbidities With Mild Elevation of D-Dimer

Since the coronavirus (COVID-19) pandemic started, new challenges have emerged regarding the management of coronavirus-infected patients. One of the most known devastating complications associated with COVID-19 is hypercoagulability. This can lead to severe disability or even death, especially in critically ill patients with known chronic comorbidities such as hypertension (HTN) and diabetes. D-dimer and clinical condition are among the most important tools currently used by clinicians to guide therapy and anticoagulation prophylaxis. Here we present a case of a COVID-19-infected patient with no known comorbidities and mild elevation in initial D-dimer level who had a rapid deterioration ultimately leading to death within weeks of admission.

Subacute Stent Thrombosis in a Patient With COVID-19 Despite Adherence to Antiplatelets

The coronavirus disease 2019 (COVID-19) creates a significant burden on the cardiovascular system. Moreover, diagnosing coronary artery disease in patients with COVID-19 may be clinically challenging. Herein, we present a case of in-hospital stent thrombosis and thrombotic occlusion of the right coronary artery after initial revascularization and adherence to antiplatelet therapy.

Maternal and Neonatal Outcomes of COVID-19 in Pregnancy: A Single-Centre Observational Study

Background: The current coronavirus disease 2019 (COVID-19) pandemic is one of the most challenging healthcare crises faced globally. Adequate information and understanding of the clinical presentation and impact of the disease on maternal and neonatal outcomes is the key to successfully manage a pregnancy with COVID-19.

Objective: The purpose of the present study was to evaluate the clinical presentation of COVID-19 in pregnancy, its course during pregnancy and its effects on maternal and neonatal outcomes.

Study design and setting: This study was a retrospective observational study conducted at Tata Main Hospital, Jamshedpur, a tertiary care hospital in Eastern India.

Population and study period: All COVID-19-positive (by reverse transcription polymerase chain reaction or rapid antigen test) pregnant women admitted to the hospital from 15^th May 2020 to 15^th November 2020. 

Results: A total of 132 COVID-19-positive pregnant women were included in the study. Eighty-six women (65.15%) were asymptomatic, 45 women (34.09%) had mild symptoms and one woman had severe disease. Major co-morbidities seen were hypertensive disorders (pre-eclampsia, gestational hypertension and chronic hypertension) in 18 (13.64%) and diabetes (gestational diabetes, diabetes mellitus type 2) in 14women (10.60%). The rate of preterm delivery was 28.69% (n=35). Caesarean section was done for 78 women (63.93%) and 44 (36.07%) delivered vaginally. Average birth weight reported was 2.59 kilograms. Forty babies (33.06%) were admitted to the neonatal intensive care unit. Two babies (1.65%) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within 24 hours of delivery. 

Conclusion: COVID-19 in pregnancy commonly presents as an asymptomatic or mild disease. It is associated with high rates of preterm births and neonatal admissions to the intensive care unit. Intrauterine and neonatal death rates remain low. Vertical transmission is possible; however, the incidence is low, and the majority of these neonates are asymptomatic.

Musculoskeletal Attendances to a Minor Injury Department During a Pandemic

Introduction: As coronavirus disease 2019 (COVID-19) became a public health emergency of international concern, countries across the globe began to instate strict social distancing restrictions or “lockdowns”. During these times emergency departments in the United Kingdom (UK) recorded a significant drop in patients attending when compared to the same months of previous years. Attendances related to musculoskeletal (MSK) trauma also saw a significant drop in numbers

Objective: The purpose of this retrospective audit was to investigate patterns of injuries attending during the pandemic and more specifically during times of lockdown.

Method: Retrospective audit data was collected from an electronic medical record system (MediTech V6) during the time period of the first lockdown in the UK. Data was collected for patients attending the emergency department at the Queens Hospital Burton site of the University Hospitals of Derby and Burton National Health Service (NHS) Trust. Presenting complaints were recorded for the entire emergency department, and diagnosis on discharge and activity status was recorded for minor injuries only. This data was then compared to the same date from 2019.

Results: Overall attendances in the emergency department decreased by 45.42% during the first lockdown when compared to the same time period in 2019. MSK problems also saw a significant drop as back pain decreased by 58.88%, neck pain fell by 78.52% and limb problems decreased by 59.74%. When comparing data from the minor injury department, limb problems decreased by 20.45%. The number of soft tissue injuries decreased by 24.05% and fractures decreased by 7.96%.

Conclusion: Attendances in the emergency department were greatly reduced during the COVID-19 pandemic, especially during the first lockdown. The rates of fractures and soft tissue injuries within the minors’ area of the emergency department were also reduced but not at the same rate as the overall attendance. A large number of fractures and soft tissue injuries still presented to the emergency department despite reduced national activity. These attendances may be as a result of the increased rate of Do It Yourself (DIY)-related injuries and altered patient/social behaviour due to lockdown, social distancing, and seasons/weather. Further research would be required to investigate the changing patterns of behaviour especially as we enter a second wave of cases.

Renin-Angiotensin-Aldosterone System Inhibitors and COVID-19: A Meta-Analysis and Systematic Review

Introduction

Increased virulence, the severity of illness, and mortality have all been hypothesized with respect to angiotensin-converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB) use in coronavirus disease 2019 (COVID-19) infection. Our study aims to assess whether ACEi/ARB use in patients with COVID-19 conferred worsened severity of illness or increased mortality. Additionally, we explore the possibility of an unearthed protective benefit due to their interruption of the RAS signaling pathway as observed in cardiovascular diseases.

Methods

The Cochrane Library, MEDLINE, and EMBASE were searched for studies relevant to COVID-19 severity, mortality, and inflammation in the context of ACEi/ARB use. Eight studies were included with a total of 17,943 patients, 4,292 (23.9%) of which were taking an ACEi or an ARB. The study population was 47.9% female and the average age across all studies was 65. The studies chosen had a sample size of at least 100 patients.

Results

Mortality outcomes were assessed in six studies and showed no significant difference in mortality among the ACEi/ARB and control groups (odds ratio [OR]: 0.99, 95%CI: 0.48-2.04). Seven studies assessed the severity of COVID-19 and showed no statistically significant difference in disease severity when comparing the ACEi/ARB group to the control group (odds ratio [OR]: 1.30, 95% CI 0.87-1.94). Four studies reported the length of stay with no significant difference between the ACEi/ARB groups as compared to non-users. Four studies included inflammatory markers C-reactive protein (CRP) and D-Dimer, which were noted to be consistently lower in the ACEi/ARB groups when compared to control groups, however, this was not statistically significant.

Conclusion

Our study found no significant difference in mortality, severity of illness, or length of stay between ACEi/ARB users and non-users with COVID-19 infection. These results support the continuation of ACEi and ARBs in the setting of COVID-19 as advised by the American College of Cardiology (ACC)/American Heart Association (AHA). The decrease in CRP and D-dimer suggests a possible protective effect related to ACEi/ARB use in COVID-19, however, more studies with larger sample sizes are needed to establish this effect.

Low cost Covid-19 preliminary diagnosis utilizing cough samples and keenly intellective deep learning approaches

Covid19 an ecumenical pandemic perpetuates to take lakhs of lives and consistently taking its shape as major threat. Skeptically and turmoil in divergent perspectives perpetuate to grow. The most prominent contributing factor to all this is the lack of methodologies to test Covid samples at a more immensely colossal scale. Highly scalable, cost efficacious and flexible diagnosis methodology can contribute greatly towards handling this arduous situation in a more controlled manner. Working towards this the major symptom found among the covid patients is cough. With the avail of Deep learning approaches, this cough is processed to understand the distinctions between the conventional and covid cough. One of the major arduousness to address this quandary is the right amplitude of data to build a deep learning model that can authentically take decisions about the cough recordings. We have extracted some of the recordings from the public platforms and performed deep learning predicated analysis. This gave us the prognostication precision of 94% thus authoritatively mandating a better cough dataset to further carry out the research at a more immensely colossal scale. This paper accommodates as a baseline to cerebrate beyond the customary clinical diagnosis and identify the disease at least in the preliminary in fraction of seconds thus requiring the buildup of covid cough data.