Outcomes of Elective Major Cancer Surgery During COVID 19 at Tata Memorial Centre: Implications for Cancer Care Policy

BACKGROUND

Overburdened systems and concerns of adverse outcomes have resulted in deferred cancer surgeries with devastating consequences. In this COVID pandemic, the decision to continue elective cancer surgeries, and their subsequent outcomes, are sparsely reported from hotspots.

METHODS

A prospective database of the Department of Surgical Oncology was analysed from March 23rd to April 30th, 2020.

FINDINGS

Four hundred ninety-four elective surgeries were performed (377 untested and 117 tested for Covid 19 before surgery). Median age was 48 years with 13% (n = 64) above the age of 60 years. Sixty-eight percent patients were American Society of Anaesthesiology (ASA) grade I. As per surgical complexity grading, 71 (14·4%) cases were lower grade (I-III) and 423 (85.6%) were higher grade complex surgeries (IV - VI).Clavien-Dindo ≥ grade III complications were 5.6% (n = 28) and there were no postoperative deaths. Patients >60 years documented 9.3% major complications compared to 5.2% in <60 years (P = 0.169). The median hospital stay was 1 to 9 days across specialties.Postoperatively, 26 patients were tested for COVID 19 and 6 tested positive. They all had higher grade surgeries but none required escalated or intensive care treatment related to COVID infection.

INTERPRETATION

A combination of scientific and administrative rationale contributed to favorable outcomes after major elective cancer surgeries. These results support the continuation of elective major cancer surgery in regions with Covid 19 trends similar to India.

Coronavirus Disease 2019-Induced Rhabdomyolysis

Rhabdomyolysis is caused by necrosis of muscles and leakage of intracellular contents into blood circulation. It is most commonly caused by trauma, crush injuries, drugs, toxins, immobilization, compartment syndrome, prolonged surgical procedures, and less likely by infections. Infection-related rhabdomyolysis is rare, but not uncommon, and is seen in both viral and bacterial infections. Extrapulmonary manifestations of coronavirus disease 2019 (COVID-19) include thrombotic like pulmonary emboli, acute cerebrovascular accident, myocardial infarction, cardiac arrhythmias, liver injury, gangrene, diarrhea, acute renal failure, and so on. We here describe a case of COVID-19-induced rhabdomyolysis in a 19-year-old Hispanic male presenting with muscle aches, fatigue, fevers, and no pulmonary symptoms. 

A Complication of Pneumothorax and Pneumomediastinum in a Non-Intubated Patient With COVID-19: A Case Report

COVID-19 disease can lead to multiple complications such as severe acute respiratory distress syndrome (ARDS), coagulopathy, renal failure, cardiac and neurological complications. We describe a case of a patient who developed pneumothorax and pneumomediastinum in the setting of COVID-19 without having ARDS or requiring mechanical ventilation. Our patient developed sudden onset of shortness of breath and desaturation. Chest X-ray and CT chest revealed pneumothorax and pneumomediastinum. Though pneumothorax in pulmonary infection is most likely associated with increased airway pressure in acute respiratory distress syndrome and positive pressure mechanical ventilation. Pneumothorax is a life-threatening complication and if diagnosed early it can reduce mortality. In patients with COVID-19 infection, sudden clinical worsening with shortness of breath and desaturation should prompt the clinician to look for potentially treatable causes such as pneumothorax.

Acute Liver Failure in a COVID-19 Patient Without any Preexisting Liver Disease

In December 2019, an outbreak of novel coronavirus started in Wuhan, China, which gradually spread to the entire world. The World Health Organization (WHO) on February 11, 2020, officially announced the name for the disease as coronavirus disease 2019, abbreviated as COVID-19. It is caused by severe respiratory distress syndrome coronavirus 2 (SARS-CoV-2). The WHO declared SARS-CoV-2 as a pandemic on March 11, 2020. SARS-CoV-2 mainly causes fever as well as respiratory symptoms such as cough and shortness of breath. Gastrointestinal/hepatic sequelae such as diarrhea, nausea, vomiting, and elevated liver enzymes have been reported as well. Studies and data so far on coronavirus infections from China, Singapore, and other countries showed that liver enzymes elevation could be seen in 20-50% of cases. More severe disease can correlate with the worsening of liver enzymes. However, acute liver failure in patients with COVID-19 has not been described. Herein we report a case of acute liver failure in an elderly patient with COVID-19 infection who did not have a history of preexisting liver disease.

Gastrointestinal Symptoms and Elevation in Liver Enzymes in COVID-19 Infection: A Systematic Review and Meta-Analysis

Background Corona virus has become a global health pandemic since its origin in Wuhan, China, in December 2019. The present systematic review and meta-analysis aims to assess gastrointestinal symptoms and liver enzymes trend in corona virus infection. Methods Pooled proportions were calculated using both fixed and random effects model. Weighted mean difference and 95% CI were calculated. Results We included 15 relevant articles in the meta-analysis (n = 3762). The pooled proportion of patients with nausea/vomiting was 7.00% (95% CI = 6.00-8.00) while that of diarrhea was 6.00% (95% CI = 5.00-7.00). Weighted mean difference of aspartate aminotransferase (AST), alanine aminotransferase (ALT) in non-severe COVID-19 patients was higher by 20.54 U/liter (95% CI = 19.95-21.13) and 21.38 U/liter (95% CI = 20.92-21.84) while that in severe patients was higher by 22.70 U/liter (95% CI = 19.09-26.45) and by 22.94 U/liter (95% CI = 20.46-25.42) respectively, as compared to general population. Pooled proportions showed ALT levels to be elevated in 16.00% (95% CI = 14.00-18.00) of patients with non-severe and 25.00% (95% CI = 20.00-31.00) of patients with severe COVID-19. Weighted mean difference of albumin and platelet count was found to be lower by 3.28 g/liter (95% CI = 3.05-3.50) and by 14.21 x 10⁹/liter (95% CI = 11.87-16.55) in non-severe patients and by 11.39 g/liter (95% CI = 10.16-12.63) and 40.70 x 10⁹/liter (95% CI = 33.62-47.77) in severe patients. Conclusions Our meta-analysis shows that patients with COVID-19 infection can present with nausea, vomiting and diarrhea in addition to elevated liver enzymes including AST, ALT and a decline in albumin and platelet count which is more marked in severe disease.

Making Data Reports Useful During the COVID-19 Pandemic

During the coronavirus disease 2019 (COVID-19) pandemic, anxiety regarding hospitals resulted in patients risking their lives and not seeking emergency medical care when needed. Early into the pandemic, hospital emergency room utilization plummeted more than 40% in some hospitals, according to the Centers for Disease Control and Prevention. As COVID-19 outbreaks intensified in the Western regions of the country, emergency room census began to increase significantly in the middle of June. Local safety net health care resources were struggling with the increase in emergency room utilization and scrambled to increase patient care capacity, especially their emergency rooms and intensive care units. The data collected during this time is of great value. Unfortunately, it is often poorly reported, overlooked, and ignored when it should be used to make better decisions and allocations. During the pandemic, underserved populations were especially impacted, overwhelming safety net health organizations. The findings from a simple data analysis provide a template for resource acuity among communities and depict the importance of health equity.

Paying in Blood: A Case of Thrombocytopenia in Covid-19

Novel coronavirus disease 2019 (COVID-19) primarily involves the respiratory system. Consumptive coagulopathy is seen in acute respiratory distress syndrome (ARDS) and multi-organ failure (MOF). Usually, only severely sick patients develop mild thrombocytopenia. We present a case of mildly symptomatic young adult, presenting with severe thrombocytopenia. She responded well to corticosteroids.

Concurrent Diagnosis of Acute Myeloid Leukemia and COVID-19: A Management Challenge

The emergence of coronavirus disease 2019 (COVID-19) has created new challenges in the management of serious diseases. We describe a 41-year-old male who presented with fever, watery diarrhea, and epistaxis. Initial workup revealed pancytopenia with >50% blasts on the peripheral smear raising suspicion of acute myeloid leukemia (AML) (later confirmed by bone marrow biopsy as AML with myelodysplasia-related changes) and a positive polymerase chain reaction (PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Given the extraordinary risk, he was treated with remdesivir and convalescent plasma for COVID-19. On admission day 8, repeat PCR for SARS-CoV-2 returned negative and the patient was deemed stable for chemotherapy. Therefore, induction was done with liposomal daunorubicin and cytarabine. However, he did not respond to the therapy and was started on re-induction therapy with decitabine and venetoclax. In our discussion, we review the current principles of treatment of patients with concurrent COVID-19 and AML.

An Intriguing Presentation of Epstein-Barr Virus-Associated Hemophagocytic Lymphohistiocytosis

Hemophagocytic lymphohistiocytosis (HLH) is an immune related clinical syndrome with protean manifestations, varying presentation, clinically complex, with diverse causes, and is an under-recognized entity which carries high morbidity and mortality. It is precipitated by an immunological trigger in a susceptible host resulting in immune activation and dysregulation leading to disruption of immune homeostasis, cytokine storm and multi-organ failure. We describe a case of Epstein-Barr virus (EBV) associated HLH with its typical diagnostic challenges and associated high mortality rate. Certain diagnostic criteria and online tools may help to arrive at an earlier presumptive diagnosis which, in turn, may expedite treatment and lead to better clinical outcomes.

Convalescent Plasma Therapy and Its Effects On COVID-19 Patient Outcomes: A Systematic Review of Current Literature

Started in late 2019, coronavirus disease 2019 (COVID-19) has rapidly turned into a global pandemic. Considering there is no proven therapy for COVID-19 infection, there is a need to propose potential treatment options. The use of convalescent plasma is one such option as convalescent plasma has previously been used for treating outbreaks of Ebola, influenza, Middle East Respiratory Syndrome Coronavirus (MERS-CoV), and severe acute respiratory (SAR) viruses. Therefore, we carried out an early systematic review to evaluate the efficacy of convalescent plasma (CP) therapy and its effects on COVID-19 patient outcomes. A structured and rigorous systematic review was carried out that included all studies conducted on this topic between December 2019 and June 2020. A total of 10 studies containing a mix of case reports, case series, observational studies, and randomized control trials were identified. Most of the studies lacked randomization and included only small groups of patients. Considering the limitations in the design of current studies, it is difficult to draw a definitive conclusion. However, our results showed that plasma therapy produces notable improvements in patients' clinical symptoms and radiological and biochemical parameters associated with COVID-19 infection. Based on the available information, it is difficult to draw a tangible conclusion about whether plasma therapy improves patient mortality. Until we have concrete evidence to prove otherwise, convalescent plasma therapy may be used as adjuvant therapy for treating COVID-19 infection in critically ill patients.

Cross-Sectional Abdominal Imaging Findings in Patients With COVID-19

Objective We aimed to review and analyze cross-sectional abdominal imaging findings in a cohort of 10 patients who had tested positive for coronavirus disease 2019 (COVID-19). Methods This retrospective study conducted from April 1, 2020, to May 13, 2020, involved two institutions that comprised a central tertiary academic institution and multiple smaller community hospitals. We reviewed and examined cross-sectional imaging studies of patients who tested positive for COVID-19 either during the emergency room (ER) visit or hospital admission. Salient imaging findings and medical records were reviewed. Results A total of 10 COVID-19-positive patients (seven males and three females) of ages ranging from 21-75 years underwent cross-sectional abdominopelvic imaging. Nine of the 10 patients demonstrated typical lung base findings associated with COVID-19 on both CT and MRI. Twelve CT abdominopelvic examinations, one MRI abdomen, and one right upper quadrant ultrasound (RUQ US) were performed, with three patients undergoing two CT scans during the course of hospitalization. Gastric and bowel wall abnormalities were found on 25% (n=3/12) of abdominal CT scans. Acute interstitial pancreatitis and acute cholecystitis were both found on one CT exam. The remaining (n=7/12, 58%) CT studies demonstrated no acute intraabdominal pathology with incidental findings including fatty liver disease, cirrhosis, and splenomegaly. Conclusion A spectrum of abdominal imaging findings ranging from colitis to pancreatitis may be correlated with COVID-19 infection, even though the majority of our patients with gastrointestinal (GI) symptoms did not have identifiable GI pathology on imaging.

Lung Compliance in a Case Series of Four COVID-19 Patients at a Rural Institution

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic has generated a plethora of scientific articles. One interesting aspect of the virus is the binary phenotypic presentation in patients. While patients might meet the Berlin criteria for acute respiratory distress syndrome (ARDS), not all patients experience the same decrease in lung compliance as typically seen with ARDS. We have observed patients meeting ARDS criteria with higher lung compliance as measured through peak pressures at our institution. This phenotype difference is important with regard to how the patients are managed. Lower positive end-expiratory pressure (PEEP) and higher tidal volumes can be used in this phenotype.

Right Atrial Thrombus in a Patient With COVID-19

Coronavirus disease 2019 (COVID-19) is a worldwide pandemic. Evidence suggests a strong association between COVID-19 and pro-thrombotic states. We report our experience in managing a patient with COVID-19 complicated by a right atrial thrombus. We highlight the successful use of half-dose anticoagulation in the treatment of right atrial thrombus in a patient with COVID-19. To our knowledge, this is a first reported case of right atrial thrombus in a COVID-19 patient who was treated successfully with half-dose anticoagulation.

Dermatological Manifestations in Patients With SARS-CoV-2: A Systematic Review

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been initially defined as a disease of the respiratory tract; however, with the increasing number of patients and announcing that the virus became a pandemic, new systemic clinical manifestations are observed, including dermatological manifestations. However, the identification and characteristics of these manifestations are still controversial. This review article aims to evaluate the medical literature and explore the dermatological clinical manifestations in patients with SARS-CoV-2. The literature was reviewed through MEDLINE®, Ovid, PubMed®, and Embase®. Searching terms included were a combination of "dermatological" OR "skin" AND "symptoms" OR "manifestations" AND "SARS-CoV-2". The following step was filtering the results to include only original research studies investigating the different types of skin and dermatological clinical manifestations in patients with SARS-CoV-2. A total of 879 studies were retrieved. Following the exclusion of studies on animals and including only studies on humans, 32 studies emerged. Altogether, seven studies were identified as eligible, covering 555 patients with SARS-CoV-2 who had dermatological symptoms. Three studies were retrospective, two studies were prospective, and two studies were case series. Different types of dermatological lesions can occur in patients with SARS-CoV-2, most commonly erythema, urticaria, and varicella-like rash. Dermatological manifestations with SARS-CoV-2 can be misdiagnosed with other conditions. Further studies with robust design are needed.

Chilblains in COVID-19 Infection

COVID-19 has quickly become a worldwide pandemic and is well-known for its pulmonary complications. Dermatologic manifestations such as chilblain-like lesions have been recently described, but it is unclear if they are truly secondary to the infection or not. Here we describe a young patient who developed chilblain-like eruptions on his toes, likely secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We discuss the literature that supports the hypothesis that these are in fact secondary to the infection, as well as provide insight into the pathology of these lesions.

An Atypical Presentation of Fulminant Myocarditis Secondary to COVID-19 Infection

The potential etiologies of fulminant myocarditis include autoimmune diseases, infections, drug hypersensitivity, and drug/toxin reactions. We present an atypical case of fulminant myocarditis in a patient with a history of diabetic ketoacidosis with recent novel coronavirus (COVID-19) infection, who presented with acute upper gastrointestinal bleeding. The patient improved with a three-day course of methylprednisolone 1 gram daily.

Acute Limb Ischemia in COVID-19 Disease: A Mysterious Coagulopathy

Severe coronavirus disease 2019 (COVID-19) as a respiratory tract infection has been noted to be a causative agent for acute respiratory distress syndrome, shock, and multiple organ failure. It is also being suggested that COVID-19 results in serious systemic coagulopathies similar to disseminated intravascular coagulation. We describe a case of severe arterial thrombosis induced by COVID-19 infection along with its pathological implications.

Cardiovascular Considerations of Experimental Hydroxychloroquine Therapy on Patients Diagnosed With COVID-19: A Case Series Review

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and its high virulence along with its variable presentation have generated a significant amount of interest within the medical community. The heterogeneous nature of the symptoms of the disease caused by SARS-CoV-2, coronavirus disease 2019 (COVID-19), ranging from being asymptomatic to severe acute respiratory distress syndrome (ARDS), has created significant interest in potential therapeutics. Given the lack of randomized controlled trials, most medications are experimental, and only anecdotal evidence is available so far regarding their efficacy. One medication that emerged as an early frontrunner as a promising therapeutic was hydroxychloroquine (HCQ), a common antimalarial and lupus drug. The adverse side effects that could result from its use did not gain much attention initially. We present the cases of two COVID-19-positive patients treated with HCQ at our institution, which showed adverse effects of the medication. While HCQ may have some therapeutic effect, it should be borne in mind that patients may experience more harm than benefit from its use.

COVID-19 as a Possible Cause of Functional Exhaustion of CD4 and CD8 T-cells and Persistent Cause of Methicillin-Sensitive Staphylococcus aureus Bacteremia

We report a case of a 73-year-old male with a history of diabetes mellitus, osteomyelitis, methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia who recently completed an extended intravenous course of cefazolin eight days back, and presented with MSSA bacteremia complicated by epidural abscess, endocarditis, and aortic root abscess. Meanwhile, the patient was tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by reverse transcription-polymerase chain reaction (RT-PCR). Even with aggressive antibiotic treatment, the patient remained bacteremic and developed endocarditis with a worsening aortic root abscess. We suspect coronavirus disease 2019 (COVID-19) as a cause for the infectious paradox and will discuss the possible mechanisms in this case report.

Impact of COVID-19 on the Mental Health of Healthcare Professionals in Pakistan

Introduction

As a result of the ongoing COVID-19 pandemic, health care professionals (HDPs) are facing immense strain due to the heavy load of cases. In many cases, they work increasingly long hours, often with limited resources and a dubious infrastructure. Thus, it is important to check on the mental health of caregivers.

Methods and materials

This cross-sectional study was conducted in May 2020, at various hospitals in Karachi, Pakistan. All HCPs posted in the COVID-19 isolation wards were invited to participate and a total of 112 completed this study. A carefully structured form was created, which included the Depression Anxiety Stress Scale-21 (DASS-21).

Results

The overall mean score of anxiety was 19.01 ± 9.2, depression was 18.12 ± 10, and stress was 20.12 ± 12.0. There were 81 (72.3%) participants who suffered from moderate to extremely severe depression, 96 ( 85.7%) participants who suffered from moderate to extremely severe anxiety, and 101 (90.1%) participants who reported moderate to extreme stress levels

Conclusions

It is evident that there are a high number of healthcare workers affected by various psychological ailments such as anxiety, stress, and depression. It is important that the government take steps to ensure that HCPs' mental health is regularly checked and that efforts are made to reduce their burdens.

A Case of Combined Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State in a Patient With COVID-19

The novel coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome-corona virus-2 (SARS-CoV-2). Diabetes mellitus (DM) is one of the risk factors associated with severe illness in COVID-19 leading to increased hospital admissions and mortality. COVID-19 can precipitate hyperglycemic emergencies like diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) in patients with DM. We present a case of a patient with COVID-19 admitted to the hospital with combined DKA and HHS. The case highlights the challenge of managing patients with DM suffering from COVID-19.

[Infection Prevention in Anesthesiology during the SARS-CoV 2-pandemic]

It is necessary to discuss the sometimes competing goals of sufficient critical care capacity, maintenance of regular patient care, protection of medical staff, interruption of infectious chains within the general public and individual aspects of patient care in anesthesia and the operating room in times of the SARS CoV-2 pandemic, given the uncertainty of many data on which decisions need to be based. Basic hygiene remains the cornerstone of infection prevention especially when resources are sparse and SARS-CoV-2 specific additional measures need to be taken according to a risk analysis taking the dynamic of the pandemic as well as local factors into account.

A Case of COVID-19 Infection With Delayed Thromboembolic Complication on Warfarin

Novel coronavirus disease 2019 (COVID-19) pandemic has posed an unprecedented threat to humanity with more than eight million infections and 450,000 deaths reported worldwide so far. The spectrum of the disease varies from mild asymptomatic infection to severe disease with rapid progression to acute respiratory distress syndrome and multiorgan failure. It is associated with a prothrombotic state and hence there is a risk of thromboembolic complications in critically ill patients, even after recovery. However, the duration of prothrombotic risk after recovery is yet to be determined. We present the case of a 78-year-old man with a history of atrial fibrillation on warfarin who had been recently discharged to a nursing home after recovering from COVID-19 pneumonia and presented to the emergency department a month later with worsening shortness of breath and cough. He was found to have worsening respiratory failure with multiple segmental pulmonary emboli, despite being on warfarin, and supratherapeutic international normalized ratio (INR). He required mechanical ventilation and was started on steroids and therapeutic enoxaparin anticoagulation. This case highlights the risk of delayed thromboembolic complications in patients with COVID-19 infection and the need to identify the subgroup of patients with a higher risk of thromboembolism, such as discharges to nursing homes and those in need of oxygen requirement; and those with underlying comorbid conditions that may require anticoagulation for a longer duration. The role of heparin is being increasingly investigated in patients with COVID-19 infection; however, the role of other anticoagulants such as warfarin is yet to be defined.

The Role of Interleukin-6 Inhibitors in the Treatment of COVID-19 Infections: A Case Series

An outbreak of severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) infection started in December 2019 in China that resulted in a global health emergency. The World Health Organization later named the disease as coronavirus disease 2019 (COVID-19). Currently, there is no effective treatment available and the data are evolving through continuous clinical trials and ongoing research. Severe infections present with hypoxemic respiratory failure from acute respiratory distress syndrome as one of the major complications. We report two cases of COVID-19 patients who initially presented with moderate to severe symptoms. Later, their clinical course worsened despite ongoing treatment with multiple medications such as hydroxychloroquine and azithromycin until they were started on tocilizumab. Within a short period after they were administered tocilizumab, their oxygen saturation improved and other inflammatory markers such as D-dimer levels, lactate dehydrogenase, and ferritin levels decreased. There is an increase in the amount of research citing the role of various cytokines in the pathophysiology of COVID-19. Targeting the inflammatory mediators in the pathogenesis, especially interleukin-6 pathway inhibitors, would improve overall morbidity and mortality, thus decreasing the burden on healthcare systems.

COVID-19 Induced Hepatitis B Virus Reactivation: A Novel Case From the United Arab Emirates

The novel coronavirus disease 2019 (COVID-19) clinically manifests as respiratory and gastrointestinal presentations, most commonly vomiting, diarrhea, and abdominal pain. Although the impaired liver function is prevalent in COVID-19, it is poorly understood. We report the first case of hepatitis B virus (HBV) reactivation caused by COVID-19 in a young adult with altered mental status and severe transaminitis. The patient was asymptomatic, hypothermic, his skin was jaundiced with the icteric sclera, with very high levels of aspartate aminotransferase (AST; 4,933 U/L), alanine aminotransferase (ALT; 4,758 U/L), and total bilirubin (183.9 mmol/L) levels. It is warranted that patients with abnormal liver functions tend to have an increased risk of COVID-19. Thus, increased attention should be paid to the care of patients with abnormal liver functions, and testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA is warranted in the COVID era.

SARS-CoV-2 (COVID 19) Infection in Hypertensive Patients and in Patients With Cardiac Disease

COVID 19, caused by the SARS-CoV-2 virus, a newly discovered coronavirus, has caused the global pandemic of early 2020. The first case was described in December 2019 in Wuhan, China, and by March 2020, most countries around the world have put in place some of the strictest restrictions seen in decades in order to slow down the spread of the disease. Patients with pre-existing hypertension and cardiovascular comorbidities were reported to be at an increased risk of serious infections caused by SARS-CoV-2. Considering that those are among the most common chronic medical conditions in the Western world, the potential impact of it is huge. The proposed mechanism behind those associations is the expression of angiotensin converting enzyme II (ACE II) in those patients. Furthermore, the association between ACE inhibitors/AR blockers, which are among the most frequently prescribed medications, and serious cases of COVID 19 has been studied with the same mechanism in mind. The reports on the association between hypertension and COVID 19 morbidity and mortality are less clear, and the International Society of Hypertension even claims that there is none. The reports on the association between heart failure or coronary disease and COVID 19 are more uniform, and all seem to point to a greater risk from serious infections faced by patients with those comorbidities. A significant effort will need to be invested by the scientific community into finding strategies for protecting those patients from contracting the virus in the first place and then, once infected, into developing management plans aimed at preserving cardiac function as much as possible.

Fatal Superimposed Bacterial Sepsis in a Healthy Coronavirus (COVID-19) Patient

Coronavirus disease 2019 (COVID-19) is a highly infectious disease caused by the newly discovered coronavirus, SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). The novel coronavirus first emerged in Wuhan, China, in December 2019 and has led to a global pandemic. The virus mainly spreads through respiratory droplets from an infected person, but environmental contamination can also act as a source of infection, making social distancing an important key in containing the spread of infection. Those with underlying health conditions are more susceptible to complications such as acute respiratory distress syndrome, which can be fatal. However, healthy individuals experience a mild flu-like illness or may be asymptomatic, recuperating from the infection even without any particular intervention. We present a case of a healthy COVID positive individual, with no underlying comorbidities, who rapidly deteriorated overnight on readmission to the hospital after initial discharge and succumbed to this disease due to a superimposed bacterial infection with COVID pneumonia. This case report highlights the importance of educating COVID-19 positive patients about the precautions, as well as signs and symptoms of a superimposed bacterial infection, when their plan of care is in a home setting. It also emphasizes the potential role of checking procalcitonin levels as a part of routine laboratory investigation at initial presentation in all suspected as well as confirmed COVID-19 cases to rule out an on-going bacterial infection that can prove fatal in the course of the disease.

Vaccines and Drug Therapeutics to Lock Down Novel Coronavirus Disease 2019 (COVID-19): A Systematic Review of Clinical Trials

The ongoing novel coronavirus disease 2019 (COVID-19) pandemic has been responsible for millions of infections and hundreds of thousands of deaths. To date, there is no approved targeted treatment, and many investigational therapeutic agents and vaccine candidates are being considered for the treatment of COVID-19. To extract and summarize information on potential vaccines and therapeutic agents against COVID-19 at different stages of clinical trials from January to March 2020, we reviewed major clinical trial databases such as ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP), and other primary registries between January and March 15, 2020. Interventional studies at different phases under the COVID-19 pipeline were included. A total of 249 clinical trials were identified between January to March 15, 2020. After filtering observational studies (194 studies), a total of 56 interventional trials were considered. The majority of clinical trials have been conducted on chloroquine (n=10) and traditional Chinese medications (TCMs; n=10), followed by antivirals (n=8), anti-inflammatory/immunosuppressants (n=9), cellular therapies (n=4), combinations of different antivirals therapies (n=3), antibacterial (n=1), and other therapies (n=5). Five vaccines are under phase I, and there are a couple of phase III trials on the Bacillus Calmette-Guérin (BCG) vaccine under investigation among healthcare workers. Many novel compounds and vaccines against COVID-19 are currently under investigation. Some candidates have been tested for other viral infections and are listed for clinical trials against the COVID-19 pipeline. Currently, there are no effective specific antivirals or drug combinations available for the treatment of COVID-19.

COVID-19: our last teachable moment

COVID-19 is bringing hardship and tragedy.  Health workers are having to take appalling risks; loved ones are being lost; lockdown is causing great distress.  And, as always in testing times, the disadvantaged are being hit worst. As we emerge from the shadows, the call from the vested interests, from the systems current winners, will be for a rapid return to business as usual. We must resist this; business as usual got us into this mess. 

COVID-19 is trying to tell us something; we health educators and social marketers must listen, think and, above all, take action.

Pitfalls of Computed Tomography in the Coronavirus 2019 (COVID-19) Era: A New Perspective on Ground-Glass Opacities

Aim To study ground-glass opacities (GGO) not only from the coronavirus 2019 (COVID-19) pneumonia" perspective but also as a radiological presentation of other pathologies with comparable features. Methods We enrolled 33 patients admitted to Policlinico Universitario G. B. Rossi who underwent non-contrast-enhanced (NCE) or contrast-enhanced (CE) chest computed tomography (CT) between March 12 and April 12. All patients with CT-detected ground-glass opacity (GGO) were included. All patients resulted as COVID-19 negative at the reverse transcription-polymerase chain reaction (RT-PCR) assay. We studied the different pathologies underlying GGO features: neoplastic diseases and non-neoplastic diseases (viral pneumonias, interstitial pneumonias, and cardiopulmonary diseases) in order to avoid pitfalls and to reach the correct diagnosis. Results All CT scans detected GGOs. Symptomatic patients were 25/33 (75.7%). At the clinical presentation, they reported fever and dry cough; in six out of 25 cases, dyspnea was also reported (24%). Thirty-three (33; 100%) showed GGO at CT: 15/33 (45.45%) presented pure GGO, and 18/33 (54.54%) showed GGO with consolidation. The RT-PCR assay was negative in 100%. We investigated other potential underlying diseases to explain imaging features: neoplastic causes (8/33, 24.24%) and non-neoplastic causes, in particular, infectious pneumonias (16/33, 48,48 %, viral and fungal), interstitial pneumonias (4/33, 12,12%), and cardio-pulmonary disease (5/33, 15,15%). Conclusions GGO remains a diagnostic challenge. Although CT represents a fundamental diagnostic tool because of its sensitivity, it still needs to be integrated with clinical data to achieve the best clinical management. In the presence of typical imaging features (e.g. GGO and consolidation), the radiologist should focus on the pandemic and manage a suspect patient as COVID-19 positive until proven to be negative.

COVID-19 Pandemic: Knowledge and Perceptions of the Public and Healthcare Professionals

Background and objective

The recent pandemic due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a major concern for the people and governments across the world due to its impact on individuals as well as on public health. The infectiousness and the quick spread across the world make it an important event in everyone’s life, often evoking fear. Our study aims at assessing the overall knowledge and perceptions, and identifying the trusted sources of information for both the general public and healthcare personnel.

Materials and methods

This is a questionnaire-based survey taken by a total of 1,246 respondents, out of which 744 belonged to the healthcare personnel and 502 were laypersons/general public. There were two different questionnaires for both groups. The questions were framed using information from the World Health Organization (WHO), UpToDate, Indian Council of Medical Research (ICMR), Center for Disease Control (CDC), National Institute of Health (NIH), and New England Journal of Medicine (NEJM) website resources. The questions assessed awareness, attitude, and possible practices towards ensuring safety for themselves as well as breaking the chain of transmission. A convenient sampling method was used for data collection. Descriptive statistics [mean(SD), frequency(%)] were used to portray the characteristics of the participants as well as their awareness, sources of information, attitudes, and practices related to SARS-CoV-2.

Results

The majority (94.3%) of the respondents were Indians. About 80% of the healthcare professionals and 82% of the general public were worried about being infected. Various websites such as ICMR, WHO, CDC, etc., were a major source of information for the healthcare professional while the general public relied on television. Almost 98% of healthcare professionals and 97% of the general public, respectively, identified ‘Difficulty in breathing” as the main symptom. More than 90% of the respondents in both groups knew and practiced different precautionary measures. A minority of the respondents (28.9% of healthcare professionals and 26.5% of the general public) knew that there was no known cure yet. Almost all respondents from both the groups agreed on seeking medical help if breathing difficulty is involved and self-quarantine if required.

Conclusion

Most healthcare professionals and the general public that we surveyed were well informed about SARS-CoV-2 and have been taking adequate measures in preventing the spread of the same. There is a high trust of the public in the government. There are common trusted sources of information and these need to be optimally utilized to spread accurate information.

Encephalopathy as the Sentinel Sign of a Cortical Stroke in a Patient Infected With Coronavirus Disease-19 (COVID-19)

The novel coronavirus has challenged medical systems worldwide to provide optimal medical care in the setting of limited resources. Although we are uncovering many facets of its disease spectrum, with rapidly emerging data, there is still limited knowledge of the sequelae of this infection, making treatment guidelines incomplete and resulting in serious unpredictable outcomes in patients at seemingly low risk, especially ones afflicted by neurological consequences. We present a case of a cortical stroke in a 31-year-old coronavirus disease-19 (COVID-19) positive female with otherwise no stroke risk factors. We noted a correlation between cytokine release, encephalopathy, and the onset of stroke symptoms. Patients with marked pro-thrombotic and inflammatory markers may benefit from closer neurological monitoring and thromboprophylaxis at therapeutic doses. The establishment of acute care pathways to manage critically ill patients with neurological consequences may reverse the suboptimal outcome trends seen during the pandemic.

SARS-COV-2 Presenting as New Onset Atrial Fibrillation: A Case Report

Current literature has documented numerous different presentations of SARS-COV-2 (COVID-19). Common symptoms include fever, cough and shortness of breath, however, lack of these symptoms does not exclude COVID-19. Given the incomplete understanding of the virus at this time, healthcare professionals must continue to remain informed of the vast number of clinical presentations of the virus to ensure early supportive treatment, ideally leading to improved outcomes.

A Review of Cardiac Complications in Coronavirus Disease 2019

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has shown an association with acute myocardial injury, cardiomyopathy, and myocarditis. Individuals with myocardial involvement in association with the coronavirus disease 2019 (COVID-19) may be at increased risk of developing severe illness. Cardiomyopathies are a heterogeneous group of diseases of the myocardium associated with mechanical and/or electrical dysfunction that usually exhibit inappropriate ventricular hypertrophy or dilation and are due to a variety of causes that frequently are genetic. It has been primarily divided into three subsets: genetic, mixed, and acquired cardiomyopathy. We anticipate that, because of the high inflammatory response, other cardiovascular complications may also occur in COVID-19 patients with severe symptoms. This review explores new information as it pertains to COVID-19 and cardiac complications.

Neurological Complications of Coronavirus Disease (COVID-19): Encephalopathy, MRI Brain and Cerebrospinal Fluid Findings: Case 2

The neurological complications of coronavirus disease 2019 (COVID-19) are being better understood as the pandemic progresses. We report a second case of a patient who presented with COVID-19 infection and encephalopathy to our institution. In addition, we report MRI brain and cerebrospinal fluid data. COVID-19 does not seem to cross the blood-brain barrier. The exact mechanisms of encephalopathy and pathological response of COVID-19 are unknown.

Preparing Children for Pandemics

COVID-19 has given us a food for thought that whether we are prepared for such pandemics or not. Developed nations may say that they have enough resources to tackle such situations, but when it comes to the physical and emotional security of the children, even they have to think manifolds because preparing children for such pandemics need lot of effort and apt planning. The purpose of this chapter is to reflect issues related to children during any infectious disease outbreak like COVID-19. Adults are mature enough to control their emotions and can act patiently, but immature minds are always perplexed and act in a very clingy way when some adverse situation is thrown to them. Children are ardent observers and act according to the reactions of the folks around them. It is difficult for them to conceal their behavior, and it is difficult for parents as well to manage their anxiety levels. During crisis period when social distancing and refrained outdoor activities have brought our children into a knotty situation, it is necessary that we understand their fears and myths, try to resolve their concerns in a polite way and strengthen their minds. At this stage the role of parents, teachers, educational institutes, social media, and international children’s organizations need to be redefined. The importance of the decisions taken by the governing bodies should be explained to the children in an effective way, so that they do not panic and reflect a brave attitude. UNICEF in collaboration with international health support systems and departments has a major role to play. Appropriate planning for preparing the children for pandemics has to be incorporated in our system, so that any future crisis can be dealt in an easier way. Schools colleges and other educational institutes should execute immunization and hygiene and health practices in advance to promote prevention.

COVID-19 Outbreak Response for an Emergency Department Using In Situ Simulation

In January 2020, the WHO declared COVID-19 an epidemic in China and the possibility of evolving into a pandemic. During early phases, most emergency departments did not have contingency plans for an outbreak of this scale and therefore necessitating adequate preparation.

This study aims to describe the utility of in situ simulation in identifying system errors and latent safety hazards in response to preparation for the expected COVID-19 surge. We also aim to describe the corrective measures taken to improve our outbreak response locally. We hope that others may be able to use this information as foresight in preparing their own departments for this outbreak.

The emergency department and anesthesiology department of Galway University Hospital conducted a series of multidisciplinary, in situ simulations to rapidly identify operational errors and latent safety hazards in response to this outbreak. Each simulation involved an interdisciplinary response to a suspected/COVID-19 patient. The cases were used as a training opportunity for staff and ultimately a platform to expeditiously implement system changes in response to deficits identified during the simulations.

Conclusively, with the complexities and intricate structure of every emergency department, we understood that preparation for an outbreak requires evaluation of the current system before implementing any changes. It is not a "one size fits all" concept. Therefore, conducting in situ simulations and the use of foresight, is pivotal as it could prevent loss of resources and time in preparing for an outbreak.

Refractory Acute Respiratory Distress Syndrome Secondary to COVID-19 Successfully Extubated to Average Volume-assured Pressure Support Non-invasive Ventilator

Coronavirus disease 2019 (COVID-19) is a respiratory illness caused by the highly infectious novel SARS-CoV-2 coronavirus spread by droplet transmission. Consequently, the use of respiratory devices that may potentially promote aerosolization like non-invasive positive pressure ventilation (NIPPV) for diseases such as obstructive sleep apnea (OSA), advanced chronic obstructive lung disease, pulmonary hypertension (PH), and neuromuscular respiratory disease has been called into question. We present a case of a patient with history of OSA and PH convalescing from refractory acute respiratory distress syndrome (ARDS) secondary to COVID-19 who was successfully extubated to average volume-assured pressure support (AVAPS).

A 74-year-old male with medical history notable for OSA on NIPPV, PH, and hypertension presented with respiratory failure secondary to COVID-19 confirmed on polymerase chain reaction (PCR) test. His respiratory status worsened leading to ARDS requiring intubation. He was initially extubated to high flow nasal cannula (HFNC) due to hospital policy to avoid NIPPV due to concerns of viral dissemination. He did not tolerate HFNC and required re-intubation for prolonged period. He was then medically optimized for a second attempt and extubated two days later to AVAPS with an anti-viral filter and negative pressure room with a goal of optimizing his critical illness myopathy and pre-existing OSA and PH. He tolerated extubation well, and over the next five days was weaned from alternating AVAPS/HFNC to eventually requiring two liters nasal cannula in the day and AVAPS mode at night.

This case highlights a potential therapeutic option for patients with severe respiratory failure secondary to COVID-19. This patient’s pre-existing comorbidities of OSA and PH markedly increased his risk for extubation failure on HFNC. The use of AVAPS after his second extubation attempt helped ensure ventilation and oxygenation non-invasively. COVID-19 can lead to prolonged dependence on mechanical ventilation. This pandemic has the potential to create medical resource scarcities, especially in rural areas where ventilators and trained personnel are already in short supply. By using AVAPS mode, this patient was able to rehabilitate his myopathy and participate in intermittent weaning of HFNC to ultimately simple nasal cannula.

AVAPS is useful tool to facilitate extubation, as it allows non-invasive support of respiratory dynamics, particularly in those with co-morbidities such as OSA and PH. Further, larger scale studies are needed to determine its exact role during the COVID-19 pandemic.

Successful Conservative Management of Acute Appendicitis in a Coronavirus Disease 2019 (COVID-19) Patient

Appendectomy is the gold standard of treatment for acute appendicitis; however, recent evidence suggests conservative management with intravenous antibiotics may provide similar outcomes and can be used as an alternative in selected patients. Performing appendectomy in acute appendicitis patients with 2019 novel Coronavirus Disease (COVID-19) is challenging, as it involves considerable operative risks for the patients and risks for health care professionals (HCPs) exposed to COVID-19. Medical management eliminates the morbidity and mortality associated with surgery but involves significant risks of treatment failures that, in turn, may lead to perforation, peritonitis, and death. We are reporting a case of a middle-aged man with multiple co-morbidities, who was diagnosed with COVID-19 and acute appendicitis. Our patient received intravenous antibiotics for seven days with a significant improvement in symptoms. Our case report illustrates the implementation of successful conservative treatment for acute appendicitis in COVID-19 patients.

Protected Stroke Mechanical Thrombectomy Code During the Coronavirus (COVID-19) Pandemic: Southwestern Part of Saudi Arabia Stroke Unit Local Protocol

Cerebrovascular diseases are a significant cause of mortality and morbidity worldwide, in particular those with large vessels occlusion (LVO). Coronavirus disease 2019 (COVID-19) has become a global crisis rapidly since its initial outbreak in Wuhan, China, in December, 2019. Stroke due to LVO needs rapid assessment and timely endovascular intervention which can be very challenging during the time of pandemic where you need to deliver proper, safe, and timely care to acute ischemic stroke (AIS) patients with LVO, yet, protecting healthcare workers and existing patients at the medical facility. In this article, we share our local experience in the stroke unit at Aseer Central Hospital which is the main hub of stroke patients in the southwestern part of Saudi Arabia and the primary regional COVID center to provide guidance to perform smooth, safe, and swift mechanical thrombectomy during the coronavirus (COVID-19) pandemic as well as possible similar future situations.