Gastrointestinal Complications in Critically Ill Patients With COVID-19. Ann Surg. 2020;272:e61-e62. [PMID: 32675498 PMCID: PMC7268843 DOI: 10.1097/sla.0000000000004004]

A reduced proteomic signature in critically ill Covid-19 patients determined with plasma antibody micro-array and machine learning

BACKGROUND

COVID-19 is a complex, multi-system disease with varying severity and symptoms. Identifying changes in critically ill COVID-19 patients' proteomes enables a better understanding of markers associated with susceptibility, symptoms, and treatment. We performed plasma antibody microarray and machine learning analyses to identify novel proteins of COVID-19.

METHODS

A case-control study comparing the concentration of 2000 plasma proteins in age- and sex-matched COVID-19 inpatients, non-COVID-19 sepsis controls, and healthy control subjects. Machine learning was used to identify a unique proteome signature in COVID-19 patients. Protein expression was correlated with clinically relevant variables and analyzed for temporal changes over hospitalization days 1, 3, 7, and 10. Expert-curated protein expression information was analyzed with Natural language processing (NLP) to determine organ- and cell-specific expression.

RESULTS

Machine learning identified a 28-protein model that accurately differentiated COVID-19 patients from ICU non-COVID-19 patients (accuracy = 0.89, AUC = 1.00, F1 = 0.89) and healthy controls (accuracy = 0.89, AUC = 1.00, F1 = 0.88). An optimal nine-protein model (PF4V1, NUCB1, CrkL, SerpinD1, Fen1, GATA-4, ProSAAS, PARK7, and NET1) maintained high classification ability. Specific proteins correlated with hemoglobin, coagulation factors, hypertension, and high-flow nasal cannula intervention (P < 0.01). Time-course analysis of the 28 leading proteins demonstrated no significant temporal changes within the COVID-19 cohort. NLP analysis identified multi-system expression of the key proteins, with the digestive and nervous systems being the leading systems.

CONCLUSIONS

The plasma proteome of critically ill COVID-19 patients was distinguishable from that of non-COVID-19 sepsis controls and healthy control subjects. The leading 28 proteins and their subset of 9 proteins yielded accurate classification models and are expressed in multiple organ systems. The identified COVID-19 proteomic signature helps elucidate COVID-19 pathophysiology and may guide future COVID-19 treatment development.

Rapid Development of Achalasia After SARS-CoV-2 Infection: Polymerase Chain Reaction Analysis of Esophageal Muscle Tissue

INTRODUCTION

Achalasia has been linked to viruses. We have observed cases of rapid-developing achalasia post-coronavirus disease 2019 (COVID-19).

METHODS

We aimed to prospectively evaluate esophageal muscle for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) from patients with rapid-onset achalasia post-COVID-19 and compare them with achalasia predating COVID-19 and achalasia with no COVID-19.

RESULTS

Compared with long-standing achalasia predating COVID-19 and long-standing achalasia with no COVID-19, the subjects with achalasia post-COVID-19 had significantly higher levels of messenger RNA for the SARS-CoV-2 nucleocapsid (N) protein, which correlated with a significant increase in the inflammatory markers NOD-like receptor family pyrin domain-containing 3 and tumor necrosis factor.

DISCUSSION

SARS-CoV-2, the virus responsible for COVID-19, is a possible trigger for achalasia.

Nurses' knowledge and protective health behaviors about prevention of COVID-19 pandemic complications at Baghdad Teaching Hospitals

BACKGROUND

Coronavirus disease (COVID-19) is a global pandemic caused by the severe acute respiratory syndrome coronavirus, SARS-CoV-2. Infection with SARS-CoV-2 primarily occurs through binding to angiotensin-converting enzyme-2 (ACE2), which is abundantly expressed in various anatomical sites, including the nasopharynx, lungs, cardiovascular system, and gastrointestinal and genitourinary tracts. This study aimed to nurses' knowledge and protective health behaviors about prevention of covid-19 pandemic complications.

MATERIALS AND METHODS

A descriptive design study was conducted from October 1, 2022, to March 15, 2023. A non-probability purposive sample of 50 nurses from different educational levels, genders, and departments at Baghdad teaching hospitals was selected. Data collected were analyzed using SPSS version 25.0.

RESULTS

The study comprised an equal distribution of male and female participants, with the majority (44%) aged between 22 and 30 years. A significant proportion (52%) of nurses held institute degrees. Forty-six percent were single, and the majority (74%) had 1-5 years of experience. The mean scores were 0.70 for nurses' knowledge and 3.22 for nurses' protective health behaviors.

CONCLUSIONS

The findings indicate that nurses possess satisfactory knowledge and exhibit high levels of protective health behaviors regarding complications associated with the COVID-19 pandemic. It is recommended to conduct future research focusing on nurses' knowledge and practices related to patient care in the context of a pandemic.

Acalculous Cholecystitis in COVID-19 Patients: A Narrative Review

Acute acalculous cholecystitis (AAC) represents cholecystitis without gallstones, occurring in approximately 5-10% of all cases of acute cholecystitis in adults. Several risk factors have been recognized, while infectious diseases can be a cause of cholecystitis in otherwise healthy people. Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has spread worldwide, leading to an unprecedented pandemic. The virus enters cells through the binding of the spike protein to angiotensin-converting enzyme 2 (ACE2) receptors expressed in many human tissues, including the epithelial cells of the gastrointestinal (GI) tract, and this explains the symptoms emanating from the digestive system. Acute cholecystitis has been reported in patients with COVID-19. The purpose of this review is to provide a detailed analysis of the current literature on the pathogenesis, diagnosis, management, and outcomes of AAC in patients with COVID-19.

Prevalence of SARS-CoV-2 variants in Prague wastewater determined by nanopore-based sequencing

The early detection of upcoming disease outbreaks is essential to avoid both health and economic damage. The last four years of COVID-19 pandemic have proven wastewater-based epidemiology is a reliable system for monitoring the spread of SARS-CoV-2, a causative agent of COVID-19, in an urban population. As this monitoring enables the identification of the prevalence of spreading variants of SARS-CoV-2, it could provide a critical tool in the fight against this viral disease. In this study, we evaluated the presence of variants and subvariants of SARS-CoV-2 in Prague wastewater using nanopore-based sequencing. During August 2021, the data clearly showed that the number of identified SARS-CoV-2 RNA copies increased in the wastewater earlier than in clinical samples indicating the upcoming wave of the Delta variant. New SARS-CoV-2 variants consistently prevailed in wastewater samples around a month after they already prevailed in clinical samples. We also analyzed wastewater samples from smaller sub-sewersheds of Prague and detected significant differences in SARS-CoV-2 lineage progression dynamics among individual localities studied, e.g., suggesting faster prevalence of new variants among the sites with highest population density and mobility.

Elevated level of circulating calprotectin correlates with severity and high mortality in patients with COVID-19

BACKGROUND

Patients with coronavirus disease-2019 (COVID-19) are characterized by hyperinflammation. Calprotectin (S100A8/S100A9) is a calcium- and zinc-binding protein mainly secreted by neutrophilic granulocytes or macrophages and has been suggested to be correlated with the severity and prognosis of COVID-19.

AIM

To thoroughly evaluate the diagnostic and prognostic utility of calprotectin in patients with COVID-19 by analyzing relevant studies.

METHODS

PubMed, Web of Science, and Cochrane Library were comprehensively searched from inception to August 1, 2023 to retrieve studies about the application of calprotectin in COVID-19. Useful data such as the level of calprotectin in different groups and the diagnostic efficacy of this biomarker for severe COVID-19 were extracted and aggregated by using Stata 16.0 software.

RESULTS

Fifteen studies were brought into this meta-analysis. First, the pooled standardized mean differences (SMDs) were used to estimate the differences in the levels of circulating calprotectin between patients with severe and non-severe COVID-19. The results showed an overall estimate of 1.84 (95% confidence interval [CI]: 1.09-2.60). Diagnostic information was extracted from 11 studies, and the pooled sensitivity and specificity of calprotectin for diagnosing severe COVID-19 were 0.75 (95% CI: 0.64-0.84) and 0.88 (95% CI: 0.79-0.94), respectively. The AUC was 0.89 and the pooled DOR was 18.44 (95% CI: 9.07-37.51). Furthermore, there was a strong correlation between elevated levels of circulating calprotectin and a higher risk of mortality outcomes in COVID-19 patients (odds ratio: 8.60, 95% CI: 2.17-34.12; p < 0.1).

CONCLUSION

This meta-analysis showed that calprotectin was elevated in patients with severe COVID-19, and this atypical inflammatory cytokine might serve as a useful biomarker to distinguish the severity of COVID-19 and predict the prognosis.

Atypical Complications during the Course of COVID-19: A Comprehensive Review

COVID-19 is primarily a respiratory disease, but numerous studies have indicated the involvement of various organ systems during the course of illness. We conducted a comprehensive review of atypical complications of COVID-19 with their incidence range (IR) and their impact on hospitalization and mortality rates. We identified 97 studies, including 55 research articles and 42 case studies. We reviewed four major body organ systems for various types of atypical complications: (i) Gastro-intestinal (GI) and hepatobiliary system, e.g., bowel ischemia/infarction (IR: 1.49-83.87%), GI bleeding/hemorrhage (IR: 0.47-10.6%), hepatic ischemia (IR: 1.0-7.4%); (ii) Neurological system, e.g., acute ischemic stroke/cerebral venous sinus thrombosis/cerebral hemorrhage (IR: 0.5-90.9%), anosmia (IR: 4.9-79.6%), dysgeusia (IR: 2.8-83.38%), encephalopathy/encephalitis with or without fever and hypoxia (IR: 0.19-35.2%); (iii) Renal system, e.g., acute kidney injury (AKI)/acute renal failure (IR: 0.5-68.8%); (iv) Cardiovascular system, e.g., acute cardiac injury/non-coronary myocardial injury (IR: 7.2-55.56%), arrhythmia/ventricular tachycardia/ventricular fibrillation (IR: 5.9-16.7%), and coagulopathy/venous thromboembolism (IR: 19-34.4%). This review encourages and informs healthcare practitioners to keenly monitor COVID-19 survivors for these atypical complications in all major organ systems and not only treat the respiratory symptoms of patients. Post-COVID effects should be monitored, and follow-up of patients should be performed on a regular basis to check for long-term complications.

Gastrointestinal Tract and Kidney Injury Pathogenesis in Post-COVID-19 Syndrome

COVID-19 is a global health emergency that requires worldwide collaboration to control its spread. The scientific community is working to understand the different aspects of the post-COVID-19 syndrome and potential treatment strategies. Interestingly, there have been reports of gastrointestinal tract (GIT) involvement in the post-COVID-19 syndrome, suggesting the presence of both severe and mild GIT disorders. The development of the post-COVID-19- GIT syndrome involves various factors, such as impaired GIT mucosa cells, disruptions in the feeling of satiety, reduced blood supply due to the formation of small blood clots, and increased prostaglandin secretion caused by an excessive immune response. GIT symptoms have been observed in around 16% of COVID-19 patients. Other complications include kidney damage and prolonged impairment in the filtration and excretion functions of the glomeruli and tubules. The pathogenesis of post-COVID-19 renal syndrome involves factors, like an overactive immune response, reduced lung perfusion and oxygenation, viral infection in kidney tissues, endothelial dysfunction, and decreased blood volume. Roughly 20% of hospitalized patients experience renal manifestations after recovering from COVID-19.

Abdominopelvic CT in COVID-19 patients with abdominal complaints including both waves and controls: reader agreement and overcalls after consensus review

BACKGROUND

Since many COVID-19 publications lack consensus reviews or controls, interpretive accuracy is unclear; abdominal processes unique or infrequent during the pandemic remain unknown. The incidence and nature of CT findings accounting for abdominal complaints in COVID patients, reader agreement and overcalling will be determined.

METHODS

A retrospective study was performed on COVID patients with abdominal complaints from 3/15/2020-5/31/2020 and 11/1/2020-4/15/2021 including matched controls. Reviewers blinded to initial reads interpreted abdominopelvic CT exams, with discordant cases resolved in consensus. Reader agreement was measured by Cohen's Kappa, differences between cohorts by permutation tests and factors affecting false positive/negative rates by Fisher's Exact Test and logistic regression.

RESULTS

116 first wave (average age 65 years [±15.3], 63 [54%] women) and 194 second wave COVID cases (average age 64 years [±16.3], 103 [53%] women) including 116 wave 1 and 194 wave 2 prepandemic controls were included. Concordance was lower among COVID cases than controls (Cohen's Kappa of 0.58 vs. 0.82 [p ≤ 0.001]) and among wave 1 than wave 2 cases (Cohen's Kappa of 0.45 vs. 0.66 [p = 0.052]). With true positives defined as consensus between the initial reader and study reader, false positive rates were higher among COVID cases than controls (OR = 0.42, p = 0.003) and for initial than study reader (OR = 0.36, p ≤ 0.001), but lower in wave 2 than 1 (OR = 0.5, p = 0.028).

CONCLUSION

Greater reader disagreement occurred during COVID than prepandemic with no reader bias as both initial and study readers called more false positives among COVID cases than controls. More overcalling occurred during COVID with colitis and cystitis most common.

Antimicrobial and anti-viral effects of selenium nanoparticles and selenoprotein based strategies: COVID-19 and beyond

Deficiency of selenium (Se) has been described in a significant number of COVID-19 patients having a higher incidence of mortality, which makes it a pertinent issue to be addressed clinically for effective management of the COVID-19 pandemic. Se nanoparticles (SeNPs) provide a unique option for managing the havoc caused by the COVID-19 pandemic. SeNPs possess promising anti-inflammatory and anti-fibrotic effects by virtue of their nuclear factor kappa-light-chain-stimulator of activated B cells (NFκB), mitogen-activated protein kinase (MAPKs), and transforming growth factor-beta (TGF-β) modulatory activity. In addition, SeNPs possess remarkable immunomodulatory effects, making them a suitable option for supplementation with a much lower risk of toxicity compared to their elemental counterpart. Further, SeNPs have been shown to curtail viral and microbial infections, thus, making it a novel means to halt viral growth. In addition, it can be administered in the form of aerosol spray, direct injection, or infused thin-film transdermal patches to reduce the spread of this highly contagious viral infection. Moreover, a considerable decrease in the expression of selenoprotein along with enhanced expression of IL-6 in COVID-19 suggests a potential association among selenoprotein expression and COVID-19. In this review, we highlight the unique antimicrobial and antiviral properties of SeNPs and the immunomodulatory potential of selenoproteins. We provide the rationale behind their potentially interesting properties and further exploration in the context of microbial and viral infections. Further, the importance of selenoproteins and their role in maintaining a successful immune response along with their association to Se status is summarized.

Acute abdomen in patients with covid-19: an integrative review

INTRODUCTION

upon infection with SARS-CoV-2, patients presented with non-classical symptoms, such as gastrointestinal phenomena including loss of appetite, nausea, vomiting, diarrhea, and abdominal pain abdominal pain. These occurrences, typically, were found in severely affected patients with COVID-19. With this, the aim of this paper is to analyze the available knowledge on the development of acute abdomen in SARS-CoV-2 infected patients.

METHODOLOGY

this is an Integrative Review in PubMed, Web of Science and VHL databases. The following descriptors were used: "Acute abdomen", "COVID-19", "Abdominal pain" and "SARS-CoV-2" with the Boolean operator "AND", and articles relevant to the theme were selected. Initially, 331 articles were selected, all published between 2020 and 2023, in Portuguese and/or English. After analysis, 11 articles matched the proposed objective.

RESULTS

the relationship between tenderness in the right upper region or the presence of Murphy's sign contributed in the association between abdominal pain and the more severe forms of COVID-19 in infected patients. The number of diagnoses for acute conditions such as cholecystitis, appendicitis, diverticulitis and pancreatitis decreased with the pandemic, but at the same time there was an increase in the duration of surgical procedures and in the length of hospital stays. These acute abdominal conditions were the result of delayed demand for hospital care, which also contributed to an increase in the conversion rate to open surgery and in the number of perforative conditions.

CONCLUSION

the development of acute abdomen in SARS-CoV-2 infected patients was predictive of an unfavorable prognosis.

Hypercoagulability status, operative mortality, and long-term survival in patients operated on for mesenteric venous thrombosis

OBJECTIVE

Mesenteric venous thrombosis (MVT) is a rare cause of acute surgical abdomen, with high mortality. The aim of this study was to analyze long-term outcomes and possible factors influencing its prognosis.

METHODS

All patients who underwent urgent surgery for MVT from 1990 to 2020 in our center were reviewed. Epidemiological, clinical, and surgical data; postoperative outcomes; origin of thrombosis; and long-term survival were analyzed. Patients were divided into two groups: primary MVT (hypercoagulability disorders or idiopathic MVT) and secondary MVT (underlying disease).

RESULTS

Fifty-five patients, 36 (65.5%) men and 19 (34.5%) women, mean age 66.7 years (standard deviation: ±18.0 years), underwent surgery for MVT. Arterial hypertension (63.6%) was the most prevalent comorbidity. Regarding the possible origin of MVT, 41 (74.5%) patients had primary MVT and 14 (25.5%) patients had secondary MVT. From these, 11 (20%) patients had hypercoagulable states, 7 (12.7%) had neoplasia, 4 (7.3%) had abdominal infection, 3 (5.5%) had liver cirrhosis, 1 (1.8%) patient had recurrent pulmonary thromboembolism, and 1 (1.8%) had deep venous thrombosis. Computed tomography was diagnostic of MVT in 87.9% of the cases. Intestinal resection was performed in 45 patients due to ischemia. Only 6 patients (10.9%) had no complication, 17 patients (30.9%) presented minor complications, and 32 patients (58.2%) presented severe complications according to the Clavien-Dindo classification. Operative mortality was 23.6%. In univariate analysis, comorbidity measured by the Charlson index (P = .019) and massive ischemia (P = .002) were related to operative mortality. The probability of being alive at 1, 3, and 5 years was 66.4%, 57.9%, and 51.0%, respectively. In univariate analysis of survival, age (P < .001), comorbidity (P < .001), and type of MVT (P = .003) were associated with a good prognosis. Age (P = .002; hazard ratio: 1.05, 95% confidence interval: 1.02-1.09) and comorbidity (P = .019; hazard ratio: 1.28, 95% confidence interval: 1.04-1.57) behaved as independent prognostic factors for survival.

CONCLUSIONS

Surgical MVT continues to show high lethality. Age and comorbidity according to the Charlson index correlate well with mortality risk. Primary MVT tends to have a better prognosis than secondary MVT.

Acute colonic pseudo-obstruction syndrome in patients with severe COVID-19 in Buenos Aires, Argentina

BACKGROUND

Several gastrointestinal complications have been reported in patients with COVID-19, including motility disorders, such as acute colonic pseudo-obstruction (ACPO). This affection is characterized by colonic distention in the absence of mechanical obstruction. ACPO in the context of severe COVID-19 may be related to neurotropism and direct damage of SARS-CoV-2 in enterocytes.

METHOD

We conducted a retrospective study of patients who were hospitalized for critical COVID-19 and developed ACPO between March 2020 and September 2021. The diagnostic criteria to define ACPO was the presence of 2 or more of the following: abdominal distension, abdominal pain, and changes in the bowel movements, associated with distension of the colon in computed tomography. Data of sex, age, past medical history, treatment, and outcomes were collected.

RESULTS

Five patients were detected. All required admission to the Intensive Care Unit. The ACPO syndrome developed with a mean of 33.8 days from the onset of symptoms. The mean duration of the ACPO syndrome was 24.6 days. The treatment included colonic decompression with placement of rectal and nasogastric tubes, endoscopy decompression in two patients, bowel rest, fluid, and electrolytes replacement. One patient died. The remaining resolved the gastrointestinal symptoms without surgery.

CONCLUSIONS

ACPO is an infrequent complication in patients with COVID-19. It occurs especially in patients with critical condition, who require prolonged stays in intensive care and multiple pharmacological treatments. It is important to recognize its presence early and thus establish an appropriate treatment, since the risk of complications is high.

Post-infection functional gastrointestinal disorders following coronavirus disease-19: a prospective follow-up cohort study

BACKGROUND

Acute gastrointestinal infections can lead to post-infectious irritable bowel syndrome (PI-IBS). Moreover, coronavirus disease (COVID-19) is related to long-term gastrointestinal sequelae. In this study, the frequency, disease spectrum, and risk factors for post-infection functional gastrointestinal disease (PI-FGID) in COVID-19 patients and healthy controls were prospectively examined.

METHODS

Validated Rome III and Rome IV questionnaires and limited objective assessment were used to assess the incidence of PI-FGID in 190 COVID-19 patients, and 160 healthy controls prospectively followed for 1, 3, and 6 months.

RESULTS

Six(3.2%), 1(0.5%), 3(1.6%), 5(2.6%), 6(3.2%)COVID-19 patients had diarrhea, abdominal pain, constipation, dyspepsia and their overlap at 1 month, respectively, while 4(2.1%), 1(0.5%), 4(2.1%), 4(2.1%), and 6(3.2%)COVID-19 patients had diarrhea, abdominal pain, constipation, dyspepsia and their overlap at three months, respectively. Furthermore, 2(1.3%), 4(2.5%), and 3(1.9%)healthy controls developed constipation, dyspepsia, and their overlap at one month, respectively (P = 0.193), while 2(1.3%), 4(2.5%), and 2(1.3%)healthy controls developed constipation, dyspepsia and their overlap at three months, respectively (P = 0.286). FGIDs incidence was higher among COVID-19 patients(8.9%) than in healthy controls(3.1%) at 6-month follow-up (P = 0.025). Moreover, 7 (3.7%), 5 (2.6%), 3 (1.6%), and 2 (1.1%) COVID-19 patients developed IBS, functional dyspepsia(FD), functional diarrhea(FDr), functional constipation(FC)at six months, respectively, while only 2 (1.3%) and 3 (1.9%) healthy controls developed IBS and FD at six months, respectively. Notably, gastrointestinal(GI)symptoms at onset were the independent risk factors for post-COVID-19 FGIDs at six months.

CONCLUSIONS

COVID-19 increases new-onset PI-FGID at six months compared with healthy controls. GI symptom at the onset of COVID-19 is an independent risk factor for post-COVID-19 FGIDs.

The COVID-19 Infection Resulted Delayed Esophagogastroduodenoscopy in Patients Admitted with Variceal Bleeding: Hospital-Based Outcomes of a National Database

During the COVID-19 pandemic in 2020, most healthcare services, including inpatient and outpatient procedures, got delayed. We reviewed the effect of COVID-19 infection on the timing of esophagogastroduodenoscopy (EGD) in variceal bleeding patients and analyzed the complications of delayed EGD. Using the National Inpatient Sample (NIS) 2020, we identified patients admitted for variceal bleeding with COVID-19 infection. We performed a multivariable regression analysis and adjusted it for patient and hospital-related variables. The International Classification of Disease Tenth Revision (ICD-10) codes were used for patient selection. We measured the effect of COVID-19 on the timing of EGD and further analyzed the effect of delayed EGD on hospital-based outcomes. A total of 49,675 patients diagnosed with variceal upper gastrointestinal bleeding were analyzed, out of which 915 (1.84%) were COVID-19 positive. Variceal bleeding patients who were COVID-positive had a significantly lower rate of EGD performed within the first 24 h of admission (36.1% vs. 60.6% p = 0.001) compared to the patients who tested negative for COVID-19. The performance of EGD within 24 h of admission resulted in a decrease in all-cause mortality by 70% (adjusted odds ratio (AOR) 0.30, 95% CI 0.12-0.76, p = 0.01) compared to EGD after 24 h. A significant decrease was noted in the odds of ICU admission rate (AOR 0.37, 95% CI 0.14-0.97, p = 0.04) in patients who got EGD within the first 24 h of admission. No difference in odds of sepsis (AOR 0.44, 95% CI 0.15-1.30, p = 0.14) and vasopressor use (AOR 0.34, 95% CI 0.04-2.87, p = 0.32) was seen in COVID positive vs. COVID negative group. The hospital mean length of stay (2.14 days, 95% CI 4.35-0.06, p = 0.06), mean total charges ($51,936, 95% CI $106,688-$2816, p = 0.06), and total cost (11,489$, 95% CI 30,380$-7402$, p = 0.23) was similar in both COVID-positive and -negative groups. In our study, we found that the presence of COVID-19 infection in variceal bleeding patients resulted in a significant delay in EGD compared to COVID-negative patients. This delay in EGD resulted in increased all-cause mortality and intensive care unit admissions.

Subacute Enteritis Two Months After COVID-19 Pneumonia With Mucosal Bleeding, Perforation, and Internal Fistulas

Chronic sequelae of COVID-19 remain undetermined. We report a case of postinfection sequelae in a patient presenting with subacute obstruction 2 months after COVID-19 infection. A 34-year-old man with a prior prolonged hospital stay due to COVID-19 complicated by upper gastrointestinal (GI) bleed presented with subacute obstruction and failure to thrive. Upper GI push enteroscopy revealed residual ulcers and multiple proximal jejuno-jejunal fistulae. Midline laparotomy revealed strictures with dense intra-abdominal adhesions, a large jejuno-jejunal fistula, and evidence of prior jejunal perforation following severe COVID-19 infection. The patient recovered after small bowel resection with anastomoses and was discharged home. Histopathological examination of resected specimen confirmed transmural infarction with evidence of prior hemorrhage, diffuse ulcers, and multifocal inflammation. This is the first report of a chronic GI sequelae resulting from COVID-19. As the pandemic evolves, medical professionals must be vigilant to consider alternative GI diagnoses in the COVID-19 survivors.

COVID-19: Findings in nuclear medicine from head to toe

COVID-19 is a multisystemic disease, and hence its potential manifestations on nuclear medicine imaging can extend beyond the lung. Therefore, it is important for the nuclear medicine physician to recognize these manifestations in the clinic. While FDG-PET/CT is not indicated routinely in COVID-19 evaluation, its unique capability to provide a functional and anatomical assessment of the entire body means that it can be a powerful tool to monitor acute, subacute, and long-term effects of COVID-19. Single-photon scintigraphy is routinely used to assess conditions such as pulmonary embolism, cardiac ischemia, and thyroiditis, and COVID-19 may present in these studies. The most common nuclear imaging finding of COVID-19 vaccination to date is hypermetabolic axillary lymphadenopathy. This may pose important diagnostic and management dilemmas in oncologic patients, particularly those with malignancies where the axilla constitutes a lymphatic drainage area. This article aims to summarize the relevant literature published since the beginning of the pandemic on the intersection between COVID-19 and nuclear medicine.

Is perioperative COVID-19 really associated with worse surgical outcomes? A nationwide COVIDSurg propensity-matched analysis

BACKGROUND

Patients undergoing surgery with perioperative COVID-19 are suggested to have worse outcomes, but whether this is COVID-related or due to selection bias remains unclear. We aimed to compare the postoperative outcomes of patients with and without perioperative COVID-19.

METHODS

Patients with perioperative COVID-19 diagnosed within 7 days before or 30 days after surgery between February and July 2020 from 68 US hospitals in COVIDSurg, an international multicenter database, were 1:1 propensity score matched to patients without COVID-19 undergoing similar procedures in the 2012 American College of Surgeons National Surgical Quality Improvement Program database. The matching criteria included demographics (e.g., age, sex), comorbidities (e.g., diabetes, chronic obstructive pulmonary disease, chronic kidney disease), and operation characteristics (e.g., type, urgency, complexity). The primary outcome was 30-day hospital mortality. Secondary outcomes included hospital length of stay and 13 postoperative complications (e.g., pneumonia, renal failure, surgical site infection).

RESULTS

A total of 97,936 patients were included, 1,054 with and 96,882 without COVID-19. Prematching, COVID-19 patients more often underwent emergency surgery (76.1% vs. 10.3%, p < 0.001). A total of 843 COVID-19 and 843 non-COVID-19 patients were successfully matched based on demographics, comorbidities, and operative characteristics. Postmatching, COVID-19 patients had a higher mortality (12.0% vs. 8.1%, p = 0.007), longer length of stay (6 [2-15] vs. 5 [1-12] days), and higher rates of acute renal failure (19.3% vs. 3.0%, p < 0.001), sepsis (13.5% vs. 9.0%, p = 0.003), and septic shock (11.8% vs. 6.0%, p < 0.001). They also had higher rates of thromboembolic complications such as deep vein thrombosis (4.4% vs. 1.5%, p < 0.001) and pulmonary embolism (2.5% vs. 0.4%, p < 0.001) but lower rates of bleeding (11.6% vs. 26.1%, p < 0.001).

CONCLUSION

Patients undergoing surgery with perioperative COVID-19 have higher rates of 30-day mortality and postoperative complications, especially thromboembolic, compared with similar patients without COVID-19 undergoing similar surgeries. Such information is crucial for the complex surgical decision making and counseling of these patients.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level IV.

Intestinal barrier dysfunction as a key driver of severe COVID-19

The intestinal lumen harbors a diverse consortium of microorganisms that participate in reciprocal crosstalk with intestinal immune cells and with epithelial and endothelial cells, forming a multi-layered barrier that enables the efficient absorption of nutrients without an excessive influx of pathogens. Despite being a lung-centered disease, severe coronavirus disease 2019 (COVID-19) affects multiple systems, including the gastrointestinal tract and the pertinent gut barrier function. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can inflict either direct cytopathic injury to intestinal epithelial and endothelial cells or indirect immune-mediated damage. Alternatively, SARS-CoV-2 undermines the structural integrity of the barrier by modifying the expression of tight junction proteins. In addition, SARS-CoV-2 induces profound alterations to the intestinal microflora at phylogenetic and metabolomic levels (dysbiosis) that are accompanied by disruption of local immune responses. The ensuing dysregulation of the gut-lung axis impairs the ability of the respiratory immune system to elicit robust and timely responses to restrict viral infection. The intestinal vasculature is vulnerable to SARS-CoV-2-induced endothelial injury, which simultaneously triggers the activation of the innate immune and coagulation systems, a condition referred to as “immunothrombosis” that drives severe thrombotic complications. Finally, increased intestinal permeability allows an aberrant dissemination of bacteria, fungi, and endotoxin into the systemic circulation and contributes, to a certain degree, to the over-exuberant immune responses and hyper-inflammation that dictate the severe form of COVID-19. In this review, we aim to elucidate SARS-CoV-2-mediated effects on gut barrier homeostasis and their implications on the progression of the disease.

COVID-19, the Gut, and Nutritional Implications

PURPOSE OF REVIEW

Our goal is to provide the most recent and accurate scientific evidence available regarding COVID-19's interaction with the human gut and the role of nutrition/nutritional supplementation in the prevention and treatment of the disease.

RECENT FINDINGS

Gastrointestinal symptoms of COVID-19 are common and often persist even after classically defined illness resolution. Nutritional status and content have been shown to impact infection risk and severity. Well-balanced diets are associated with decreased infection risk/severity, and early nutrition is associated with better outcomes in the critically ill. No specific vitamin supplementation regimen has shown consistent benefit for infection treatment or prevention. The impact of COVID-19 extends far past the pulmonary system, and its impact on the gut should not be ignored. For those interested in adopting lifestyle modifications to prevent severe COVID-19 infection/side effects, consideration should be made for adoption of a well-balanced diet (e.g., Mediterranean style), utilization of probiotics, and addressing nutritional/vitamin deficiencies. Future, high-quality research is needed in this arena.

A Surgical Perspective of Gastrointestinal Manifestations and Complications of COVID-19 Infection

The coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, has quickly spread over the world since December 2019. COVID-19 is a systemic disease that can affect various organs throughout the body. Gastrointestinal (GI) symptoms have been reported in 16% to 33% of all patients with COVID-19 and in 75% of critically ill patients. This chapter reviews the GI manifestations of COVID-19 as well as their diagnostic and treatment modalities.

Surgical Implications of Coronavirus Disease-19

As the coronavirus disease-19 (COVID-19) pandemic continues to evolve in 2022 with the surge of novel viral variants, it is important for physicians to understand and appreciate the surgical implications of the pandemic. This review provides an overview of the implications of the ongoing COVID-19 pandemic on surgical care and provides recommendations for perioperative management. Most observational studies suggest a higher risk for patients undergoing surgery with COVID-19 compared with risk-adjusted non-COVID-19 patients.

Paralytic Ileus as an Extra-Pulmonary Manifestation of COVID-19

Extra-pulmonary manifestations of COVID-19 (SARS-CoV-2) are of increasing interest as a consequence of the increase in cases worldwide and a better understanding of the pathophysiology of the disease. However, gastrointestinal symptoms are rarely described but are a common occurrence. We report a case of a 62-year-old male with severe pulmonary infection with COVID-19, who presented with abdominal pain, hematemesis, bloody diarrhea, and abdominal distention, which led to the diagnosis of paralytic ileus after diagnostic laparoscopy. Further, we discuss the potential pathophysiological mechanisms behind this manifestation of COVID-19.

Commentary on COVID-19-induced liver injury in various age and risk groups

Towards the end of 2019, a new type of coronavirus, severe acute respiratory syndrome, emerged in the city of Wuhan in China's Hubei Province. The first occurrence was described as a case of pneumonia. Coronavirus disease 2019 (COVID-19) can progress primarily with symptoms varying from a mild upper respiratory tract infection to severe pneumonia, acute respiratory distress syndrome, and death. Determining the mechanisms of action of this virus, which can affect all systems including gastrointestinal, is vital for predicting the progression of the disease and managing its treatment. It is important to demonstrate the mechanisms of action of COVID-19 in patients without a previously known chronic or systemic disease. Although there is still no specific treatment for the virus, various algorithms have been created. As a result of the applied algorithms, the response to the treatment was satisfactory in some patients, while unexpected side effects occurred in some patients. It helps to clarify whether the unwanted effects that occur are due to the effect of the disease or the side effects of the drugs used in the treatment. There is currently increasing interest in COVID-19 interaction with liver tissue. Therefore, we would like to discuss the details of liver injury/dysfunction in the current literature.

SARS-CoV-2 and its impact on the cardiovascular and digestive systems - The interplay between new virus variants and human cells

Since infection with the novel coronavirus SARS-CoV-2 first emerged in Wuhan, China, in December 2019, the world has been battling the pandemic COVID-19. Patients of all ages and genders are now becoming infected with the new coronavirus variant (Omicron) worldwide, and its subvariants continue to pose a threat to health and life. This article provides a literature review of cardiovascular and gastrointestinal complications resulting from SARS-CoV-2 infection. COVID-19 primarily caused respiratory symptoms, but complications can affect many vital organs. SARS-CoV-2 binds to a human cell receptor (angiotensin-converting enzyme 2 - ACE2) that is predominantly expressed primarily in the heart and gastrointestinal tract, which is why we focused on complications in these organs. Since the high transmissibility of Omicron and its ability to evade the immune system have raised worldwide concern, we have tried to summarise the current knowledge about its development from a structural point of view and to highlight the differences in its binding to human receptors and proteases compared to previous VOC.

COVID, the Gut, and Nutritional Implications

Purpose of Review

The purpose of this review is to provide an overview of the current literature, recommendations, and practice guidelines on the nutritional management of and implications associated with COVID-19 infection.

Recent Findings

Particular attention should be paid to the screening, prevention, and treatment of malnutrition in critically ill individuals with COVID-19 infection given the significant risk for complications and poor outcomes. Extrapolation of existing literature for the nutritional support in the critically ill patient has demonstrated early enteral nutrition is safe and well-tolerated in patients with severe COVID-19 infection.

Summary

Futures studies should focus on the long-term nutritional outcomes for patients who have suffered COVID-19 infection, nutritional outcomes/recommendations for special populations with COVID-19, nutritional outcomes based on the current recommendations and guidelines for nutrition therapy, and the role for micronutrient supplementation in COVID-19 infection.

A Case Report of Bowel Perforation in a Gravid COVID-19 Patient

Background

Bowel perforation in a pregnant patient with COVID-19 infection is a rarely reported complication. With the uncovering of the different treatment modalities and complications of this disease, this case highlights diagnostic and therapeutic dilemmas and limitations in a special population. Clinical Presentation. A 35-year-old female, Gravida 2 Para 1 at 31 weeks age of gestation (AOG) who underwent cesarean section for nonreassuring fetal status in 2019, was admitted for severe COVID-19 infection presenting with dyspnea. During her hospitalization, she developed progressive dyspnea from worsening of COVID-19 infection. Patient was eventually intubated and was given a total of two doses of tocilizumab, adequate antibiotic treatment, remdesivir, and dexamethasone. An emergency repeat cesarean section was performed due to maternal deterioration and poor variability of the fetus. She delivered to a live preterm baby girl, with an Apgar score of 1 and 7 on the 1st and 5th minute of life respectively. During the postoperative days, patient remained intubated and sedated. Increasing residuals were noted per nasogastric tube (NGT). Serial scout film of the abdomen (SFA) and medical management were performed. Upon weaning from sedation, patient complained of right lower quadrant pain. A whole abdominal computed tomography (CT) scan with contrast was requested which revealed large bowel obstruction. Patient was referred to surgery service. Upon assessment, abdomen was noted to be rigid with guarding during palpation. A scout film of the abdomen was requested and revealed extensive amount of pneumoperitoneum with scanty to absent colonic gas suggestive of bowel perforation. Patient underwent emergency exploratory laparotomy. Upon opening the peritoneum, free air was evacuated. Approximately 1.4 liters of fecaloid peritoneal fluid was suctioned and adhesive band was noted at the pelvic area. A 2 cm full thickness perforation at the cecum with 17 cm serosal tear from the cecum to ascending colon was noted. Bowel loops proximal to the perforation were dilated. Nasogastric tube was inserted for bowel decompression. Right hemicolectomy was performed. Specimen was sent for histopathology. Acute inflammatory cells infiltrating the blood vessels and possible microthrombi and beginning thrombus formation were noted in the subserosa. Patient eventually expired on the 14^th hospital day from sepsis.

Conclusion

This case highlights a rarely reported complication of COVID-19 infection. Confluence of factors that predisposed the patient include pregnancy, COVID-19 infection, use of tocilizumab, and recent surgery. High index of suspicion is vital in the management and improvement of outcomes.

Is the Sars-CoV-2 virus a possible trigger agent for the development of achalasia?

BACKGROUND

Achalasia is an autoimmune disease whose probable causal agent is a neurotropic virus that chronically infects the myenteric plexus of the esophagus and induces the disease in a genetically susceptible host. The association between achalasia and coronaviruses has not been reported.

AIMS

To evaluate the presence of the SARS-CoV-2 virus, the ACE2 expression, the tissue architecture, and immune response in the lower esophageal sphincter muscle (LESm) of achalasia patients who posteriorly had SARS-CoV-2 (achalasia-COVID-19) infection before laparoscopic Heller myotomy (LHM) and compare the findings with type II achalasia patients and transplant donors (controls) without COVID-19.

METHODS

The LESm of 7 achalasia-COVID-19 patients (diagnosed by PCR), ten achalasia patients, and ten controls without COVID-19 were included. The presence of the virus was evaluated by in situ PCR and immunohistochemistry. ACE2 receptor expression and effector CD4 T cell and regulatory subsets were determined by immunohistochemistry.

KEY RESULTS

Coronavirus was detected in 6/7 patients-COVID-19. The SARS-CoV-2 was undetectable in the LESm of the achalasia patients and controls. ACE2 receptor was expressed in all the patients and controls. One patient developed achalasia type II post-COVID-19. The percentage of Th22/Th17/Th1/pDCreg was higher in achalasia and achalasia-COVID-19 pre-HLM vs. controls. The Th2/Treg/Breg cell percentages were higher only in achalasia vs. controls.

CONCLUSION & INFERENCES

SARS-CoV2 and its receptor expression in the LESm of achalasia patients who posteriorly had COVID-19 but not in the controls suggests that it could affect the myenteric plexus. Unlike achalasia, patients-COVID-19 have an imbalance between effector CD4 T cells and the regulatory mechanisms.

Risk stratification for selecting empiric antibiotherapy during and after COVID-19

PURPOSE OF REVIEW

SARS-CoV-2 deeply modified the risk of bacterial infection, bacterial resistance, and antibiotic strategies. This review summarized what we have learned.

RECENT FINDINGS

During the COVID-19 pandemic, we observed an increase in healthcare-acquired infection and multidrug-resistant organism-related infection, triggered by several factors: structural factors, such as increased workload and ongoing outbreaks, underlying illnesses, invasive procedures, and treatment-induced immunosuppression. The two most frequently healthcare-acquired infections described in patients hospitalized with COVID-19 were bloodstream infection, related or not to catheters, health-acquired pneumonia (in ventilated or nonventilated patients). The most frequent species involved in bacteremia were Gram-positive cocci and Gram-negative bacilli in health-acquired pneumonia. The rate of Gram-negative bacilli is particularly high in late-onset ventilator-associated pneumonia, and the specific risk of Pseudomonas aeruginosa- related pneumonia increased when the duration of ventilation was longer than 7 days. A specificity that remains unexplained so far is the increase in enterococci bacteremia.

SUMMARY

The choice of empiric antibiotimicrobials depends on several factors such as the site of the infection, time of onset and previous length of stay, previous antibiotic therapy, and known multidrug-resistant organism colonization. Pharmacokinetics of antimicrobials could be markedly altered during SARS-CoV-2 acute respiratory failure, which should encourage to perform therapeutic drug monitoring.

Feeding intolerance in critically ill patients with COVID-19

BACKGROUND & AIMS

Early reports suggest significant difficulty with enteral feeding in critically ill COVID-19 patients. This study aimed to characterize the prevalence, clinical manifestations, and outcomes of feeding intolerance in critically ill patients with COVID-19.

METHODS

We examined 323 adult patients with COVID-19 admitted to the intensive care units (ICUs) of Massachusetts General Hospital between March 11 and June 28, 2020 who received enteral nutrition. Systematic chart review determined prevalence, clinical characteristics, and hospital outcomes (ICU complications, length of stay, and mortality) of feeding intolerance.

RESULTS

Feeding intolerance developed in 56% of the patients and most commonly manifested as large gastric residual volumes (83.9%), abdominal distension (67.2%), and vomiting (63.9%). Length of intubation (OR 1.05, 95% CI 1.03-1.08), ≥1 GI symptom on presentation (OR 0.76, 95% CI 0.59-0.97), and severe obesity (OR 0.29, 95% CI 0.13-0.66) were independently associated with development of feeding intolerance. Compared to feed-tolerant patients, patients with incident feeding intolerance were significantly more likely to suffer cardiac, renal, hepatic, and hematologic complications during their hospitalization. Feeding intolerance was similarly associated with poor outcomes including longer ICU stay (median [IQR] 21.5 [14-30] vs. 15 [9-22] days, P < 0.001), overall hospitalization time (median [IQR] 30.5 [19-42] vs. 24 [15-35], P < 0.001) and in-hospital mortality (33.9% vs. 16.1%, P < 0.001). Feeding intolerance was independently associated with an increased risk of death (HR 3.32; 95% CI 1.97-5.6).

CONCLUSIONS

Feeding intolerance is a frequently encountered complication in critically ill COVID-19 patients in a large tertiary care experience and is associated with poor outcomes.

The Incidence of Post-infectious Irritable Bowel Syndrome, Anxiety, and Depression in Iranian Patients with Coronavirus Disease 2019 Pandemic: A Cross-Sectional Study

BACKGROUND

Irritable bowel syndrome refers to a subgroup of disorders of gut-brain interaction associated with stress-related symptoms, but gastrointestinal infection can also be considered the leading risk factor. It is well reported that coronavirus disease 2019 can also result in gastroenteritis. Therefore, this study aimed to evaluate the incidence of post-infectious irritable bowel syndrome and stressful status among coronavirus disease 2019 patients.

METHODS

This cross-sectional study was conducted on adults with coronavirus disease 2019 referred to the Infectious Disease Clinic in Iran from November 2020 to February 2021. Patients who met all eligibility criteria were included in the study. The data were collected using a demographic questionnaire, Rome IV criteria questionnaire, and Hospital Anxiety and Depression Scale.

RESULTS

Totally, the data obtained from 233 eligible patients (136 women, 97 men; mean age 38.41) 11.52 (years) were collected and analyzed, and 53.2% of the cases had a moderate coronavirus disease 2019. The analysis showed that 27 (11.6%) patients suffered from irritable bowel syndrome symptoms based on Rome IV criteria after the recovery from the infection. Also, Hospital Anxiety and Depression Scale-based symptoms of depression and anxiety that occurred with coronavirus disease 2019 were reported in 27.4% and 36.9%, respectively.

CONCLUSION

Our finding illustrated that irritable bowel syndrome symptoms based on Rome IV could occur in post-infected coronavirus disease 2019 patients. Also, Hospital Anxiety and Depression Scale-based symptoms of depression and anxiety were more common in females and coronavirus disease 2019 infected patients with clinical symptoms including cough, shortness of breath, and sore throat.

Nutritional intake and gastro-intestinal symptoms in critically ill COVID-19 patients

BACKGROUND & AIMS

Critically ill COVID-19 patients seem hypermetabolic and difficult to feed enterally, due to gastro-intestinal (GI) symptoms such as high gastric residual volumes (GRV) and diarrhea. Our aim was to describe the association of nutritional intake and GI symptoms during first 14 days of ICU admission.

METHODS

Observational study including critically ill adult COVID-19 patients. Data on nutritional intake [enteral nutrition (EN) or parenteral nutrition] and GI symptoms were collected during 14 days after ICU admission. Target energy and protein feeding goals were calculated conform ESPEN guidelines. GI symptoms included GRV (ml/d), vomiting, abdominal distension, and faeces (ml/d). High GRV's were classified as ≥2 times ≥150 ml/d and diarrhea as Bristol stool chart ≥6. GI symptoms were defined as mild if at least one symptom occurred and as moderate when ≥2 symptoms occurred. Acute gastrointestinal injury (AGI) grades of III were classified as GI dysfunction and grades of IV were considered as GI failure with severe impact on distant organs. Linear mixed model analysis was performed to explore the development of nutritional intake and GI symptoms over time at day (D) 0, 4, 10, and 14.

RESULTS

One hundred and fifty patients were included [75% male; median age 64 years (IQR 54-70)]. BMI upon admission was 28 kg/m² (IQR 25-33), of which 43% obese (BMI > 30 kg/m²). Most patients received EN during admission (98% D4; 96% D10-14). Mean energy goals increased from 87% at D4 to 93% D10-14 and protein goals (g/kg) were increasingly achieved during admission (84% D4; 93% D10-14). Presence of moderate GI symptoms decreased (10% D0; 6% D4-10; 5% D14), reversely mild GI symptoms increased. Occurrence of GI dysfunction fluctuated (1% D0; 18% D4; 12% D10; 8% D14) and none of patients developed grade IV GI failure. Development of high GRV fluctuated (5% D0; 23% D4; 14% D10; 8% D14) and occurrence of diarrhea slightly increased during admission (5% D0; 22% D4; 25% D10; 27% D14). Linear mixed models showed only an association between AGI grades III and lower protein intake at day 10 (p = 0.020).

CONCLUSION

Occurrence of GI symptoms was limited and seems no major barrier for EN in our group of critically COVID-19 patients. Nutritional intake was just below requirements during the first 14 days of ICU admission. The effect on nutritional status remains to be studied.

Impact of nutritional therapy during the first wave of the COVID-19 pandemic in intensive care patients: A retrospective observational study

BACKGROUND & AIMS

The COVID-19 pandemic has caused major organizational challenges to healthcare systems concerning staff, material and bed availability. Nutrition was not a priority in the intensive care unit (ICU) at the beginning of the pandemic with the need for simplified protocols. We aimed to assess the impact of a simplified nutritional protocol for critically ill COVID-19 patients during the pandemic first wave.

METHODS

We included all patients with SARS-CoV-2 infections, admitted to the ICU of the Geneva University Hospitals for at least 4 days from March 9 to May 19, 2020. Data on the route and solution of nutritional therapy, prescribed and received volume, calorie and protein intake, amount of insulin, propofol and glucose administered were collected daily during the entire ICU stay. We compared nutritional outcomes between patients admitted to the ICU before and after implementing the simplified nutritional protocol using unpaired t-test.

RESULTS

Out of 119 patients, 48 were hospitalized in the ICU before, 47 across and 24 after the implementation of the nutritional protocol. The mean age was 63.2 (±12.7) years and 76% were men without significant difference between before and after group. The nutritional protocol implementation led to an increase in caloric intake (1070 vs. 1357 kcal/day, p = 0.018) and in the percentage of days within 80-100% of the energy target (11 vs. 20%, p = 0.021). The protein debt decreased significantly from 48 g/day to 37 g/day (p = 0.015). No significant difference in the percentage of days within the protein target (80-100%) was observed.

CONCLUSIONS

Calorie and protein coverage improved after the implementation of the simplified nutritional protocol in critically ill COVID-19 patients. Further studies are needed to assess the impact of such an approach on patients' clinical outcomes.

Different epidemiology of bloodstream infections in COVID-19 compared to non-COVID-19 critically ill patients: a descriptive analysis of the Eurobact II study

BACKGROUND

The study aimed to describe the epidemiology and outcomes of hospital-acquired bloodstream infections (HABSIs) between COVID-19 and non-COVID-19 critically ill patients.

METHODS

We used data from the Eurobact II study, a prospective observational multicontinental cohort study on HABSI treated in ICU. For the current analysis, we selected centers that included both COVID-19 and non-COVID-19 critically ill patients. We performed descriptive statistics between COVID-19 and non-COVID-19 in terms of patients' characteristics, source of infection and microorganism distribution. We studied the association between COVID-19 status and mortality using multivariable fragility Cox models.

RESULTS

A total of 53 centers from 19 countries over the 5 continents were eligible. Overall, 829 patients (median age 65 years [IQR 55; 74]; male, n = 538 [64.9%]) were treated for a HABSI. Included patients comprised 252 (30.4%) COVID-19 and 577 (69.6%) non-COVID-19 patients. The time interval between hospital admission and HABSI was similar between both groups. Respiratory sources (40.1 vs. 26.0%, p < 0.0001) and primary HABSI (25.4% vs. 17.2%, p = 0.006) were more frequent in COVID-19 patients. COVID-19 patients had more often enterococcal (20.5% vs. 9%) and Acinetobacter spp. (18.8% vs. 13.6%) HABSIs. Bacteremic COVID-19 patients had an increased mortality hazard ratio (HR) versus non-COVID-19 patients (HR 1.91, 95% CI 1.49-2.45).

CONCLUSIONS

We showed that the epidemiology of HABSI differed between COVID-19 and non-COVID-19 patients. Enterococcal HABSI predominated in COVID-19 patients. COVID-19 patients with HABSI had elevated risk of mortality. Trial registration ClinicalTrials.org number NCT03937245 . Registered 3 May 2019.

Microbiological and Clinical Findings of SARS-CoV-2 Infection after 2 Years of Pandemic: From Lung to Gut Microbiota

Early recognition and prompt management are crucial for improving survival in COVID-19 patients, and after 2 years of the pandemic, many efforts have been made to obtain an early diagnosis. A key factor is the use of fast microbiological techniques, considering also that COVID-19 patients may show no peculiar signs and symptoms that may differentiate COVID-19 from other infective or non-infective diseases. These techniques were developed to promptly identify SARS-CoV-2 infection and to prevent viral spread and transmission. However, recent data about clinical, radiological and laboratory features of COVID-19 at time of hospitalization could help physicians in early suspicion of SARS-CoV-2 infection and distinguishing it from other etiologies. The knowledge of clinical features and microbiological techniques will be crucial in the next years when the endemic circulation of SARS-CoV-2 will be probably associated with clusters of infection. In this review we provide a state of the art about new advances in microbiological and clinical findings of SARS-CoV-2 infection in hospitalized patients with a focus on pulmonary and extrapulmonary characteristics, including the role of gut microbiota.

Coronavirus Disease in the Abdomen

Numerous abdominal manifestations have been reported in patients with coronavirus disease 2019 (COVID-19), including involvement of the luminal gastrointestinal (GI) tract, hepatobiliary system, pancreas, kidneys, spleen, and blood vessels. Although most of the associated radiological abnormalities are nonspecific without distinguishing imaging features to suggest COVID-19, unique presentations such as findings of bowel ischemia preceding gross findings of bowel necrosis have been reported. Awareness of the spectrum of abdominal manifestations of COVID-19 allows radiologists to optimize their search pattern and to raise the possibility of this etiology when appropriate. Awareness of the possible abdominal manifestations of COVID-19 should enhance detection by radiologists and improve patient care. This review provides a comprehensive overview with illustrative imaging examples of COVID-19 in the abdomen.

Life-threatening gastrointestinal haemorrhage requiring surgical resection caused by SARS-CoV-2 induced ANCA associated vasculitis: A case report

Introduction and importance

SARS-CoV-2 infection has been linked to the de novo diagnosis of various autoimmune conditions as well as flares in pre-existing disease. With such high prevalence of SARS-CoV-2 in the community, it is important to consider rare manifestations of autoimmune conditions when patients present with severe symptoms. Multi-specialty care is required to ensure optimal outcomes and prompt diagnosis.

Case presentation

A 28-year-old male presented to our tertiary referral centre with progressive debilitating polyarthritis, a purpuric rash on both flanks and aphthous ulcers 6 weeks after infection with SARS-CoV-2. On the second day of admission, he developed severe gastrointestinal haemorrhage requiring multiple blood transfusions. Attempted angioembolisation failed to identify a site of active haemorrhage. On failing trial of conservative management, the decision was made to perform an exploratory laparotomy. The small bowel was found to have an extensive vasculitis requiring resection to control haemorrhage. Autoimmune serology revealed c-ANCA positivity with anti-PR3 antibodies.

Clinical discussion

Patients presenting with acute vasculitic pathologies related to SARS-CoV-2 have the potential to rapidly progress to severe life-threatening gastrointestinal haemorrhage. Prompt surgical management is appropriate in selected cases.

Conclusion

In the current era of COVID-19, the differential diagnosis of SARS-CoV-2 induced ANCA vasculitis must be considered for such cases with gastrointestinal haemorrhage. Compilation of similar cases and further studies are required to determine an optimal management pathway for these patients.

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SARS-CoV-2 has been associated with de novo autoimmune vasculitis.

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SARS-CoV-2 induced vasculitis can progress to severe intestinal bleeding.

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Surgical resection is paramount in refractory vasculitic gastrointestinal bleeding.

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Multi-speciality care is essential in cases of SARS-CoV-2 induced vasculitis.

An Uncommon Cause of Acute Pancreatitis in a Patient With COVID-19

Drug-induced pancreatitis is a rare though important condition that remains a diagnostic challenge. Most of the evidence relies on case reports, and clinicians should consider a high suspicion of the diagnosis after ruling out other causes. In particular, steroids are frequently used drugs that have recently been associated with acute pancreatitis. The authors present the case of a 60-year-old female admitted to the emergency room with a fever and shortness of breath. The SARS-CoV-2 test was positive, and the chest radiography was suggestive of COVID-19 pneumonia. The patient started dexamethasone because of respiratory failure. On Day 7, she developed epigastric pain radiating to the back and the amylase level was greater than 10 times the upper reference limit (1354 U/L). A detailed evaluation of the medical history, along with the exclusion of other possible etiologies confirmed the diagnosis of steroid-induced pancreatitis. Supportive care and cessation of the offending drug led to the resolution of symptoms. As steroids are used as part of the treatment of most COVID-19 patients, this case suggests the need to consider this entity, as a delay in the diagnosis may result in complications and prolonged hospital stay.

Nutrition support for critically ill patients during the COVID-19 pandemic: the Italian SIAARTI survey

Background

Critically ill, COVID-19 patients are characterized by a hypermetabolic state and a reduced food intake and are at high risk of malnutrition and lean body mass loss. An appropriate metabolic-nutritional intervention aims to reduce complications and improve the clinical outcomes. We conducted a cross-sectional, multicenter, observational, nationwide online survey involving Italian Intensivists to assess the nutritional practices in critically ill patients with COVID-19.

Results

A group of experts in nutrition of the Italian Society of Anaesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) developed a 24-item questionnaire; the 9000 members of the Society were invited to participate through emails and social networks. Data was collected from June 1 to August 1, 2021.

A total of 545 responses were collected: 56% in northern, 25% in central, and 20% in southern Italy. Artificial nutrition support is directly handled by intensivists in > 90 of the cases; the nutritional status is assessed as suggested by the guidelines in more than 70% of the cases, and a form of nutrition support is started within the first 48 h from ICU admission by > 90% of the respondents. Nutritional targets are reached in 4–7 days in > 75% of the cases, mainly by the enteral route. Indirect calorimetry, muscle ultrasound, and bioimpedance analysis are used by a limited part of the interviewees. Only about a half of the respondents reported the nutritional issues in the ICU discharge summary.

Conclusions

This survey among Italian Intensivists during the COVID-19 epidemic showed how the beginning, progression, and route of nutritional support adhere to international recommendations, while recommendations on the tools to set the target and monitor the efficacy of the metabolic support are less followed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44158-022-00063-6.

COVID-19-Associated Superior Mesenteric Artery Thrombosis and Acute Intestinal Ischemia

The prothrombotic nature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been well-established since the start of the global coronavirus disease 2019 (COVID-19) pandemic. Mesenteric artery thrombosis and acute mesenteric ischemia are, on their own, rare occurrences and often present with fatal gastrointestinal (GI) pathologies requiring quick identification and intervention by the clinician to improve clinical outcomes. SARS-CoV-2 infection can present with acute GI pathologies and warrants further investigation regarding anticoagulation therapy in COVID-19 positive patients. We report on a 64-year-old woman infected with SARS-CoV-2 who presented with superior mesenteric artery thrombosis and acute intestinal ischemia.

Twelve Months with COVID-19: What Gastroenterologists Need to Know

Corona virus disease-19 (COVID-19) is the latest global pandemic. COVID-19 is mainly transmitted through respiratory droplets and, apart from respiratory symptoms, patients often present with gastrointestinal symptoms and liver involvement. Given the high percentage of COVID-19 patients that present with gastrointestinal symptoms (GIS), in this review, we report a practical up-to-date reference for the physician in their clinical practice with patients affected by chronic gastrointestinal (GI) diseases (inflammatory bowel disease, coeliac disease, chronic liver disease) at the time of COVID-19. First, we summarised data on the origin and pathogenetic mechanism of SARS-CoV-2. Then, we performed a literature search up to December 2020 examining clinical manifestations of GI involvement. Next, we illustrated and summarised the most recent guidelines on how to adhere to GI procedures (endoscopy, liver biopsy, faecal transplantation), maintaining social distance and how to deal with immunosuppressive treatment. Finally, we focussed on some special conditions such as faecal-oral transmission and gut microbiota. The rapid accumulation of information relating to this condition makes it particularly essential to revise the literature to take account of the most recent publications for medical consultation and patient care.

Mortality and pulmonary complications in emergency general surgery patients with COVID-19: A large international multicenter study

OBJECTIVES

The outcomes of emergency general surgery (EGS) patients with concomitant COVID-19 infection remain unknown. With a multicenter study in 361 hospitals from 52 countries, we sought to study the mortality and pulmonary complications of COVID-19 patients undergoing EGS.

METHODS

All patients 17 years or older and diagnosed preoperatively with COVID-19 between February and July 2020 were included. Emergency general surgery was defined as the urgent/emergent performance of appendectomy, cholecystectomy, or laparotomy. The main outcomes were 30-day mortality and 30-day pulmonary complications (a composite of acute respiratory distress syndrome, unexpected mechanical ventilation, or pneumonia). Planned subgroup analyses were performed based on presence of preoperative COVID-related respiratory findings (e.g., cough, dyspnea, need for oxygen therapy, chest radiology abnormality).

RESULTS

A total of 1,045 patients were included, of which 40.1% were female and 50.0% were older than 50 years; 461 (44.1%), 145 (13.9%), and 439 (42.0%) underwent appendectomy, cholecystectomy, and laparotomy, respectively. The overall mortality rate was 15.1% (158 of 1,045 patients), and the overall pulmonary complication rate was 32.9% (344 of 1,045 patients); in the subgroup of laparotomy patients, the rates were 30.6% (134 of 438 patients) and 59.2% (260 of 439 patients), respectively. Subgroup analyses found mortality and pulmonary complication risk to be especially increased in patients with preoperative respiratory findings.

CONCLUSION

COVID-19 patients undergoing EGS have significantly high rates of mortality and pulmonary complications, but the risk is most pronounced in those with preoperative respiratory findings.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level IV.

Safe provision of elective endocrine surgery operations amid the COVID-19 crisis

INTRODUCTION

The aim of this study was to determine the impact of the COVID-19 pandemic on the provision of clinical services (perioperative clinical outcomes and productivity) of the department of endocrine and general surgery at a teaching hospital in the UK.

METHODS

A retrospective chart review was conducted of all patients who were operated in our department during two periods: 1 April to 31 October 2019 (pre-COVID-19 period) and 1 April to 31 October 2020 (COVID-19 period). The perioperative clinical outcomes and productivity of our department for the two time periods were compared.

RESULTS

In the pre-COVID-19 period, 130 operations were carried out, whereas in the COVID-19 group, this reduced to 89. The baseline characteristics between the two groups did not significantly differ. Parathyroid operations decreased significantly by 68% between the two study periods. Overall, during the COVID-19 phase, the department maintained 68% of its operating workload compared with the respective 2019 time period. The clinical outcomes for the patients who had a thyroid/parathyroid/adrenal operation were not statistically different for the two study periods. There were no COVID-19 related perioperative complications for any of the operated patients and no patient tested positive for COVID-19 while an inpatient. For the COVID-19 group, the department maintained 67% of its outpatient appointments for endocrine surgery and 26% for general surgery pathologies.

CONCLUSIONS

The COVID-19 pandemic significantly reduced the clinical activity of our department. However, it is possible to continue providing clinical services for urgent/cancer cases with the appropriate safety measures in place.

Significance of digestive symptoms after COVID-19 vaccination: A retrospective single-center study

Objective

There is insufficient research on digestive symptoms and outcomes following coronavirus disease (COVID-19) vaccination. We aimed to investigate digestive symptoms and related complications among South Koreans who were administered COVID-19 vaccines.

Methods

Forty-six patients (men: 22, women: 24) with a median age of 68 years (interquartile range:55.5, 73.8 years) who experienced digestive symptoms following COVID-19 vaccination between March 1 and July 30, 2021, were included. This retrospective single-center study collected information on clinical symptoms, laboratory tests, imaging results, comorbidities, complications, treatment type, and prognosis.

Results

Thirty-three (71.7%), nine (19.6%), and three (6.5%) patients were administered AZD1222 (AstraZeneca), BNT162b2 (Pfizer/BioNTech), and JNJ-78436735 (Johnson and Johnson) vaccines, respectively. Patients were classified with mild (25 patients, 54.3%), moderate (five patients, 10.9%), and severe (16 patients, 34.8%) based on disease severity. Digestive symptoms included abdominal pain, diarrhea, dyspepsia, and nausea, which usually developed within 1 day (78.3%) following the first vaccination. In total, 14 (30.4%) patients experienced only gastrointestinal symptoms, whereas 32 (69.6%) experienced non-gastrointestinal symptoms. Complications included enterocolitis (76%), acute kidney injury (9%), anaphylactoid reaction (2%), and duodenal perforation (2%).

Conclusions

COVID-19 vaccines caused digestive symptoms and other complications that ranged from mild to severe. While further validation is required, our results suggest that monitoring digestive symptoms following COVID-19 vaccination can help detect rather severe complications that require medical intervention.

Nutritional therapy for hospitalized patients with COVID-19: A narrative and integrative review

Hospitalized patients affected by coronavirus disease 19 (COVID-19) have a sustained pro-inflammatory state and recurrent gastrointestinal symptoms that correlate with a decline in the nutritional status, which is directly related to poor immune response and clinical evolution. Nutritional therapy has proven crucial in COVID-19 treatment through the provision of adequate amounts of nutrients. Since the beginning of the pandemic, medical societies have mobilized to provide practical nutritional guidelines to support decision-making; despite this, there are only a few studies dedicated to compiling the most relevant recommendations. In this narrative review, we aimed to summarize and stratify the current scientific literature on nutritional support for hospitalized COVID-19 patients. We carried out a literature review from three databases between January 2020 and July 2021, using nutrition therapy (or medical nutrition or enteral nutrition or parental nutrition or nutritional support) and COVID-19 (SARS-CoV-2 infection) as the search terms. Only those studies that evaluated adult hospitalized patients with admissions to wards, specific clinics, or intensive care units were included. The nutritional intervention considered was that of specific nutritional support via oral, enteral, or parenteral modes. A total of 37 articles were included. In general, the nutritional care provided to COVID-19 patients follows the same premises as for other patients, i.e., it opts for the most physiological route and meets nutritional demands based on the clinical condition. However, some protocols that minimize the risk of contamination exposure for the health team have to be considered. Energy requirements varied from 15 kcal/kg/day to 30 kcal/kg/day and protein goals from 1.2 g/kg/day to 2 g/kg/day. In both cases, the ramp protocol for increased supply should be considered. In cases of enteral therapy, ready-to-use diet and continuous mode are recommended. Attention to refeeding syndrome is essential when parenteral nutrition is used.

[Systemic and extrapulmonary manifestations of COVID-19]

Although fever and respiratory symptoms are the main clinical expression of COVID-19 disease, important extrapulmonary complications that affect the majority of the organs and systems may occur. Multisystemic involvement can mainly be attributed to the generalized location of ACE2 receptors throughout the body, which act as the main point of entry for the virus. Systemic manifestations may occasionally appear before the typical symptoms, although they generally occur later or are sequelae of the disease. Thromboembolic complications are concerning due to their frequency and severity; they are the result of a hypercoagulable state with multiple possible clinical manifestations. Cardiac, neurological, gastrointestinal, renal, endocrine-metabolic, skin, and ocular complications may occur. The manifestations and specific therapeutic aspects of COVID-19 disease in pregnant women as well as implications of the disease on children are discussed. The corresponding tests must be performed in all patients with a clinical suspicion of COVID-19 in order to confirm the diagnosis of the infection. The specific diagnostic tests that are indicative of involvement of different organs are guided based on clinical suspicion. These tests are conducted on an individual basis taking into account the isolation measures required and the severity of each case. Likewise, the corresponding treatment is administered according to criteria that generally similar to those for the general population.

Predictors of biliary intervention in patients hospitalized for COVID-19

Background

Gastrointestinal complications of coronavirus disease-2019 (COVID-19) include abnormal liver function and acalculous cholecystitis. Cholecystostomy performed during the COVID-19 pandemic reflected a shift toward non-surgical treatment of cholecystitis and increased number of critically ill patients suffering from acalculous cholecystitis.

Purpose

(1) To determine demographic, clinical, laboratory, and ultrasound features associated with cholecystostomy placement during hospitalization for COVID-19. (2) To develop multivariable logistic regression modeling for likelihood of biliary intervention.

Methods

This retrospective review received institutional review board approval. Informed consent was waived. Between March 2020 and June 2020, patients with confirmed SARS-CoV2 infection admitted to New York-Presbyterian Hospital (NYP)/Weill Cornell Medical Center, NYP/Lower Manhattan Hospital, and NYP/Queens were evaluated for inclusion in this study. Inclusion criteria were (1) patient age ≥ 18, (2) confirmed COVID-19 infection by polymerase chain reaction testing of a nasopharyngeal swab, and (3) abdominal ultrasound performed during hospitalization. Exclusion criteria were (1) history of cholecystectomy and (2) biliary intervention performed prior to abdominal ultrasound. Patients were stratified into two groups based on whether they received cholecystostomy during hospitalization. Differences in demographics, medical history, clinical status, medications, laboratory values, and ultrasound findings between the two groups were evaluated using Chi-square test or Fisher’s exact test for categorical variables and t test or Wilcoxon-rank sum test for continuous variables. Multivariable logistic regression was used to model likelihood of biliary intervention.

Results

Nine patients underwent cholecystostomy placement and formed the “Intervention Group.” 203 patients formed the “No Intervention Group.” Liver size and diuretics use during hospitalization were the only variables which were significantly different between the two groups, with p-values of 0.02 and 0.046, respectively. After controlling for diuretics use, the odds of receiving cholecystostomy increased by 30% with every centimeter increase in liver size (p = 0.03). ICU admission approached significance (p = 0.16), as did mechanical ventilation (p = 0.09), septic shock (p = 0.08), serum alkaline phosphatase level (p = 0.16), and portal vein patency (0.14).

Conclusion

Patients requiring biliary intervention during hospital admission for COVID-19 were likely to harbor liver injury in the form of liver enlargement and require diuretics use.